9 20 371 https://staging.drfop.org/files/original/8ecb54a3012ed38f7b171812350a731d.pdf 05c8e25798ef9b43b1cb55d9b9839e68 https://staging.drfop.org/files/original/6098481d015061b362e56ee04136384f.jpg 11d8c7e9bba2ec02aa1e933df086c33a https://staging.drfop.org/files/original/46a799d6d2420300645917eaf2723c59.jpg e63018f515b90c2eb69c4ec89a8898ca https://staging.drfop.org/files/original/624a1233ecee23ac46ae637b18ba146b.jpg a6de0ab1da660648e99d40c903b27f11 https://staging.drfop.org/files/original/ab290fff59eadd267873a2decbd4e440.jpg 5bbfa7208d171dc56b90017e06f551e2 https://staging.drfop.org/files/original/520e88e49706cc661d53c602c6e33230.jpg 24830d3188a99030c51f97e3e6dea71a https://staging.drfop.org/files/original/de6139b99b662a5dfe5610dfbab30787.jpg 8947cfdfdd64cad477ba692f14656a82 https://staging.drfop.org/files/original/c3b9f7080112397202c2fbd0564d6efe.jpg e1aed6122e85990b09b25c20ed48a2a8 https://staging.drfop.org/files/original/230a7ff66eb4ce78118fada1bc78690f.jpg d1ad6fe57d3b51df0d72ad4bb9ab701c https://staging.drfop.org/files/original/38421551a83fa4614592b3b366304871.jpg e537771eaa35ec2c0fec8c6fd155000b https://staging.drfop.org/files/original/8905983959c857a3fe44468e0648daa2.jpg c124186a879f11ce49da830054807aaf https://staging.drfop.org/files/original/9507fd0de770b04b5b6b8e66a960c096.jpg 7243d43f3f603331b9462b61af3bd63c https://staging.drfop.org/files/original/acdca25dbb06cf22df9a79b8cf50487c.jpg ed2380d140dd85f67e802126564821f4 https://staging.drfop.org/files/original/ba2951f2e3d1435d01cfab4a4e31b29a.jpg 07a034fc807db2900fe28dd8c647f4ce https://staging.drfop.org/files/original/eff10f36de6ee111d6f50738c3442319.jpg 1f3a3b4d0f9af8451b1947b0c7e73341 https://staging.drfop.org/files/original/38b0e67c23198fd71257d8e8feed8cc6.jpg b2cf1ba3890019f43e712145bfd7b3d3 https://staging.drfop.org/files/original/b952520c020ff58786ca31aa71420aef.jpg 2c49308b27810bfa3ae14cb5897584ae https://staging.drfop.org/files/original/921292d7f6c4054098369270f1c94ceb.jpg 104f419a0f65a4dd1c13dbf1c3905dd3 https://staging.drfop.org/files/original/88a9ff9aebe0c40faa2273099450814e.jpg 8abd9344644628bec1edebd0dc336e1a https://staging.drfop.org/files/original/37804103eaaa550d65be09f5159b801b.jpg 8f81c43924b242f36e3c7f23e9daf146 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_046.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 46 - 67 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_046.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_046.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>Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>In certain pathological conditions of the lower extremity, the stress of weight-bearing cannot be tolerated because of pain or the possibility of actual tissue damage. Pathologies encountered in such situations fall into three broad categories: <a></a> those affecting bone-delayed unions or nonunions of fractures; <a></a> those involving the ankle or foot joints, such as traumatic arthritis or similar conditions; and <a></a> those involving the soft tissue, such as ulcers and traumatic loss of the heel pad or other soft tissues.</p> <p>In these circumstances, bracing is frequently used as an aid to management, the brace serving as a weight-bearing device to relieve the skin-muscle-bone complex of intolerable stresses.</p> <p>Historically, the application of a brace to unweight the lower extremity has involved provision for support of the body weight at the level of the pelvis, typically some form of ischial weight-bearing. A variable proportion of body weight is then transmitted to the ground through side bars and a locked knee. This type of brace is inherently disadvantageous because of its bulk and because the locked knee imposes a stiff-legged gait which increases energy costs. In situations where the pathology is located above the knee, avoidance of these disadvantages may be impossible. However, in selected below-knee lesions, a brace which bears weight about the knee (like the patellar-tendon-bearing prosthesis) appears not only desirable but possible. A brace of this type would not only allow unrestricted knee motion, and hence a more natural gait, but it would have the advantages of reduced bulk and the absence of equipment above the knee.</p> <p>In 1958, VAPC designed such a below-knee weight-bearing brace. <a></a> The VAPC design was based on the then current below-knee patellar-tendon-bearing (PTB) prosthetic techniques. The primary weight-bearing component is a partial socket of laminated plastic with a soft (Kemblo [TM]) liner similar to the proximal portion of a PTB prosthesis (<b>Fig. 1</b>). Stainless-steel uprights were used with a stainless-steel limited-motion stirrup (<b>Fig. 2</b>). The ankle joints were modified to permit 10 degrees of plantar flexion and to limit dorsiflexion at 90 degrees. The stirrup and uprights were fitted and aligned as in a conventional ankle brace. In wearing the brace, an open-end wool stump sock was used as with a below-knee prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Proximal weight-bearing portion of the PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Completed brace of initial design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As experience with the PTB-type brace accumulated at VAPC, a number of modifications were introduced (<b>Fig. 3</b>). A compressible heel, similar to that of the solid-ankle cushion-heel (SACH) prosthetic foot, and a rocker bar attached to the sole of the shoe became incorporated as standard components of the device. The SACH heel wedge and rocker bar were incorporated in the shoe to simulate plantar flexion and provide a more natural roll from heel to toe, thus minimizing gait deviations imposed by limited ankle motion. <a></a> The SACH heel wedge is also considered to function as a shock absorber, contributing to a smoother gait. Some patients with painful ankles were unable to tolerate motion in the ankle joint at the brace and were fitted with rigid joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Views of the modified brace showing application of SACH heel and rocker bar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center submitted the PTB weight-bearing brace to the Committee on Prosthetics Research and Development for evaluation. Unfortunately, at that time procedures for the testing of orthotic devices were not available. However, in December 1963 an orthotic evaluation program was inaugurated by New York University, and the VAPC device was selected by CPRD as a suitable item for this program.</p> <p>The initial phase of the NYU evaluation involved the review and examination of patients fitted by VAPC. Of the 22 patients who had been fitted by VAPC between 1958 and November 1963, 8 accepted the invitation to appear for interview and examination. The findings of this review study indicated that the VAPC pa-tellar-tendon-bearing brace was an effective device from the medical, orthotic, functional, and wearer-reaction points of view. <a></a></p> <h3>Clinical Fittings</h3> <p>On September 1, 1966, the National Academy of Sciences-National Research Council entered into Contract SAV-1053-67 with the Vocational Rehabilitation Administration (now the Social and Rehabilitation Service) to establish a pilot program for the clinical evaluation of prosthetic and orthotic devices under the jurisdiction of the Committee on Prosthetics Research and Development. Two orthotic items were selected to initiate this program: the Baylor (Engen) hand orthosis and the University of California dual-ankle control system. The Engen study was undertaken <a></a> but, for various reasons, the UC study could not be undertaken, and evaluation of the VAPC PTB brace was substituted for the UC item.</p> <p>Since the earlier favorable NYU review, an instructional manual has been prepared by the developer. <a></a> Accordingly, five treatment centers were recruited as participants in a clinical application study of the VAPC PTB brace: the University of Alabama Medical Center, Birmingham, Ala.; Goldwater Memorial Hospital, New York, N.Y.; Jackson Memorial Hospital, Miami, Fla.; Rancho Los Amigos Hospital, Downey, Calif.; and the Rehabilitation Institute of Chicago, Chicago, Ill.</p> <p>A course of instruction in the fabrication and application of the VAPC PTB brace was conducted at the Veterans Administration Prosthetics Center, New York, by the developers. Orthotists from the participating clinics undertook training for five days (May 8-12, 1967), while physicians had a one-day orientation (May 12, 1967).</p> <p>A protocol for the study, together with appropriate data-recording forms, was prepared by the CPRD staff.</p> <p>Following the instructional course, several fittings were accomplished at each of the participating centers. Subsequently, a number of factors arose to militate against the completion of the planned course of study. Two of the clinics suffered the loss of the physician member of the participating team, and two other centers became engaged in studies of cast braces for fractures of the lower extremity. These fracture-cast braces had some of the same characteristics and performed similar functions as the test item. The physician member of the fifth participating team suffered a prolonged illness, which disrupted the progress of the study at his center.</p> <p>The clinical study of the VAPC PTB brace was reactivated early in 1970 when the physician who had been ailing recovered his health and it was discovered that the orthotics clinical group at the Duke University Hospital had been fitting the test item since 1962 and had accumulated a sizable series of patients. Arrangements were made, therefore, to review patients fitted in Birmingham and Durham. The data obtained in these reviews form the basis for this report. The experience of these two centers is presented in the following sections of this report.</p> <h4>Birmingham, Alabama</h4> <p>Following the return of the physician—orthotist team from the instructional course at VAPC, seven patients were fitted in the study. Two of these patients were civilians (one woman and one boy) and five were veterans. The injuries of three of the veterans were non-service-connected.</p> <p>Review of the data available on these seven patients fitted in Birmingham indicates that in four instances the experimental brace was used satisfactorily and successfully. In two cases, the results were inconclusive in that the follow-up data are not available. The seventh patient must be considered a probable failure, although again follow-up data are not available. Condensed case histories on these patients follow.</p> <h4>Successful Outcomes</h4> <p><i>Case No. 1</i></p> <p><i>P.S. </i>was born on February 28, 1953. He suffered from congenital pseudarthrosis of the right tibia and fibula, essentially constituting a defect similar to an ununited fracture. Prior to referral to the Crippled Children's Service Clinic in Birmingham, he had undergone surgery at an early age. This surgery, involving the use of metallic screws and sutures, was unsuccessful. Further surgical procedures were attempted subsequently, an onlay bone graft being done on July 20, 1965. This surgery was followed by infection and was unsuccessful. A sliding bone graft was attempted on June 6, 1967, but this also was unsuccessful.</p> <p>The VAPC PTB brace was fitted in April 1968. The condition of the right tibial and fibular defects at that time is shown in <b>Fig. 4</b>. The brace prescription included a SACH heel and a rocker bar incorporated into the shoe build-up (the right leg being shorter than the left). Initially, no motion was provided at the ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. X-ray of P.S.'s leg at time of fitting the VAPC PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following application of the brace, the leg shrank rapidly, and a new socket was required in approximately one month. Because of this loss of fit, the amount of weight borne on the defective limb was increased. This boy was a very active user; he played basketball and reported that he went hunting almost every day. As a result of this active use, numerous breakages occurred at the junction of the brace upright and shoe plate. The upright was eventually strutted for extra strength, and after about a year and a half of wear a few degrees of motion were introduced at the ankle joint. This limited motion resulted in reduction of the breakage problems.</p> <p>Although the patient was well pleased with the brace and wore it satisfactorily, the tibial and fibular defects failed to unite (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. P.S.'s leg after wearing the experimental brace approximately 14 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The physician, orthotist, and patient all considered this brace to be superior to any previously worn.</p> <p><i>Case No. 2</i></p> <p><i>C.S. </i>was born on April 17, 1915. He was injured on March 2, 1967, when he slipped on the ice and fell, sustaining fractures of the left tibia and fibula. He was treated with plaster casts, but union of the tibial fracture was delayed.</p> <p>He was fitted with the VAPC PTB brace in September 1968. The prescription was standard, and included a SACH heel, a rocker bar, and a rigid ankle. A full leather cuff was applied over the fracture site.</p> <p>This patient's treatment program proceeded uneventfully, and by June 1969 a good bone union was evident clinically and confirmed by X-ray (<b>Fig. 6</b>). This patient was discharged from the doctor's care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. C.S.'s X-rays after wearing the experimental brace for 9 months Good bone union is evident at the fracture site. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 3</i></p> <p><i>H.E. </i>was born on October 25, 1933. He was hit by a car on October 12, 1966, sustaining a fracture of the right tibia, which failed to unite. Draining osteomyelitis also was present.</p> <p>He was fitted with the experimental brace on October 25, 1968. The prescription included a SACH heel, a rocker bar, a fixed ankle, a short leather cuff, and a high shoe. He initially walked with crutches or canes but later discontinued these aids.</p> <p>This patient is a large, heavy man and very active. Many repairs were required at the shoe-plate junction, and eventually a strut had to be added for additional strength.</p> <p>This patient's treatment program proceeded relatively uneventfully. In August 1969, the brace was reported as working well, and no drainage had been experienced since October 1968. Although the fracture had not healed, X-rays revealed some indications of healing (<b>Fig. 7</b>). In March 1970, apparent ankylosis of the ankle joint was noted, and progressive ossification within the fracture area was evident. The patient continues to wear the brace and tolerates it well. He still wears an elastic below-knee stocking, but this is apparently more for insurance than because of actual need.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. H.E.'s X-rays show indications of healing of fracture after the brace was worn for 10 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 4</i></p> <p><i>J.C. </i>was born on October 27, 1948. He was injured by shrapnel on May 14, 1967, sustaining a fracture of the neck of the talus on the right leg and loss of soft tissue on the right heel. <b>Fig. 8</b> shows the condition of his right ankle approximately five months after the injury.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. X-ray of J.C.'s right ankle 5 months after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The experimental brace was prescribed for this patient on November 21, 1967, and it was delivered on December 13. The prescription incorporated a SACH heel, a rocker bar, a reinforced foot plate, and no ankle motion. This patient experienced no particular problems other than the need for shoe changes. He found the brace useful and comfortable. X-rays taken on April 9, 1968, showed marked improvement (<b>Fig. 9</b>). His injuries proceeded to complete healing, and he is no longer wearing the VAPC brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marked improvement is evident in J.C.'s ankle after wearing the experimental brace approximately 5 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>S.D. </i>was born on May 18, 1927. She was injured on August 30, 1967, sustaining a comminuted fracture of the right tibia and fibula. The tibial fracture failed to unite.</p> <p>She was treated with long and short leg casts and fitted with the PTB brace on May 29, 1968. The prescription was standard, and included a SACH heel, a rocker bar, and no ankle motion. The patient tolerated the brace well, and X-rays taken on July 1, 1968, indicated satisfactory progress (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. S.D. shows satisfactory progress one month after fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Few maintenance requirements were found, except that the shoes had to be changed and one upright and one foot plate broke.</p> <p>The patient was seen in August 1969, at which time she was using the brace with crutches. She has not been seen since, so the end result is unknown.</p> <p><i>Case No. 6</i></p> <p><i>D.E. </i>was run over by a truck in May 1966, and he sustained fractures of both legs and the left foot. The left tibia failed to unite, as indicated in X-ray films taken six months after the injury (<b>Fig. 11</b>). He was fitted for the VAPC PTB brace in December 1968, but left the hospital before the brace was delivered. The brace was delivered at home just before Christmas 1968, and he apparently has not been seen since except for a casual encounter with the or-thotist on the street, when it was reported that the fracture had healed and that the patient no longer needed the brace. Again, because of the loss of this patient to active follow-up, the full story is not known.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Condition of D.E.'s leg prior to fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Assumed Unsuccessful Outcome</h4> <p><i>Case No. 7</i></p> <p><i>R. McK. </i>was born on May 21, 1908. His injury occurred as a result of a land-mine explosion on February 27, 1942. He sustained the loss of the os calcis and the heel pad bilaterally.</p> <p>He was fitted with the VAPC PTB brace on the right side only, the device having a fixed ankle, SACH heel, and rocker bar.</p> <p>This patient was apparently dubious about the brace from the outset, and expressed lack of confidence in the doctors and the course of treatment. He wore the experimental brace for a very limited period (approximately five days) and claimed that it limited his freedom, particularly when driving. This patient subsequently became lost to follow-up, and all indications were that the application of the brace in this case was unsuccessful as well as perhaps ill-advised.</p> <h4>Discussion And Conclusions</h4> <p>The evidence in the Birmingham fittings of the VAPC PTB brace was strongly positive with respect to its value as a means of patient management. In some instances, this value was in providing partial un-weighting so that the damaged part could heal. In other instances, the unweighting provided by the brace permitted the patients to engage in vigorous programs of activity despite a lack of union in the tibia.</p> <p>In addition to these general findings, some specific findings of interest emerged.</p> <ol> <li>Following application of the VAPC PTB brace, shrinkage of the limb enclosed by the plastic cuff was encountered. Close control of the fitting during this period is essential in order to avoid the development of loose fit and a reduction in the amount of weight borne by the brace.</li><li>As in all prosthetic-orthotic applications, judicious selection of patients is essential. In the Birmingham group, one fitting was apparently doomed to failure from the outset because of the patient's attitude, while another patient was a chronic alcoholic, so that the possibility of securing follow-up data was negated from the outset.</li></ol> <p>It should be emphasized that the Birmingham fittings closely followed the technique practiced and taught by the Veterans Administration Prosthetics Center. Review by one of the co-developers of the device on a number of the cases fitted early in the study indicated good workmanship and generally excellent fit and alignment.</p> <p>Some observations by the orthotist member of the fitting team were:</p> <ol> <li>Fabrication of the VAPC PTB brace requires experience in both prosthetics and orthotics, since elements of both specialties are involved.</li><li>A course of instruction in the technique during which the braces are actually fabricated under competent instructors is a most desirable means of transmitting fitting knowledge and skill.</li><li>The selection of patients for the device is most important and should include not only considerations of psychological factors such as those described above but also of physical factors which may increase the difficulty of fitting. (The presence of loose tissue around the knee which could become a flesh roll above the brace cuff was cited as an example of this type of difficulty.)</li><li>All patients fitted in the Birmingham group were initially provided with braces with no provision for motion at the ankle joint. In active and/or heavy patients, this resulted in numerous brace-upright and shoe-plate breakages. Later, some patients were provided with a small amount of ankle motion, and this had the effect of reducing incidence of breakage. Criteria for the prescription of fixed or limited motion in ankle joints should therefore be defined more carefully.</li></ol> <h4>Durham, North Carolina</h4> <p>Mr. Bert Titus, director of the Department of Prosthetics and Orthotics, Duke University, began fitting the VAPC-PTB-type brace in 1962. The initial braces were fabricated in accordance with the VAPC manual of January 3, 1961. <a></a> Over the years, however, the original VAPC procedures were modified at Duke in a number of ways. Although the original concept of patellar-tendon weight-bearing for reduction in the amount of weight borne by the affected part of the limb was maintained, the changes are significant enough to be worthy of note.</p> <ol> <li>The socket, which in the VAPC version was hinged on the medial side, was first changed to a bivalve construction involving anteroposterior sections joined by adhesive tape (<b>Fig. 12</b>). The type of socket now fitted in Durham involves a plastic laminate without liner which is flexible on the posterior aspect and the posteromedial corner (<b>Fig. 13</b>). The socket is split along the posterolateral corner and closure is effected by two or more Velcro (TM) straps (<b>Fig. 14</b> and <b>Fig. 15</b>). The fabrication of this socket is described in a report being prepared by Titus. An abbreviated description of the Duke procedures appears as a supplement to this article.</li><li>The sidebars in the Durham version of the weight-bearing brace are of either stainless steel or aluminum, and most recently have been attached to the outside of the socket with rivets. This procedure is in contradistinction to the VAPC method, which involves insertion of the proximal ends of the sidebars into prepared channels. Distally, the bars are detachable from the shoe.</li><li>All the VAPC-type braces fitted at Durham incorporated some degree of ankle motion. Typically, this was 20 degrees to 25 degrees of dorsiflexion with a 90 degrees stop. However, some of the ankle joints were completely free. This feature again contrasts with the VA practice in which the brace ankles are frequently of the rigid type. It was reported that none of the braces fitted at Durham had completely rigid ankles.</li><li>Typically, the Durham version of the weight-bearing brace does not include either a SACH heel or a rocker bar. Doubtless, the need for such aids to roll-over is reduced or eliminated by the provision of ankle motion.</li></ol> <p>Between the initial fittings in 1962 and June 15, 1970, the Duke Limb and Brace Shop fitted approximately 27 PTB-type braces. Of these patients, 20 were civilians seen through the Orthopaedic Department of Duke University Hospital and 7 were veterans who were treated through the Veterans Administration Hospital at Durham. Three additional braces were being fabricated at the time of this review.</p> <p>On June 22-23, 1970, the author, accompanied by William McIlmurray from the VAPC, reviewed 8 patients who had been fitted through the Duke University Department of Prosthetics and Orthotics. The group of patients reviewed included 5 civilians and 3 veterans. The case-history files of 12 additional patients were also reviewed. The data obtained in these reviews are presented below in three sections-one indicating the types of disabilities for which the brace was used, the second containing illustrative case histories of patients treated, and the third containing comments on fit and alignment. In general, the outcomes of the fittings appeared to be very positive.</p> <h4>Types Of Disabilities</h4> <ul> <li>Chronic osteomyelitis with secondary deformity of distal tibia and fibula and partial ankle fusion.</li> <li>Slow-healing spiral fracture of the tibia and fibula.</li> <li>Compound fracture of the tibia and fibula and fracture of the left foot followed by infection and numerous operative procedures culminating in ankle fusion.</li> <li>Fracture of the tibia and fibula.</li> <li>Nonunion of the tibia and fibula with compression-plate fixation.</li> <li>Nonunion of a tibial fracture with draining osteomyelitis.</li> <li>Comminuted fractures of the distal right tibia and proximal right fibula and fracture dislocation of the right ankle. A painful ankle led to the performance of a triple arthrodesis.</li> <li>Comminuted fractures of the ankle mortice bilaterally (right medial malleolus and tibia, left spiral fracture of tibia and fibula; both ankles stabilized with pins). Six pins were subsequently removed.</li> <li>Traumatic arthrosis of the right ankle following fracture of the distal right tibia and fibula.</li> <li>Compound trimalleolar fractures of the left ankle with dislocation.</li> <li>Nonunion of a left tibial fracture with osteoporosis.</li> <li>Calcaneal valgus deformity of the right foot treated with a triple arthrodesis of the right foot and ankle; delayed healing of subtalar, talonavicular, and calcaneocuboid joints with severe osteoporosis.</li> <li>Pain on plantar aspect of heel following fracture of the os calcis.</li> <li>Foot pain following football injury; triple arthrodesis performed.</li> <li>Degenerative changes in left knee secondary to old fracture of the tibial plateau.</li> <li>Nonunion of medial malleolus following trimalleolar fracture sequelae of traumatic arthrosis and arthrodesis.</li> <li>Comminuted fracture of os calcis leading to a crushed heel pad, osteoporosis, and triple arthrodesis subsequently.</li> <li>Right heel pain, characteristic of traumatic or degenerative arthritis.</li> <li>Fracture of the right os calcis with painful right foot and ankle.</li> </ul> <h4>Case Histories</h4> <p><i>Case No. 1</i></p> <p><i>W.J. </i>was born on April 3, 1927. From early childhood, he had suffered from a defect in his left leg which had been attributed to an aftermath of diphtheria. His condition was reported as being chronic osteomyelitis with a secondary deformity of the distal tibia and fibula combined with partial ankle union.</p> <p>The patient was fitted with a PTB brace in August 1962, and thus had worn the device for almost eight years. The brace worn had an ankle with a positive 90 deg. stop and approximately 30 deg. of dorsiflexion motion. He wore a low shoe with a 2 1/2-in. build-up. Otherwise, the brace was of the Durham type as described previously. He reported that he wore the brace for more than nine hours daily, and that it was generally quite comfortable and satisfactory. His condition was reported to have stabilized, although his ankle and shin sometimes ached after prolonged standing or walking. He stated that he felt that he was bearing more than 50% of his weight on the brace. From his remarks, it would appear that the brace was a definite aid to his mobility.</p> <p><i>Case No. 2</i></p> <p>J.G. is a 30-year-old male garbage collector who was jammed between the garbage truck and a brick wall, sustaining a fracture of his left tibia and fibula on March 22, 1967. A nonunion of the fractures with a draining osteomyelitis ensued (<b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. J.G., with nonunion of fractures and draining osteomyelitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient was fitted with a PTB brace in September 1969. He reported that he was feeling fine, the osteomyelitis had stopped draining, and he had returned to work driving a garbage truck.</p> <p>The brace worn was the Durham bivalve device with the ankle completely free (<b>Fig. 17</b>). He wore the brace all day every day and reported absolutely no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. J.G,, with Durham bivalve-type brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From the patient's remarks, his return to work, and his comments concerning the brace, it would appear that this fitting was quite successful.</p> <p><i>Case No. 3</i></p> <p><i>T.L., </i>a physician, sustained a spiral fracture of the tibia and fibula on February 5, 1969. He wore a long leg cast for six months following the injury, and on August 8, 1969, he was fitted with the PTB brace. The condition of his fractures just prior to fitting is shown in <b>Fig. 18</b>. With the device, he was able to return to his medical practice. The fracture was pronounced healed in November 1969, and the PTB brace was discarded. His brace was of the standard Durham type with a completely free ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Views of T.L.'s fractures before fitting with PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When interviewed, the patient's comments concerning the brace were very positive. So much so, in fact, that when the interviewer remarked that he seemed like a happy customer, he retorted that he was more than happy—he was delighted—and in fact had sent two patients with fractures to be fitted with the same type of brace.</p> <p><i>Case No. 4</i></p> <p><i>F.E., </i>a 43-year-old male, was buried under eight to ten tons of chemical in March 1966, sustaining compound fractures of the left tibia and fibula, a fracture of the left foot, and fractures of the pelvis and of the right upper femur. Following open reduction and internal fixation, the injury became infected and the fixation was removed. The patient had a number of operative procedures on his right hip, and on October 3, 1967, underwent multiple fusions of the ankle bones.</p> <p>He was fitted with a PTB brace on March 27, 1968, and thus had worn it for slightly more than two years. The device is of a standard Durham type with a 90 degrees ankle stop and with approximately 5 degrees of dorsiflexion. The sidebars were of aluminum with an anterior aluminum calf band. A low shoe was worn with a build-up on the opposite side because of a shortening of the right leg related to the pelvic and femoral fractures. The brace was of the bivalve type. <b>Fig. 19</b> and <b>Fig. 20</b> show the condition of the foot and distal tibia and fibula over the period from January to October 1969. The patient reported that without the brace he experienced discomfort at the fracture sites, but that with the device he was reasonably comfortable and could wear the brace all day. He claimed that he took about 30<i>% </i>of his weight on the brace. Again, it appeared that this brace is a highly acceptable aid to the mobility of the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. X-rays of F.E.'s distal leg, ankle, and foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Condition of F.E.'s limb 9 months later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>H.H., </i>40 years of age, sustained multiple fractures of the lower extremities on August 4, 1969. His injuries included fractures of the left femur, tibia, and fibula, and right tibia and fibula. He was fitted with a PTB-type brace in February 1970. His condition two months after fitting (eight months after injury) is shown in <b>Fig. 21</b>. His device was of the single-lamination type and incorporated a free ankle and a high shoe. The fit of the socket was somewhat loose, and the patient expressed the opinion that no weight was being taken on the socket. He used Canadian-type crutches bilaterally. The clinical notes on his condition indicated good alignment of the bony fragments and no pain. He was wearing the brace all day and had no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Condition of H.H.'s fractures 8 months after injury (2 months' wear of PTB brace). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 6</i></p> <p><i>J.H., </i>born in 1927, suffered his injury in December 1966. Nonunion of the left tibia and fibula ensued, with compression-plate fixation.</p> <p>The patient had been fitted initially with the bivalve-type socket (separate anterior and posterior sections), but was currently wearing the one-piece laminated socket with a flexible posterior section. The brace incorporated a free ankle, and a low shoe was worn.</p> <p>Recent clinical notes on this case indicated that on March 25, 1970, there was good alignment of the bony fragments, and early bridging of bone had begun in the tibia and fibula. On May 27, 1970, the patient was reported to be feeling well, but there was still nonunion of the fibula (<b>Fig. 22</b>). The patient reported no problems with the brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Persisting nonunion of fibula approximately 4 1/2 years after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 7</i></p> <p><i>R.C.M., </i>39 years old, sustained a comminuted fracture of the left tibia and fibula when a tree fell on his leg in March 1967. Nonunion of the left tibial fracture ensued, with chronic osteomyelitis and drainage (<b>Fig. 23</b>). A bone graft to the tibia was attempted in March 1968.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Nonunion of tibial fracture 10 months after accident. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient wore a long leg cast, followed by an initial weight-bearing brace. He was fitted with the PTB device in December 1969. His clinical record indicated that there was intermittent drainage in December and January but no drainage in February or March 1970 (<b>Fig. 24</b>). On April 1, 1970, it was reported that no active osteomyelitis was evident. However, at the time of the review (June 24, 1970), the patient reported that drainage had restarted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Nonunion persisting 3 years after accident. PTB brace worn 3 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>His brace included a 90 degrees posterior stop with about 10 degrees of dorsiflexion motion evident. The patient wore a built-up low shoe to accommodate a 2 1/2-in. shortness of the affected limb. His socket was of the two-part (bivalve) type. He used a cane as an aid in ambulation.</p> <p>The patient reported that the brace felt comfortable most of the time, although he had occasional swelling of the leg after long use and some discomfort at the site of the fracture after prolonged sitting.</p> <p><i>Case No. 8</i></p> <p><i>R.McC, </i>69 years old, was injured in an automobile accident on November 15, 1969. He sustained fractures of the head of the tibia, the head of the fibula, and the proximal third of the fibula (<b>Fig. 25</b>). He was fitted with the PTB brace on April 6, 1970 (<b>Fig. 26</b>). Thus, at the time of the review, he had been wearing the device for approximately two and one-half months. He reported that the brace was generally comfortable, but that he had had some problems with swelling and stiffness in the ankle. He estimated that the brace was taking approximately 25% of his body weight. His brace was a standard Durham type with a 90 degrees posterior stop and dorsiflexion motion of approximately 30 degrees. When first fitted with the PTB brace, he had used two crutches, but now was only using one.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. <i>Left, </i>R.McC.'s initial injury, Nov. 15, 1969. <i>Right, </i>after open reduction and internal fixation, Jan. 2. 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. <i>Left, </i>R.McC.'s fractures at time of fitting the PTB brace, 4 1/2<i> </i>months after injury, April 1970. <i>Right, </i>after 1 month's wear of PTB brace, May 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this instance the period of brace wear was too short for definite conclusions to be drawn, the brace was being tolerated well by the patient and was of assistance to him in ambulation.</p> <p><i>Case No. 9</i></p> <p><i>J.B., </i>67 years old, was admitted to Duke University Hospital on March 12, 1969, with a closed comminuted fracture of the left distal tibia, fibula, and ankle joint, and an open trimalleolar fracture of the right ankle. Operative procedures were carried out the same night, and the patient was discharged from the hospital on April 11, 1969, with the wounds healed and the feet in apparently satisfactory condition, with the right foot in a better state than the left.</p> <p>X-rays taken on January 12, 1970, showed an old fracture of the right ankle with fixation by metallic pins and screws and good external bony bridging and normal alignment (<b>Fig. 27</b>). On the left side, internal-external bridging of the fibula with marked angulation, as well as poor healing of the tibial fragments, was evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. <i>Left, </i>J.B.'s left ankle 10 months after reduction, Jan. 1970. <i>Right, </i>views of ankle 12 months after reduction (1 month after fitting with PTB brace) March 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted with the PTB brace in February 1970. Four weeks later, the clinic notes reported that the fibula had healed, and that the tibia was nontender.</p> <p>No significant further changes were noted at examination on May 26, 1970. However, that patient reported that since wearing the PTB brace he had experienced practically no pain in the ankle or foot. He was to continue wearing the brace.</p> <h3>Critique Of Fabrication And Alignment</h3> <p>William McIlmurray of the Veterans Administration Prosthetics Center, one of the co-developers of the PTB brace, participated in the review of patients at the Durham facilities. Mr. Mcllmurray described the fitting and alignment of the braces seen as generally good. He noted some of the characteristics of the Durham devices previously mentioned: the one-piece socket lamination, the ankle motion provided in all prostheses in contrast to the need that VA found to fit some braces with rigid ankles, the external attachment of the sidebars, the use of detachable stirrups, and the absence of SACH heels and rocker bars on the shoes of the patients. The absence of a liner in the sockets fitted and the fact that some patients did not wear stump socks was also noted.</p> <p>Mr. Mcllmurray subsequently discussed these features of the Duke fittings with Werner Greenbaum, the other co-developer of the VAPC technique. Their joint comments follow.</p> <blockquote><p>No objection is raised to the use of hard, unlined sockets which have a flexible medioposterior corner. However, it should be emphasized that, if this portion of the socket is too flexible, it will not offer support and the weight-bearing effectiveness of the brace will be reduced.</p> <p>In courses of instruction on the PTB brace, it would be desirable to teach fabrication methods for both lined and unlined sockets. Clinics would then have the choice of using either method, thus creating a situation similar to current practice in the prescription of PTB prostheses.</p> <p>VAPC also employs a one-piece socket fabrication procedure, and the use of this method is endorsed by the Duke experimentation.</p> <p>The channels which are prepared in the socket for insertion of the sidebars result in a product which is cosmetically more acceptable than one with bars externally attached. Moreover, these channels are very necessary for alignment adjustability during the fitting procedures. They permit us to make minute height adjustments and to tilt the socket either medially or laterally. This adjustability is a most important feature, and we would not agree to its elimination.</p> <p>We think that, in general, detachable stirrups are contraindicated, although they might possibly be used on lightweight, inactive patients.</p> <p>Usually we do allow some ankle motion if warranted by the pathology. However, the weight-bearing characteristics of the brace are better maintained if only plantar flexion is allowed. When mechanical ankle-joint motion is not provided, SACH-heel and rocker-bar principles are applied.</p> </blockquote> <h4>Discussion And Conclusions</h4> <p>The clinical records of 27 patients fitted with the patellar-tendon-bearing brace through the Department of Prosthetics and Orthotics at Duke University were reviewed. A number of the patients in this series were interviewed and examined. From the data gathered, it appears incontrovertible that this type of brace has useful applications for a variety of below-knee problems.</p> <p>Two broad areas of application were noted:</p> <ol> <li>In instances where fractures or operative procedures were slow to heal, the brace was used as a means of mobilizing the patients more rapidly than might otherwise have been the case.</li><li>In cases of chronic pain in the leg, ankle, or foot arising from fractures, traumatic arthritis, and the like, the weight-bearing relief provided by the brace permitted patients to be ambulatory with considerably less pain and discomfort than was the case without the brace.</li></ol> <p>The review data indicated that the outcomes of the application of the brace were viewed very positively by the orthopedists, the orthotists, and the patients.</p> <p>The variations in fabrication and fitting procedures used at Durham as compared with those originally promulgated by VAPC are noteworthy:</p> <ol> <li>One-piece fabrication of the PTB-type socket or cuff without a liner appears to be a possible improvement over the original VA procedure.</li><li>The external attachment of sidebars appears somewhat less cosmetic than the original technique, but is probably somewhat simpler and faster to do.</li><li>Detachable stirrup-type upright applications showed some loosening tendencies.</li></ol> <p>In some cases, the provision of ankle motion in the brace undoubtedly eliminated the need for a SACH heel and a rocker bar, and resulted in less breakage of sidebars at the shoe attachment. However, the question as to whether some of these patients should have had rigid ankles with a SACH heel and/or rocker bar is unclear. The rule of thumb used at Duke appeared to be that, the closer the disability was to the ankle joint, the less motion had to be provided. However, as reported, all patients were given some degree of ankle motion.</p> <p>In conclusion, it would appear that the Duke application of the PTB brace was in general highly successful. Some of the changes made in the original VAPC procedures appeared to have definite merit.</p> <h3>Recommendations</h3> <p>Since the results of this study indicate that the VAPC PTB brace can be successfully and beneficially applied by unaffiliated treatment centers, thus corroborating the developer, it is recommended that: (1) the results of the study be broadly disseminated by publication in <i>Artificial Limbs </i>and by other means, (2) the prosthetics-orthotics schools be encouraged to include instruction in the PTB brace as part of the lower-extremity orthotics curriculum, and (3) the fabrication modifications introduced by the Duke University Department of Prosthetics and Orthotics be tried at VAPC, and that following these trials the two institutions collaborate on the production of a fabrication manual for the PTB brace which will incorporate the best procedures currently known.</p> <h3>Summary</h3> <p>In the late 1950s, a brace to unweight the leg was designed at the Veterans Administration Prosthetics Center (VAPC), New York, N.Y. This brace incorporated a lined plastic cuff essentially similar to the proximal portion of the patellar-tendon-bearing (PTB) prosthesis. By varying the tightness of this cuff and the lengths of the uprights connecting it to the shoe, the amount of body weight borne on the proximal shank could also be varied. By these mechanisms, the distal portions of the limb could be unweighted to the desired degree.</p> <p>The VAPC PTB brace was reported by the developer as having beneficial applications in cases of delayed or ununited fractures (tibia and fibula), painful ankles, and soft-tissue damage to the heel and the plantar aspect of the foot. It appeared potentially useful in any leg condition which produced pain on weight-bearing. Patients fitted by VAPC were reviewed by an independent agency (New York University) in 1963, and the developer's claims for the device were essentially substantiated.</p> <p>The present report presents the results of VAPC PTB brace fittings performed by two groups other than the developer. The clinical records of 36 patients were reviewed, and approximately one-third of the patients were examined and interviewed.</p> <p>The studies generally corroborated the positive findings previously reported by the developer. Wide dissemination of information concerning the VAPC item and its incorporation in orthotics instructional courses is recommended.</p> <h3>Acknowledgments</h3> <p>To all who participated in the various phases of the VAPC PTB brace evaluation study, we express our sincerest appreciation. To Chestley L. Yelton, M.D., Moody L. Smitherman, Jr., of Birmingham, Ala., and Bert R. Titus of Durham, N.C., we extend our special thanks for their extraordinary efforts in scheduling and reviewing patients and in providing the X-rays and pictures for this report.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Front, rear, and side views of PTB brace with earlier Durham bivalve socket lined with horsehide, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Front, rear, and side views of current Durham socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Medial, lateral, rear, and oblique views of socket with sidebars and shoe attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Current version of Durham modification fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</li> <li>McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</li> <li>McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</li> <li>Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 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>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 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>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-16.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-17.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-18.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-19.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-20.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-21.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-22.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-23.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 Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace Creator An entity primarily responsible for making the resource Hector W. Kay * https://staging.drfop.org/files/original/211972ac2450f7c379e75a6afbeee2dc.pdf ae8db5d5134f237d958bbd2b68be6d08 https://staging.drfop.org/files/original/520946adfb02dd1afbd9b4c67af73f08.jpg 61cd9ff898171a3445f27886c90a2493 https://staging.drfop.org/files/original/9170dd45d7ca4e14488f584a811dd23e.jpg fe5833e8ce6bc7bdf61f5f73baf816e3 https://staging.drfop.org/files/original/3b0777a43f09e4e4ee2114768fb56d30.jpg d22944087f7c13edf9ac4ccc260893d8 https://staging.drfop.org/files/original/fe459c0ecfb645ab7220642b51f9c593.jpg f2423f9a630bfe7e433bda250a03a58c https://staging.drfop.org/files/original/7cfdf4864b7be4044c17cc555926b0e2.jpg 05467aefe472260562820f5c91fb6f4c https://staging.drfop.org/files/original/54b46adc00046b649185688bcfa06ed8.jpg d9288be7f7a62533a8e62cb9e56ac3e8 https://staging.drfop.org/files/original/e21b7388fdb6d845283dd747b9618c11.jpg dfe82d1c37e1a9669c31bcfda7e97869 https://staging.drfop.org/files/original/c228c40b5262dd433fd295410cdae1e4.jpg 6f2c4233f38372d631252e490f83e18f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_013.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 13 - 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/1969_01_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_013.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>Clinical Evaluation of the Engen Plastic Hand Orthosis</h2> <h5>Hector W. Kay, M Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>A primary function of the hand is prehension, the ability to grasp an object. While the hand can perform numerous types of grasp, of major importance is the type involving flexion of the index and middle fingers towards or against the opposing thumb to provide what is sometimes referred to as "three-jaw-chuck" prehension.</p> <p>Temporary or permanent paralysis can impair or completely inhibit the function of hand, wrist, or entire upper extremity, and the ability to oppose the thumb to the flexing fingers may be lost. In these instances, various types of orthotic systems have been designed to achieve the goals of prevention or correction of deformities, or restoration of function, or both. A key feature of these systems is the stabilization of the thumb in opposition to the fingers.</p> <p>Pioneering efforts in the area of hand-splinting were undertaken at the Georgia Warm Springs Foundation where many types of assistive devices were developed to meet the needs of a large patient population having residuals of poliomyelitis. Although the number of polio patients has decreased in recent years, rehabilitative medicine has expanded to include patients with many other types of neuromuscular and skeletal disorders. A systematic method of hand splinting to meet the needs of these patients has continued to be of paramount importance. On-going efforts in this regard have been maintained not only at GWSF but also at Rancho Los Amigos Hospital and other institutions. <a></a></p> <p>As part of Research Project VRA RD-1564, Thorkild J. Engen, Project Director, Baylor University College of Medicine, Houston, Texas, in 1959 initiated the development of a plastic hand orthosis having the basic configuration shown in <b>Fig. 1</b>. <a></a> Based on the premise that preservation of hand posture is best maintained by support, rather than suspension, the device is designed to hold the thumb in the opposed position and simultaneously support the metacarpal arch. The aim has been to develop a standardized item shaped to conform to the natural contours of the hand which could then be adapted to meet individual needs. The Engen orthosis is made in four sizes: large, medium-large, medium, and small; and for both right and left hands. Because the orthosis is fabricated of polyester resins, it can be remolded upon application of heat.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic Engen plastic hand orthosis being prepared for individual application. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the early stages of redevelopment, the Engen orthoses were fabricated of epoxy resins with and without fiberglass reinforcement. Ultimately these models were discarded because of breakage problems. The plastic shells originally submitted to New York University for a laboratory evaluation program were made of fiberglass and polyester resins. <a></a> The current shell is a polyester resin and nylon laminate prepared by means of a vacuum-molding technique. With the new materials, the fitting technique is essentially unchanged; the orthosis is molded and modified by the orthotist as necessary to provide a custom fit.</p> <p>In the course of development, attachments were devised or adapted to provide wrist support and to provide prehension.</p> <p>Three versions or adaptations of the Engen plastic hand orthosis were selected as the subject of the field evaluation: the short opponens orthosis, the long oppo-nens orthosis, and the reciprocal wrist-extension, finger-flexion unit. Additional modifications of the basic concept involving the use of external power were specifically not included in the study.</p> <h3>Short Opponens Orthosis</h3> <p>The so-called short opponens orthosis is the simplest application or adaptation of the Engen equipment. <a></a> It consists essentially of the basic hand shell with a retaining strap (<b>Fig. 2</b>). The prime purpose of this device is to maintain the thumb in apposition to the index and long fingers and to support the metacarpal arch. The functional goal is the achievement of "three-jaw-chuck" prehension as distinct from "lateral" grasp. Patients said to benefit from this orthosis are those with neuromuscular disorders resulting in various degrees of muscle imbalance of the intrinsic and opponens muscle groups. Such patients would typically have spinal cord injuries at the C-7, C-8, and T-l levels, peripheral neuropathy (ulnar and median nerves), or hemiplegia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the short opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Long Opponens Orthosis</h3> <p>This adaptation <a></a> consists essentially of the basic plastic hand shell with an attached extension arm which is stabilized on the forearm by appropriate straps (<b>Fig. 3</b>). Like the short opponens orthosis, this device is designed to prevent deformity and achieve "three-jaw-chuck" prehension if the necessary residual muscle movements are present and can be controlled. Patients with spinal lesions at the C-5, C-6 levels, peripheral neuropathy involving the median or ulnar nerves, or both, and the radial nerve, or hemiplegia, are said to be suitable candidates for this device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Two views of the long opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h3> <p>This adaptation, which is the most complex of those studied, is designed to provide prehension when voluntary wrist-extension power is available (<b>Fig. 4</b>). Quadriplegic patients who retained innervation to the wrist-extensor muscles are said to be appropriate subjects for this type of functional orthosis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Two views of the reciprocal orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <h4>Participating Clinics and Personnel</h4> <p>As an initial step in the activation of the proposed field study, the Committee on Prosthetics Research and Development, through its staff and Subcommittee on Evaluation, selected five treatment centers known to be active and interested in the application of hand splints. These clinics were approached and each agreed to participate in the study. The institutions and personnel involved were:</p> <ol> <li>Duke University Medical Center, Durham, N. C. (Frank W. Clippinger, Jr., M.D.; Bert R. Titus; Felton Elliott).</li><li>Georgia Warm Springs Foundation, Warm Springs, Ga. (Edward Haak, M.D.; H. G. Bowden).</li><li>Highland View Hospital, <a style="text-decoration:none;">*</a> Cleveland, Ohio (Al-vin A. Freehafer, M.D.; Arthur Guilford, Jr., G. A. Guilford and Sons).</li><li>Ohio State University, Columbus, Ohio (Marvin H. Spiegel, M.D.; Lawrence Czap; Charles W. Rosenquist, Columbus Orthopaedic Appliance Co.).</li><li>Veterans Administration Hospital, Hines, Ill. (James F. Kurtz, M.D.; Vladimir T. Liberson, M.D.; Walter J. Piotrowicz, CO.).</li></ol> <h4>Instruction In Fabrication Procedures</h4> <p>The study of the Engen devices was initiated by an instructional course in the three applications to be evaluated. This course was conducted by the developer and his staff at the Texas Institute for Rehabilitation and Research, Houston, Tex., from Dec. 5 to 8, 1966 (orthotists, four days; physicians, one day). Instructional material and fitting check lists were prepared by the developer, <a></a> and used as the basis for the course. A special training session for Mr. Sigars was conducted December 4-6, 1967, after he joined the Rancho Los Amigos Hospital team.</p> <h4>The Study Plan</h4> <p>Concurrent with the recruitment and training of participating clinic personnel, the CPRD staff, in collaboration with the developer, and under the guidance of its Subcommittee on Evaluation, prepared the schedule and data-recording forms for the study. <a></a></p> <p>Essentially, each clinic was requested to seek patients appropriate for applications of the Engen devices. Data related to the fittings would be recorded on the forms developed by the Committee on Prosthetics Research and Development. Each patient fitted was to be followed for a period of 12 months unless treatment was terminated prior to that time. The CPRD staff was to provide liaison with the field clinics as necessary during the course of the study.</p> <h3>Results</h3> <h4>Technique Transferability</h4> <p>With a new fabrication or fitting technique which is said to yield excellent results in the hands of the developer, an important consideration is whether or not the skill and "know-how" involved in the applications can be successfully transferred to others.</p> <p>In the present study the means of achieving this transfer were: (1) Written instructional material prepared by the developer; (2) A course of instruction which included practice in the fabrication of devices; and (3) Follow-up visits made by the developer to each participating facility. Problems encountered locally were analyzed and supplementary instruction given.</p> <p>It was the consensus of the evaluation team as well as that of the participants that the fabrication techniques for the three EPHO adaptations under study were successfully transmitted by these procedures. Moreover, while the orthotists participating in the evaluation were selected and highly skilled, indications were that less skilled technicians could be satisfactorily taught by the same methods.</p> <h4>Patient Fittings</h4> <p><i>The Sample</i></p> <p>During the period of the evaluation program, 22 patients were fitted with the Engen Plastic Hand Orthosis. Distribution in terms of the three adaptations under study were: short opponens orthosis, 7; long opponens orthosis, 3; and reciprocal units, 12.</p> <p>Moreover, data was available on an additional 48 patients distributed as follows: short opponens orthosis, 11; long opponens orthosis, 7; and wrist-driven reciprocal units, 30. These patients were fitted at Hines VA Hospital following the closure of the official phase of the study. Some findings of interest from these additional fittings are included.</p> <p>In the total of 70 fittings reported, 18 were with short opponens, 10 with long opponens, and 42 with reciprocal units, roughly a 2:1:4 ratio. Whether this ratio could be extrapolated to the general population is not known.</p> <p>Typical conditions for which the three versions of the EPHO<a style="text-decoration:none;">*</a> were applied were: (1) short opponens orthosis: rheumatoid arthritis of the hands (<b>Fig. 5</b>); quadriplegia (to prevent deformities and support the hand in a position of function pending fitting of reciprocal units); contraction deformity of the wrist; (2) long opponens orthosis: quadriplegia (as a stabilizing device pending reduction of contractures and fitting with a reciprocal unit) (<b>Fig. 6</b>); or as a base for the addition of self-help devices (<b>Fig. 7</b>); reciprocal units: quadriplegia (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Left, palmar and dorsal views of patient's arthritic hands. Above, left hand fitted Engen short opponens orthosis and Thomas outrigger splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Patient fitted with Engen long opponens orthosis as stabilizing device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Patient fitted with Engen long opponens orthosis with attachment for self-help devices. Note atrophy of thenar cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Patient fitted with reciprocal unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Outcomes</i></p> <p>Results of the fittings in the five participating clinics were variable, success or failure being related primarily to three factors:</p> <ol> <li>Proper selection of patients. In several of the clinics patients were selected under somewhat experimental circumstances, that is, either the motivation of the patients was less than optimal or the anticipated benefit to be derived from the Engen device was marginal. In these instances, the fittings typically proved to be failures.</li><li>Objectivity in the evaluation of outcomes. Two of the clinics participating in the study had devices of their own design which were "competitive" with the Engen items. Personnel of these clinics were of the opinion that the Engen devices provided no features superior to their own devices other than perhaps the telescoping rod on the reciprocal unit application.</li><li>Meticulous care in application and follow-up. Although the Engen Plastic Hand Orthosis is essentially a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: (a) some reshaping of the plastic shell to accommodate atrophy or size discrepancy in the patient's hand; (b) the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ol> <p>Moreover, since the condition of the patient's hand changes with time and with the use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is obviously best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in the care of the patient.</p> <p>Where the foregoing conditions were satisfactorily met, excellent success was achieved in the fittings of the Engen devices. Selected cases which illustrate the applications and outcomes of the three EPHO modifications under study are presented below.</p> <h3>Case Presentations</h3> <h4>Short Opponens Orthosis</h4> <p><i>Case No. 1</i></p> <p>A. M. was a 40-year-old male with a diagnosis of quadriplegia resulting from a physiologically incomplete lesion of the spinal cord at the C-5 level. A short op-ponens orthosis was prescribed for his right, dominant hand with a view to aiding in the restoration of function, and the prevention and correction of deformities. It was hoped that eventually Mr. M. would be a candidate for a right reciprocal unit. The patient was described as having a motivational level of fair and a tolerance to pain that was average.</p> <p>Mr. M. was fitted with a medium-sized orthosis. The suitability of the preformed size and shape was rated as good and the ease of customizing and the clarity and completeness of the instructions for doing so were also rated as good. No special modifications of the shell were necessary for this patient.</p> <p>A. M. was reevaluated at 1, 3, 6, 9, and 12 months following the initial fitting. The efficacy of the splint in achieving the objectives of the fitting was rated as good in all respects. The patient's performance in such activities as turning pages in a book and writing was rated as fair. The performance in feeding and using a toothbrush was cited as being poor. The patient's reactions to the orthosis were good with respect to fit, comfort, and cosmesis, and fair as regards function. During the course of his treatment the patient was given physical and occupational therapy and special instruction in the use of the Engen device. He was also given medication for spasticity which did not involve the hands.</p> <p>The evaluation of the device with regard to this patient remained remarkably consistent throughout the entire 12 months of the test period except that the patient's own reactions to the functional assistance provided by the device declined from fair to poor from the third month on.</p> <p>The outcome in this instance was considered to be excellent, but two other patients, D. R. and J. A., whose initial conditions were remarkably similar, withdrew from the study one and four months, respectively, after the initial fitting. In these two instances the restoration of function achieved with the orthosis was minimal and this factor, combined with low levels of motivation, resulted in the withdrawals.</p> <p><i>Case No. 2</i></p> <p>Patient N. E. was a 60-year-old male with a diagnosis of rheumatoid arthritis of some eight years' duration. He was prescribed an EPHO short opponens orthosis for his right, dominant hand, the objectives being assistance in the restoration of function and the prevention and correction of deformities. His tolerance to pain was described as average, and his skin condition as thin, and his motivational level was said to be good.</p> <p>N. E. was fitted with the large-sized EPHO shell. With regard to the fitting, the suitability of the preform size and shape was rated as good, as were the ease of customizing and the clarity and completeness of instructions. No special modification was necessary initially, but some five weeks later a Thomas outrigger suspension was applied to prevent further subluxation of the metacarpophalangeal (MCP) joints (<b>Fig. 5</b>). Mr. E. was reevaluated at 1, 3, 6, 9, and 12 months following fitting and then left the clinic area taking the provided splint with him.</p> <p>Initially the achievement of objectives involving the prevention and correction of deformities was rated as good, but the restoration of function as poor. Mr. E.'s performance in typical activities of daily living were all rated as poor. The patient's reactions to the device were good with respect to fit, comfort, and cosmesis, but poor as regards function.</p> <p>As Mr. E. continued to wear the experimental device his ratings in all performance activities were raised to fair, and finally to good in such activities as page-turning, writing, and feeding. The patient's rating of the functionality of the device gradually improved until finally it was reported as good.</p> <p>In this fitting the outcomes appeared to be positive from the beginning with respect to the prevention and correction of deformities with gradually increasing benefit in the area of function.</p> <h4>Long Opponens Orthosis</h4> <p><i>Case No. 3</i></p> <p>Patient J. K. was a 21-year-old male. His primary diagnosis was quadriplegia with a spinal-cord injury at the C-5, C-6 levels which was incurred some nine months prior to his inclusion in the evaluation program. He was fitted with an EPHO long opponens orthosis, medium-size, to the right hand which was less impaired than the left. His hands were atrophied, especially in the thenar-cleft area, and he had a slight lateral palmar drift on the (right) hand fitted. The patient's motivational level was said to be good and his pain tolerance average. The objectives of the fitting were restoration of function, and prevention and correction of deformities in the hope that he might eventually be fitted with a reciprocal orthosis.</p> <p>The application of the device proceeded without difficulty except that the device was somewhat too large for the patient's atrophied thenar-cleft area. The splint tended to displace itself into this area. Three weeks after the initial fitting a reduction in the cock-up angulation was recommended by the developer, together with the addition of a T-bar to abduct the thumb and a dorsal strap for better retention.</p> <p>The patient preferred the EPHO splint to his previously worn Royalite device and requested that the EPHO be modified to include the self-aid attachments worn on the earlier splint. The device was subsequently reinforced with a Monel metal piece and has held up well since that time. The patient's flexed lateral palmar drift was held in proper position by the orthosis.</p> <p>At the one-month follow-up of this patient the ratings of outcomes were generally poor to fair with only the patient's reaction to the cosmesis of the device being designated as good. However, steady improvement occurred throughout the follow-up period, and by 9 months after initial fitting the device was rated as good in all characteristics specified in the evaluation program. Thus, in this instance, the outcomes of fitting the Engen plastic hand orthosis must be considered as excellent.</p> <p><i>Case No. 4</i></p> <p>On another patient, F. G., with a somewhat similar disability, the results of the fitting were considerably less positive. This patient was a 40-year-old male with complete transverse severance of the spinal cord at the C-6, C-7 levels. The injury to this patient had occurred some six and a half years prior to the present study and he had had a surgical transfer of the brachioradialis tendon to the wrist extensors on his left hand several years previously. The hand tended to go into marked radial deviation on voluntary extension of the wrist. He could raise his elbows and shoulders bilaterally. He had muscle spasms.</p> <p>F. G. was fitted with a medium-sized long opponens orthosis and it was immediately noticeable that the splint would not hold the patient's marked radial deviation. At the developer's suggestion the cock-up angle of the splint was reduced to prevent creeping and a plastic clip added on the proximal medial side. A lateral Velcro strap was added to pull the ulnar side of the wrist toward the radial side, and an elastic sling was added to correct the flexion of the interphalan-geal (IP) joint of the thumb. The patient was to be considered for a reciprocal orthosis if his contractures could be reduced. The patient's motivational level was rated as poor with respect to any type of splinting.</p> <p>The outcomes of this fitting initially were also mixed and failed to show appreciable improvement, particularly with regard to function, over a 6-month follow-up period. The patient was then taken off the program at his own request.</p> <h4>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h4> <p><i>Case No. 5</i></p> <p>Patient V. C. was a 42-year-old male who had sustained a spinal-cord injury at age 26. His primary diagnosis was "dislocation and compression of the spinal cord at the C-5, C-6 levels with complete paralysis." With no prior experience with orthotic devices, he was fitted with a reciprocal unit on his right, dominant hand. His motivational level was rated as good, but his pain tolerance was given as low. The objectives of the fitting were restoration of function and prevention and correction of deformities.</p> <p>The fitting utilized a large reciprocal orthosis and finger pieces but a medium-sized forearm piece. The component sizes were considered to be good for this patient. However, the shape of the plastic shell did not provide good support for the arch of the hand or conform well to the thenar-cleft area. A thumb sling and a middle-finger IP stabilizer were added. A later review of this case indicated that the MCP and the wrist joints were incorrectly placed. With these conditions the patient had no desire to try and use the splint and did not wish to keep it. Replacement of the malpositioned joints effected a marked improvement in the function of the device and the patient's acceptance of it. This high level of performance and acceptance was maintained throughout the remainder of the patient's 12-month participation in the study. In this case, obviously the difference between success and failure hinged on the proper joint positioning, emphasizing the importance of this aspect of the fitting. This type of experience was repeated with a number of other patients in the evaluation.</p> <p><i>Case No. 6</i></p> <p>Patient W. M. was a 47-year-old male who sustained a spinal-cord injury approximately one year prior to being fitted with the Engen orthosis. His diagnosis was given as "compression of cord, level C-5, C-6 incomplete, C-7 complete." Mr. M.'s motivational level was said to be good, but his pain tolerance was given as low. He was fitted with a reciprocal orthosis on his right, dominant hand, the objectives being restoration of function, and prevention and correction of deformities.</p> <p>The initial application of the device seemed to proceed satisfactorily, the component parts being a large plastic shell, a larger finger unit, and a large forearm piece. The sizes and shapes of the various components seemed to be appropriate. Three days later a "knuckle bender" was added because of tightness of the MCP joints and a modified Oppenheimer splint was fitted to increase the limited range of wrist extension and thumb abduction.</p> <p>A later review of this case indicated that the joint hinges had been incorrectly positioned and this deficiency was corrected. Again a dramatic improvement in the achievement of fitting objectives, functional level and patient acceptance, was evident, although this subject's function was not as good as that of the previous patient. This case again illustrates the importance of joint positioning and indicates the use of the Engen basic equipment as a module to which other accessories might be added.</p> <h3>Summary and Recommendations</h3> <p>In the present study it would appear evident that orthotists with prior experience and skill in the fabrication of hand splints can be taught to apply the EPHO variations successfully. In this connection the instructional manual and fitting checkout sheets developed in conjunction with the field study provided an excellent basis for the transfer of techniques from developer to field orthotists. However, this written material is not regarded as an adequate substitute for direct person-to-person instruction. Moreover, a follow-up visit to each of the clinics following initial fittings helps to insure that the techniques taught are being properly applied and assists in the solution of specific local problems.</p> <p>The outcomes of the field fittings of the Engen equipment were mixed, positive results being related primarily to three factors: (1) proper selection of patients, including consideration of motivational factors; (2) meticulous care in application and follow-up of the devices; and (3) objectivity in evaluating outcomes. Where these considerations were observed, the successful outcomes achieved support the developer's claims for the device.</p> <p>Fitting results for each subject in the study showed no significant changes after 6 months' wear of the Engen device. Hence, consideration might be given to reducing the follow-up period in similar future studies from 12 to 6 months.</p> <h4>The Devices</h4> <p><i>Prescription Criteria</i></p> <p>The criteria for prescription of the Engen adaptations as set forth above were re-affirmed by the results of the field study. The following additional comments also emerged:</p> <ol> <li>Short Opponens Orthosis <ul><li>a. has been found useful as a stabilizing splint in several instances of postsurgical management;</li> <li>b. has been used in providing patients with various self-help devices as attachments to the basic shell;</li> <li>c. with special modifications has been used in rheumatoid arthritic cases to help prevent ulnar and radial finger drift and align the fingers in proper position for finger prehension;</li> <li>d. has been used as the stabilizing splint pending evaluation for application of a reciprocal unit.</li></ul></li><li>Long Opponens Splint with Extension Arm Support <ul><li>a. has also been utilized for the same applications as the short opponens orthosis above.</li></ul></li></ol> <h4>Specific Findings</h4> <p>Specific findings relating to the design and applications of the EPHO devices were:</p> <ol> <li>Although the Engen Plastic Hand Orthosis is ostensibly a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: <ul> <li>a. some reshaping of the plastic hand shell to accommodate atrophy or size discrepancy in the patient's hand;</li> <li>b. the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ul></li><li>In the installation of the EPHO reciprocal orthosis, great care must be exercised in the location of the joint axes.</li><li>Since the condition of the patient's hand changes with use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in patient care.</li><li>The telescopic rod feature of the reciprocal unit was frequently cited as a most significant new characteristic of this type of orthosis.</li><li>Although definitely related to the level of experience gained in the application of the EPHO devices, saving of the orthotist's time was a significant feature of the system.</li><li>Some deficiencies in the design and materials of the EPHO were noted: <ul> <li>a. The range of three sizes provided initially were considered inadequate but the addition of the fourth (medium-large) size virtually eliminated this problem.</li> <li>b. A very common problem was that of fitting the hand shell to atrophied thenar-cleft musculature. The likelihood that this problem would be encountered and measures for adapting the shell to meet it should be emphasized in the instructional material.</li> <li>c. Some problems were encountered with stripping and bending of the telescopic rods.</li> <li>d. Some tendency for the shells to revert to their original shape after heating and modification was reported. However, in general, the physical properties of the splints were considered adequate to last an indefinite period with proper care and maintenance.</li></ul></li></ol> <p>In conclusion, the field evaluation of the EPHO adaptations clearly revealed that the devices are useful additions to the armamentarium of orthotic items available for the treatment of patients with disabilities of the hand. It is recommended that the outcomes of this study be forwarded to the prosthetics-orthotics schools with a view to the possible inclusion of instruction in this system as part of the orthotics curriculum.</p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H, <i>Upper extremities orthotics</i>, Charles C Thomas, Springfield, Ill., 1965.</li> <li>Bisgrove, J. G., <i>A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report</i>, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 1954.</li> <li>Engen, Thorkild J., <i>A plastic hand orthosis</i>, Orthop. Pros. Appl. J., 13:2, September 1959.</li> <li>Engen, Thorkild J., <i>A "modification" of a reciprocal wrist extension-finger flexion orthosis</i>, Or-thop. Pros. Appl. J., 14:1, March 1960.</li> <li>Engen, Thorkild J., <i>Instructional manual for a reciprocal wrist extension-finger flexion orthosis</i>, Baylor University, Houston, Tex., 1: April 1968.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, long opponens orthosis,</i> unpublished.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, short opponens orthosis</i>, unpublished.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., <i>Clinical evaluation of prosthetic and orthotic devices and techniques</i>, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Vorchheimer, Heidi, <i> Summary of fittings - Engen hand orthoses</i>, Prosthetic and Orthotic Studies, New York University, June 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>Footnote</b></td></tr><tr><td class="clsTextSmall"> Utilizing the basic Engen items as modules to which accessory equipment was added if indicated by the needs of the patient.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Instructional manual for a reciprocal wrist extension-finger flexion orthosis, Baylor University, Houston, Tex., 1: April 1968.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, long opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, short opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Unfortunately, the Highland View Hospital team had to withdraw prior to the commencement of the study. It was replaced by a team from Rancho Los Amigos Hospital consisting of E. Shannon Stauffer, M.D., and Dale Fries, orthotist. In the course of the study, Mr. Fries transferred to another position and was replaced by Mr. Charles Sigars.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vorchheimer, Heidi, Summary of fittings - Engen hand orthoses, Prosthetic and Orthotic Studies, New York University, June 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>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H, Upper extremities orthotics, Charles C Thomas, Springfield, Ill., 1965.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bisgrove, J. G., A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 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>Hector W. Kay, M Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_013/spring69-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_013/spring69-14.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_013/spring69-15.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_013/spring69-16.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_013/spring69_17.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_013/spring69_18.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_013/spring69-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_013/spring69-20.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 Clinical Evaluation of the Engen Plastic Hand Orthosis Creator An entity primarily responsible for making the resource Hector W. Kay, M Ed. * https://staging.drfop.org/files/original/854528621eb80bd8a9b4f7349f5d48a6.pdf e7ecf8eb166fd1de014a65d9a4e19c54 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_020.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 20 - 23 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_020.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>Conclusions of a Conference on Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>Following the preparation of the <i>Preliminary Design Analysis of Linkage Feeders </i>by Prosthetic and Orthotic Studies of New York University,<a></a> it seemed desirable to explore the significance of the design similarities and differences identified in the NYU report.</p> <p>Accordingly, a Workshop on Linkage Feeders was organized and conducted under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development. Participants in the workshop conference, which was held at the University of Michigan, Ann Arbor, Mich., July 26-27, 1965, included representatives from the five centers whose feeder designs were discussed in the NYU analysis, plus unattached engineering and other consultants.<a style="text-decoration:none;">*</a></p> <p>At the conference, the design and applications of linkage feeders were discussed in considerable detail, both with respect to the major components (chair-attachment assemblies, proximal and distal links, rocker-arm assemblies, and troughs) and the device as a whole. In the following presentation of major points emerging from the discussions, it will be noted that while there were areas of disagreement, a community of agreement on many considerations was evident.</p> <h4>Adjustment</h4> <h4><i>Availability to the Patient</i></h4> <p>A characteristic of the University of Michigan and the Rancho Los Amigos Hospital systems is that provisions for adjustment are retained throughout the life of the orthoses. At the other centers, apparently, a temporary feeder is used initially, with adjustments made during the course of training by physician, therapist, or orthotist. Before the patient leaves the center, the optimal adjustments are frozen, so to speak, in a permanent unit.</p> <p>A basic difference in philosophy is evident here. The belief at the University of Michigan is that the patient's family can be taught to adjust the feeder and should have the privilege of doing so; for example, to accommodate changes in the status of the patient's muscular torques with time. The belief at the other centers is that the optimal feeder geometry established during training may be lost with patient-family manipulation.</p> <p>Since proponents of both approaches are apparently satisfied with the results achieved, no categorical rule would appear to apply. To the impartial observer, retention of adjustability would seem desirable with, perhaps, provision for locking the adjustment features, if this restriction were found necessary.</p> <h4><i>Precision</i></h4> <p>Theoretically-and perhaps actually-the threaded-screw adjustments of the University of <!--Page 21--> Michigan model provide the means for securing more precise adjustments than any of the other units.</p> <p>There appears to be no question that the provision of an efficient system of balances and biases is critical to the patient's performance and increases in importance with the extent of disability.</p> <p>There is, however, considerable question concerning the degree of precision achieved or required in these units. Since motion of the forearm in the trough shifts the center of gravity of the forearm in relation to its axis of rotation, as do objects of different weights held in the hand, optimal adjustment would seem to be dynamic rather than static. Moreover, desired adjustments are in relation to a particular configuration of trough and rocker-arm assembly, for example, and this configuration itself may not represent the optimal design. It is noteworthy, though, that all the systems reviewed appeared to be very useful devices, despite these lacks.</p> <h4>Extent of Use</h4> <p>Texas Rehabilitation Center apparently applies linkage feeders primarily or solely for use with lapboards. Most of the other institutions plan more extensive use, particularly that involving activities at tables or desks, with a strong bias toward vocational rehabilitation or an approximation of normalcy. This difference in approach obviously influences feeder design and application, particularly with respect to the "reach" provided and provisions for securing adequate trough height to avoid disturbing objects on the table or desk. Total linkage length, the use of drop rather than straight swivel arms, and curved rather than straight distal links, may all be affected by these considerations.</p> <p>On this question of limited <i>vs. </i>extended feeder usage, the latter approach (maximum function and use) seems preferable unless the goals are unrealizable.</p> <h4>Link Lengths and Ratios</h4> <p>In mechanical terms, the maximum feeder reach is the sum of the lengths of the proximal and distal links, while the minimum reach is the difference between the two lengths. Kinematically, the two links should be of equal length.</p> <p>A considerable variety of link lengths and ratios was evident in the five feeders reviewed, each apparently representing a compromise between kinematic and practical considerations, that is, the need to reduce the length of the proximal links to permit passage through doorways without interference by the projecting joint between the proximal and distal link. All compromises apparently worked satisfactorily. However, the maximum length for the proximal link commensurate with noninterference would appear desirable to reduce the stress on bearings.</p> <h4>Bearings and Friction</h4> <p>Four of the feeders reviewed incorporated ball bearings to reduce joint friction while only one (Texas Institute for Rehabilitation and Research) used needle bearings. However, since these latter were said to be strong and durable and result in smaller joints, they may well be the bearings of choice.</p> <p>There was some difference of opinion concerning the need for antifriction bearings at the rocker-arm assembly (for trough function). Some conferees deemed a small amount of friction (for dampening) desirable here (for some patients); others disagreed. An obvious solution to meet both contingencies would be the incorporation of antifriction bearings, with nylon washers available for insertion if friction were desired.</p> <h4>Distal Links</h4> <p>Straight, angled, and curved distal links were represented in the feeders reviewed. Functionally (reduced interference between distal link and trough) and aesthetically, the curved links appeared to be superior.</p> <h4>Trough Pivots and Forearm Position</h4> <p>Despite the variety of rocker-arm assembly designs and trough-pivot positions (offset, below the trough, and forked to each side of the trough), the function of all designs appeared to be reasonably satisfactory. Independent engineering opinion tended to favor a forked pivot supporting the trough halfway through the thickness of the forearm rather than below it.</p> <!--Page 22--> <p>Forearm motion (sliding) within the trough was considered. The value of the typical elbow disk (dial) in stabilizing the forearm was questioned by the engineering consultants at the workshop. A strap that pivots on an axis passing through the anatomical axis of the elbow (as in the University of Michigan design) was considered to be more satisfactory. Velcro was suggested as a possible means for retaining the forearm in the trough.</p> <h4>Cosmesis</h4> <p>Feeders are rather conspicuous, mechanical, utilitarian devices. Hence the stress placed on cosmetic considerations by the conferees was all the more noteworthy. Two factors are apparently involved: <i>first, </i>the appearance of the feeder itself, that is, graceful lines, lack of obtrusiveness, etc.; <i>second, </i>the simulation of normalcy in use, for example, sitting at the table to eat a meal rather than using a lap-board.</p> <h4>An Appropriate Name</h4> <p>So-called linkage or ball-bearing feeders are obviously more than this name connotes. A less awkward term that would more appropriately define the characteristics and function of the device would be very desirable. Numerous suggestions were made by the conferees, including the term "balanced forearm orthesis" developed by Dr. Robert L. Bennett at the Georgia Warm Springs Foundation. However, none of the suggestions aroused any enthusiasm.</p> <h4>Potential Users</h4> <p>An attempt was made by the workshop participants to estimate the number of persons who would derive benefit from the use of a feeder.</p> <p>It was mentioned that a large but unspecified number of postpoliomyelitis patients would require such devices for the remainder of their lives.</p> <p>As far as new cases were concerned, the five centers represented at the workshop fitted a total of approximately 150 cases per year. It was estimated that an equal number of patients who might benefit from feeders were not being fitted because of lack of publicity concerning their value or lack of knowledge concerning applications. The conferees were also of the opinion that although new poliomyelitis patients are rare, survivors of automobile, diving, trampoline, and other accidents resulting in high spinal-cord injuries are increasing. In general, these patients require more sophisticated feeders than those developed originally for victims of poliomyelitis.</p> <h4>Need for Further Research</h4> <p>All the feeders reviewed appeared to be of fairly adequate design, and all appeared to be fairly useful devices. Presumably, each device could be improved by incorporating features in other designs, or by taking cognizance of suggestions advanced during the workshop. However, further research to develop a new design-a "super feeder"-does not seem indicated at the present time.</p> <h4>Need for Education</h4> <p>If, as postulated at the workshop, numerous patients with high spinal-cord injuries (who could benefit from the use of a feeder) are not being provided with the device, an obvious educational need exists. To meet this need, two elements are involved: <i>first, </i>information concerning the existence and usefulness of linkage feeders should be brought to the attention of physicians and institutions treating appropriate patients; <i>second, </i>hospital and rehabilitation personnel should be trained in the application and adjustment of the device.</p> <p>To these ends, it was considered that:</p> <ol> <li>Publicity might profitably be given to the NYU review and to the deliberations of the workshop conference.</li><li>Announcement should be made that commercially made feeders closely resembling the Rancho Los Amigos Hospital model described in the NYU report are available.<a style="text-decoration:none;">*</a> </li><li>Announcement should be made that instructional material dealing with the application and adjustment of feeders has been prepared by the Georgia Warm Springs Foundation<a></a> and Rancho Los Amigos Hospital<a></a>, and that reports on design principles have been published by the University of Michigan.<a></a></li><li>Based on available experience, information concerning feeder design principles and applications might well be included in one or more courses offered by the Prosthetics and Orthotics Education Program.</li></ol> <p><b>References:</b></p> <ol> <li>Georgia Warm Springs Foundation, <i>Instructions forbalanced forearm orthesis and research kit.</i></li> <li>Georgia Warm Springs Foundation, <i>Instructions foruse of balanced forearm orthesis kit.</i></li> <li>New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, <i>Preliminary design analysis of linkage feeders, </i>May 1965.</li> <li>Rancho Los Amigo Hospital, <i>How to fit and adjust aball bearing feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>How to fit and adjust asuspension feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>Uses and limitationsof mobile arm supports.</i></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Theory of"feeder" mechanics, </i>Am. J. Phys. Med., <b>42:3, June </b>1963, pp. <b>113-139.</b></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Designrefinement of the linkage feeder, </i>Arch. Phys. Med., 44, November 1963, pp. 609-615.</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>7.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Theory of'feeder' mechanics, Am. J. Phys. Med., 42:3, June 1963, pp. 113-139.</td></tr><tr><td class="clsTextSmall"><b> 8.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Designrefinement of the linkage feeder, Arch. Phys. Med., 44, November 1963, pp. 609-615.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Rancho Los Amigo Hospital, How to fit and adjust aball bearing feeder.</td></tr><tr><td class="clsTextSmall"><b> 5.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, How to fit and adjust asuspension feeder.</td></tr><tr><td class="clsTextSmall"><b> 6.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, Uses and limitationsof mobile arm supports.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Georgia Warm Springs Foundation, Instructions forbalanced forearm orthesis and research kit.</td></tr><tr><td class="clsTextSmall"><b> 2.</b> </td><td class="clsTextSmall">Georgia Warm Springs Foundation, Instructions foruse of balanced forearm orthesis kit.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Jaeco Orthopedic Specialties, Box 616 M-R5, Hot Springs, Ark. 71919; J. A. Preston Corp., 71 5th Ave., New York, N.Y.; Orthopaedic Supplies Co., Inc., 9126 East Firestone Blvd., Bldg. R, Downey, Calif.; Rehabilitation Equipment, Inc., 175 E. 83rd St., New York, N. Y. 10028.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Persons attending the workshop were: Herbert Elftman, Sidney Fishman, as co-chairmen; Edward Haak, James Poulson, of the Georgia Warm Springs Foundation; Robert C. Juvinall, James W. Rae, Jr., Edwin M. Smith, of the University of Michigan; G. Hartmann, Nancy Verdon (Appoldt), of New York University; Alice Garrett, Patrick Marer, Betty Yerxa, of Rancho Los Amigos Hospital; Thorkild Engen, of Texas Institute of Rehabilitation and Research; Linda Parker, Randolph Witt, of Texas Rehabilitation Center; Hans A. Mauch, Colin A. McLaurin, Eugene F. Murphy, as engineering consultants; Hector W. Kay, James R. Kingham, A. Bennett Wilson, Jr., of the staff of the Committee on Prosthetics Research and Development. (Mr. Wilson also served as an engineering consultant.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, Preliminary design analysis of linkage feeders, May 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>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> 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 Conclusions of a Conference on Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/76945f6516dcc0545d2b91cfc6caeb8b.pdf c7a89a78b48b8aa9065dc973197081da https://staging.drfop.org/files/original/8272f870d623593975109366a1d714b7.jpg b08648bc765812c399bac1c19cce2712 https://staging.drfop.org/files/original/4b7fd07801fb1d9d0ea15226722773a1.jpg 31e1b3419fb5675d97f4c3ca9ddaef2b https://staging.drfop.org/files/original/648d969a13a9bfcbf9776e7f897bb027.jpg e6e25a69ad3a0eecb8b14f7d3cc6e198 https://staging.drfop.org/files/original/b2768987a6f827aa82820f33774881c2.jpg 3263b9f8e8039406c257c4297c706577 https://staging.drfop.org/files/original/565d4cdb0cb7c3928f0cc609eecabbad.jpg 23623942433011b5212537b43ff50a42 https://staging.drfop.org/files/original/bf659b0d50d8c30b699e980c1f46cfc3.jpg 2a10c2a368eda3fd3271e2c3d0b654bf https://staging.drfop.org/files/original/9ce4a3a221bb7e80fe9d0ac6e9038998.jpg a5593d13ccca338b6ac13c4fa60b0c30 https://staging.drfop.org/files/original/35f43c3f17c550391dc44c8477510bc7.jpg ee2788f57195e89a29eb725640ddf569 https://staging.drfop.org/files/original/1da9a7a00eb343939657082c12fdb22c.jpg 909ebcfb948c3e308eeea4c9c6129fca https://staging.drfop.org/files/original/107f8865b76201e760a87b25a700925f.jpg ac9a63d4f56b0bfe2d3d809c5be4b62a https://staging.drfop.org/files/original/da057c8bdbf8ceb1905f88c4011035d6.jpg 1364e32658239dc95d96ff1f793bc60e https://staging.drfop.org/files/original/142e0aebc5734f02b98738402171591a.jpg 23e4623a64eb2c8d4be159bc6b0f03ac https://staging.drfop.org/files/original/60c955ee13d73d7d06dd7a1ca0a291f1.jpg f9b06353c26a48c7556434f08d6d1a30 https://staging.drfop.org/files/original/d5169c0556a5fc30c968ca2e1bee5b6d.jpg 6222c5563bd9f4c29aa01964ed644fcd https://staging.drfop.org/files/original/21aa54f2cc58f1d7bbbf371460f09293.jpg 91d6c232ce2547fd4a92b2da4bdfa3ce https://staging.drfop.org/files/original/43a8e159de0c26aa574ccfee54b66866.jpg d697bc4196132af4b6a33226ea167054 https://staging.drfop.org/files/original/bbd717fc89481bf516d899e84e674930.jpg fa7da43c15df8f4730367e7d1a28d083 https://staging.drfop.org/files/original/095050e87ef41d2f053cf7fdb2d3f9d8.jpg 8d867d08333393bb2170844cf6d76586 https://staging.drfop.org/files/original/5fd0bdf92a32a8d7b20419407e0a6e07.jpg 0d975f91d4cbfda7367c753e55bfbd73 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_031.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 31 - 87 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Systematic research in limb prosthetics has, during the past decade, produced not only better prostheses but also improved techniques for their application. Similarly, programs of prosthetics education have provided a new generation of physicians, prosthetists, therapists, and associated professional personnel with a greater appreciation of the amputee's physical and emotional needs and a greater understanding of how best to meet them. But ultimately research and education in the fitting of artificial limbs have real worth only to the extent that the individual amputee can accept and utilize the prosthesis provided him.</p> <p>The degree of acceptance and utilization is governed ultimately by the single consideration : <i>Of what value is the prosthesis to the amputee?</i> While the wearer himself must provide the essential elements of this valuation, his feelings and attitudes about other matters can significantly affect his opinions and judgments about the worth of his prosthesis. Accordingly, data which included both subjective amputee reactions and more objective ratings and judgments of independent observers were collected. Properly analyzed, these data provide a firm assessment of recent achievements in arm prostheses as well as some measure of the effectiveness of the techniques now recommended for the management of arm amputees.</p> <p>The classification, analysis, and interpretation of the more subjective portions of the data (those collected by interrogation of amputee subjects) make up Part 1 of this two-part discussion. Presentation and support of the more objective material (that obtained by tests and observation) constitute Part 2. All of the data reported were recorded on the special forms illustrated in Appendices IIIB and IIIC of Section I of this series (Artificial Limbs, Spring 1958, pp. 32 through 39).</p> <p>The opinions and statements reported in Part 1 and the test results and observations presented in Part 2 relate to the meaning and the value of program prostheses in various tasks normally encountered in everyday life. As a perceptive reader will note, the term "activities of daily living" is used throughout this article to denote that specific context and is not meant to be synonymous with the term "ADL," which through increasing currency has become part of the professional jargon of physical and occupational therapy. As used here, it encompasses a broader range of activities than it does when generally used in the treatment of human disability. Generally ADL is limited to tasks relating to personal independence and self-care in the home; in our context, recreational and vocational activities are included.</p> <h3>Part 1. Amputee Opinions Concerning Utility of Arm Prostheses in Activities of Daily Living</h3> <p>In general, the prosthesis that will be most valuable to the arm amputee will be the one with which he can perform, most efficiently and with the least effort and discomfort, the greatest number of useful activities ordinarily performed with the normal upper extremity. Thus an evaluation of an arm prosthesis can be based upon the usefulness of a prosthesis to the patient as indicated by his need for it in performing daily activities, the activity level of the patient with respect to the number of activities which he performs with his arm, the ease with which he uses the prosthesis, and the frequency with which he uses it for the performance of activities which are important to him.</p> <p>To obtain amputee reactions concerning the general utility of arm prostheses, the participating subjects were intensively interviewed, and the essential data were recorded on two sets of questionnaires. One set was used to record amputees' opinions of the usefulness of their arms in activities of daily living, the activity level as regards the number of different activities they performed, and the degree of ease or difficulty with which they were able to use their prostheses. The second set of questionnaires was used to collect data concerning the use of prostheses in 20 selected bimanual activities, specifically the frequency with which these activities were performed and the importance to the amputee of being able to perform these activities. With certain minor exceptions, the interrogation was conducted with respect both to the old prosthesis (Evaluation I) and to the new (Evaluation II). The time lapse between the two interviews varied for individual amputees; it was never less than six months for any, as much as 18 months for a few, and approximately 12 months for the average case.</p> <h3>Usefulness, Activity Level, and Ease of Use in Activities of Daily Living</h3> <p>In view of the complexities of everyday human activities, almost any attempt to study the circumstances affecting prosthetic utilization is difficult. As a practical approach to the problem, however, the subjects were queried in a pattern designed to elicit their opinions concerning the value of both their old and new prostheses in the key activity areas of eating, dressing, work, social and recreational functions, and home tasks.<a style="text-decoration:none;">*</a> To determine general usefulness, the amputees were asked to rate their prostheses (first the old and then the new) as essential, very useful, of limited use, of no use, or as a hindrance, the purpose being to establish the amputees' own valuations of their prostheses in performing activities in the five activity areas. Secondly, the subjects rendered their own estimates as to the relative number of activities performed with old and with new prostheses, again with respect to the five key areas of activity. Finally, the subjects were asked to estimate the relative ease with which their old and new prostheses could be used in each of the same five areas.</p> <p>The questionnaires regarding usefulness, number of activities performed, and ease of performance with both old and new prostheses were applied to all available types of upper-extremity amputees, unilateral and bilateral. Because the problems of the bilateral arm amputee differ from those of the unilateral, and because the number of available bilateral cases was too small to have statistical significance, the results for 349 unilateral subjects are treated first, those for the 10 bilaterals in a separate section.</p> <h4>Unilateral Subjects</h4> <p>Among unilateral arm amputees especially, the level of use to which an arm prosthesis is put is determined to a considerable extent by the ease and convenience of performance with the prosthesis as compared with the ease and convenience of performance without it or as compared with the ease and convenience of not performing at all. If a particular activity is too difficult or too time-consuming for a given unilateral arm amputee to perform with his prosthesis, he will either avoid it completely or else find some other way of getting it done. If he elects to accomplish the activity without using the prosthesis, he may do so in any of several ways:</p> <ol> <li>He may use the remaining sound hand, with or without assistance from other parts of the residual anatomy or from external objects. Unilateral arm amputees commonly perform with one hand many activities which under normal circumstances would be bimanual (e.g., tying necktie or shoelaces).</li><li>He may use special devices and techniques (e.g., various tools intended for one-handed performance of tasks ordinarily bimanual), again with or without assistance from some other available source.</li><li>He may prevail upon another person either to provide assistance or to perform the task for him more or less completely.</li></ol> <p>Although any one of these alternatives may serve the purpose of accomplishing essential activities, none of them suggests adequate restoration of loss, either in terms of true personal independence or in the sense of normal appearance. In addition, factors such as temperament, disposition, motivation, and habit patterns further influence the simple "ease-difficulty" premise of prosthetic utilization. Though the true state of affairs in any particular case is a highly complicated one, there can be little doubt that the inherent "usefulness" of the prosthesis is one of the prime factors in determining the number and kinds of purposes to which an artificial arm will be put. This first series of studies was therefore designed to discover the activities for which prostheses are used by amputees with unilateral arm loss at various levels and to delineate any changes in use patterns properly attributable to the new types of prostheses fitted during the NYU Field Studies.</p> <h5><i>Eating</i></h5> <p><i>Usefulness</i>. As regards eating, unilateral below-elbow amputees generally thought well of their old prostheses, above-elbow subjects had a considerably lower opinion of their arms, and shoulder-disarticulation amputees viewed their prostheses as being of relatively little value. In almost all cases, the amputee rated the new prosthesis more useful than the old in eating. For all types of amputees, there were fewer opinions that the prosthesis was of "no use" or "a hindrance" and a greater number of opinions that it was "very useful" or "essential." While this shift in opinion was characterized primarily by a considerable decrease in the proportion of unilateral amputees (of all types) who considered their prostheses of "no use" or "a hindrance," there was also an increase in the number of those considering the prosthesis "very useful" or "essential."</p> <p>Of major significance is the fact that even with the newer arms the majority of unilateral amputees (58 percent of the below-elbow amputees, 83 percent of the above-elbow amputees, and 96 percent of the shoulder-disarticulation subjects) felt that the prosthesis was of limited use or no use in eating. Since only 41 percent of the below-elbow amputees, 15 percent of the above-elbow amputees, and 4 percent of the shoulder-disarticulation subjects considered their new prostheses essential or very useful in eating activities, it must be concluded that, although there was some increase in usefulness in the "program" prostheses, considerably greater improvement is necessary if the artificial arm is to have a significant influence upon the eating activities of the majority of unilateral arm amputees. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Reports from all unilateral amputee groups indicated that the number of eating activities increased for a significant number of amputees while very few subjects experienced a decrease. The increase in usage was greatest for shoulder-disarticulation amputees (45 percent), less marked for the below-elbow group (34 percent), and least for above-elbow amputees (28 percent). <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. As might be expected from the foregoing, a significant number of amputees of all types reported that eating activities were easier with the new prosthesis than with the old, although the increase in facility for the below-elbow and above-elbow groups was less marked than for the shoulder-disarticulation amputees. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 1</b>, based on responses from 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation ampu- tees, presents a composite picture of the specific eating activities for which unilateral amputees of various amputation levels said they used their prostheses. Since the list of activities was compiled from amputees' responses to the unstructured request <i>List activities for which you use your [new] prosthesis</i>, and since in the experience of the authors arm amputees commonly use their prostheses more extensively than they can recall, it may be assumed to be minimal both with respect to number of activities and to incidence of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prime significance of these responses lies in their indication of use potential of the prosthesis. For example, the fact that in opening a soda bottle some below-elbow, above-elbow, and shoulder-disarticulation amputees can and do hold the bottle with their terminal device suggests that this activity is not particularly difficult and that it could be performed by most amputees. Why, then, do some amputees prefer to use one hand only or to hold the bottle between the knees to take off the cap? Such questions are worthy of more intensive investigation than was possible in the NYU Field Studies.</p> <h5><i>Dressing</i></h5> <p><i>Usefulness</i>. Amputees' opinions concerning the usefulness of the prosthesis in dressing show a pattern somewhat similar to that found in eating. There is a general shift of opinion toward the positive end of the scale, but the extent of the change varies with amputee type. It is slight in the below-elbow group, somewhat greater in the above-elbow group, and most marked among shoulder-disarticu-lation amputees. When the percentage of amputees who considered the prosthesis essential or very useful is employed as the basis of comparison, the data for new vs. old arm were: below-elbow, 63 percent vs. 59 percent; above-elbow, 24 percent vs. 14 percent; shoulder disarticulation, 17 percent vs. zero. Although because of the small number of subjects involved the data on the shoulder-disarticulation group must be interpreted cautiously, there are definite indications that a significant number of amputees considered the new prosthesis more useful than the one worn previously. It is also apparent that most groups consider a prosthesis <i>more useful for dressing than for eating</i>. The comparative percentages of amputees who considered the new prosthesis either essential or very useful were—below-elbow: dressing, 63 percent, eating 41 percent; above-elbow: dressing, 24 percent, eating 15 percent; shoulder disarticulation: dressing, 17 percent, eating 4 percent. These differences may be attributable to the larger number of discrete tasks involved in dressing as compared with eating. Despite the improved sentiment toward the usefulness of the program arms, however, a considerable proportion of unilateral amputees of all types (below-elbow, 37 percent; above-elbow, 76 percent; shoulder disarticulation, 83 percent) still considered these prostheses of limited use, no use, or a hindrance. Again it is obvious that much room for improvement still exists, particularly for the more severely handicapped above-elbow and shoulder-disarticulation groups. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. An increase in the number of dressing activities performed with the prosthesis was reported by all amputee groups. The proportion of amputees indicating increased use of the prosthesis ranged from 28 percent of the below-elbow category to 38 percent of the shoulder-disarticulation sample. An insignificant number reported decreased usage. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. Since extent of use is undoubtedly related to ease of use, it is not surprising to find that a high proportion of the amputees considered dressing activities easier to perform with their new prostheses than with their old. Easier operation was reported by 52 percent of the below-elbow, 42 percent of the above-elbow, and 55 percent of the shoulder-disarticulation subjects. Very few subjects at any amputation level reported greater difficulty of operation with the program prosthesis, although almost one in twelve below-elbow amputees fell into this category. The use of more complex terminal devices and the change from soft (leather) to hard (plastic) sockets may in some cases have contributed to this minority opinion. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 2</b> presents a tabulation of specific dressing activities in which unilateral arm amputees reported performance with their prostheses. Since this listing is based upon the responses of the subjects to open-end questions, it should be considered minimal and indicative rather than comprehensive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major significance of the data in <b>Table 2</b> lies in their indication of the use potential in existing prostheses. Equally important, however, is the corollary question, <i>Why is this potential not fully utilized by amputees? </i>For example, 88 below-elbow, 51 above-elbow, and 5 shoulder-disarticulation amputees claimed that they held one end of a necktie with the prosthesis while they tied the knot with their "good" hand. This circumstance would suggest that the activity is perfectly feasible for all three amputee types and that it might almost be considered a "typical" or "normal" prosthetic activity. Nevertheless, the fact remains that a considerable number of amputees tie their neckties using the "good" hand alone. Presumably it is "easier" or more convenient for them to employ the one-handed method, but whether the reason is related to prosthetic difficulty, lack of motivation to use the prosthesis, or prior habit pattern is not readily apparent. More intensive study in this area might be extremely fruitful in gaining deeper insight into the problems of prosthetic utilization.</p> <h5><i>Work</i></h5> <p><i>Usefulness</i>. As a result of the research program, all amputee types except the below-elbow showed an increase in positive attitude toward the usefulness of prostheses in their work. The shift in opinion was quite marked in the shoulder-disarticulation group but less apparent with the above-elbow subjects. Although the below-elbow amputees as a whole indicated little change in usefulness between the old and the new prostheses, their opinions of both prostheses were generally high.</p> <p>In spite of apparent improvement with the new prostheses, many of the amputees (below-elbow, 24 percent; above-elbow, 40 percent; shoulder disarticulation, 55 percent) felt that their prostheses were of little or no value to them on the job. Since, however, these percentages are much lower than the corresponding ones for the two activities previously discussed, it would appear that amputees consider their prostheses more useful for work than for either eating or dressing. The reason may be that eating and dressing involve a relatively small number of activities, many difficult to perform with a prosthesis, while vocational activities present a much broader variety of tasks of which perhaps many can be performed better with a prosthesis than without one. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Sixty-eight percent of the shoulder- disarticulation subjects reported that they performed more work activities with the new prosthesis. So did 41 percent of the above-elbow and 29 percent of the below-elbow participants. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. A major proportion of the amputees believed that the new arm made work activities easier. Holding this opinion were 63 percent of the be-low-elbow subjects, 75 percent of the above-elbow amputees, and 76 percent of those with shoulder disarticulations. Although this result represents a more uniform and significant "positive shift" than that found for either eating or dressing, one in eight of the below-elbow amputees felt that work activities were harder to perform with the program prosthesis. The basis for this minority opinion was not apparent from the data. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. The specific work activities that amputees can perform with their prostheses, and the kinds of jobs they can hold successfully, are of considerable interest from the viewpoint of vocational re- habilitation. <b>Table 3</b> presents a listing of vocational activities reported by the 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation amputees involved in the study. Activities reported by the subjects have been classified arbitrarily as light work {i.e., activities typical of white-collar workers), medium work {i.e., activities typical of artisans and mechanics), heavy work {i.e., farming and other heavy manual occupations), and miscellaneous. Although this listing does not reveal the full story of the employability of unilateral arm amputees, it does indicate trends. While a detailed analysis of the subject is not possible at this time, it is apparent that unilateral arm amputees are capable of a wide variety of work activities and are employable in a wide range of occupations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An additional interesting aspect of the relationship between vocation and amputation was provided by amputee responses to two questions asked at the conclusion of the study. These questions and the answers provided by 349 subjects in the study were: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From these data it is evident that, while one in five amputees changed jobs during the course of the study, few of the changes were attributed to the new prosthesis. Of the total number of subjects in the study, therefore, very few felt that the new prosthesis affected their employment. Consideration of the type of job change made by the amputees also fails to reveal any significant trend. None of the changes reported (student to farm hand, post-office clerk to wholesale manager, hospital attendant to repairman, unemployed to guard, janitor to stock clerk) indicated any marked shift in vocational status, either positive or negative. It must be concluded, therefore, that the prostheses provided in the study had little apparent effect on the employment status of the participants.</p> <h5><i>Recreational and Social Activities</i></h5> <p><i>Usefulness</i>. All amputee groups reported that in recreational and social activities the program prosthesis was an improvement over the old prosthesis. As with the activity areas previously discussed, improvement was least marked in the below-elbow subjects, but even this group showed a change for the better. For example, 72 percent of the below-elbow sample considered that their new prosthesis was either essential or very useful as against 60 percent for the old prosthesis. Shoulder-disarticulation amputees reflected a greater degree of improvement, 33 percent reporting essential or very useful for the new prosthesis as compared with 19 percent for the old. Above-elbow amputees appeared to obtain the most benefit from their new prostheses, the proportions rating their prostheses in the upper two categories of the scale being: new arm, 69 percent; old arm, 33 percent. The proportion of amputees reporting that the prosthesis was of little or no use or was a hindrance in leisure-time activities (below-elbow, 28 percent; above-elbow, 31 percent; and shoulder disarticulation, 67 percent) was greater than for vocational activities but less than for eating and dressing. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. A significant number of amputees used their new prostheses for additional leisure-time activities. One third of the above-elbow and shoulder-disarticulation subjects and one fourth of the below-elbow subjects had found new uses. A very small proportion of above-elbow and below-elbow amputees reported decreased usefulness (3 percent and 5 percent respectively). <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. More than 50 percent of all the amputees felt that the performance of social and recreational activities was easier with the new arm. A small number of below-elbow (7 percent) and above-elbow (3 percent) subjects felt that activities in this area were harder to do. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 4</b> presents a listing of leisure-time activities performed by unilateral arm amputees using a prosthesis. Some of the pursuits listed are performed vocationally also, but the subjects in the study mentioned them more frequently as a hobby than as a vocation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While an amputee's social or hobby interests are perhaps not of the same level of importance as eating, dressing, and working, they are nevertheless quite significant in his total pattern of living. It is apparent that to many arm amputees a major value of the prosthesis in leisure-time activities resides in its cosmetic contribution, this factor being mentioned most frequently by all types. In addition, many found their prostheses useful in a variety of sports and hobbies, including such relatively active endeavors as hunting, fishing, golf, and baseball.</p> <h5><i>Home Tasks</i></h5> <p><i>Usefulness</i>. Use of a prosthesis at home encompasses a wide variety of tasks, from washing dishes and sweeping floors to gardening, painting, and electrical and plumbing repairs. Some of these activities are, of course, basically of a vocational nature but are performed as avocations on a part-time or intermittent basis. As for improvement in the usefulness of the prosthesis in home tasks, the shift in opinion was relatively small in below-elbow subjects but quite pronounced in above-elbow and shoulder-disarticulation amputees. In home tasks, as in other activity areas discussed previously, a high percentage of below-elbow subjects (70 percent) considered their old prostheses either essentia] or very useful, and this opinion was maintained for the new prosthesis (73 percent). It would appear that for this type of amputee there was less margin for improvement and hence less was achieved, or, the other way round, the old arms available for below-elbow amputees were relatively more satisfactory than were those available for other amputee types. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Nearly 45 percent of the above-elbow and shoulder-disarticulation cases and a smaller proportion of the below-elbow amputees (28 percent) found new uses in the home for their program prostheses. A small minority of the below-elbow group (6 percent) found fewer uses for their new prostheses. <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. The proportion of amputees reporting greater ease in performance of home tasks with the program prostheses ranged between 64 and 75 percent. Shoulder-disarticulation amputees (75 percent) were most favorably impressed, followed by above-elbow (66 percent) and below-elbow (64 percent). A few below-elbow (9 percent) and above-elbow (3 percent) subjects found home tasks more difficult than before. <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 5</b> indicates the types of home activity for which unilateral amputees used their prostheses. From the scope of activities listed, it is apparent that unilateral amputees find a wide range of uses for their prostheses in the home. While the rate or quality of performance is not indicated by the data, several of the tasks performed imply a high degree of dexterity. For example, a number of amputees undertook automobile and electrical repairs and various types of carpentry, and they made use of a wide range of tools, including power equip- ment. Since, as mentioned earlier, many tasks performed in the home by choice or necessity are vocational in nature, a more intensive investigation of this performance pattern would throw further light on the employment potential of arm amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Subjects</h4> <p>In the performance of bimanual activities by unilateral arm amputees, the prosthesis serves primarily, as has been seen, to assist the remaining good hand. Similarly, and for various reasons, unilateral arm amputees not infrequently perform with the one remaining hand activities ordinarily bimanual. Bilateral arm amputees quite obviously are faced with an entirely different situation. Since more or less of both upper extremities is lacking, at least one prosthesis must assume more than an assistive role, and one-handed performance of tasks normally two-handed cannot be substituted for use of a prosthesis. Manual activities required of bilateral arm amputees must therefore be done prosthetically if done at all. In a very real sense, then, the performance problems and the adaptations of bilateral arm amputees are quite unlike those of any type of unilateral amputee, and they therefore warrant separate discussion.</p> <p>In the Upper-Extremity Field Studies, data were collected on 10 bilateral arm amputees (7 bilateral below-elbow, 3 bilateral above-elbow/below-elbow). Five of these subjects (4 bilateral below-elbow, 1 bilateral above-elbow/below-elbow) were wearing prostheses bilaterally when admitted. The other five had either one prosthesis only or none at all. Thus, although information as regards program prostheses was obtained on all 10 subjects, comparative data on new vs. old arms are available on only five subjects.</p> <h5><i>Experienced Wearers</i></h5> <p>Although the five amputees who had worn prostheses bilaterally prior to the NYU Field Studies rated their old arms quite useful in all five of the activity areas, they considered the new prostheses equally useful or slightly better than the old ones (<b>Table 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As shown in <b>Table 7</b>, four of the five experienced wearers of bilateral prostheses indicated equivalent or increased use of their new prostheses as compared to the old, while one reported decreased use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As might have been anticipated, the pattern of amputee responses concerning ease of use (<b>Table 8</b>) of the new prostheses as compared with the old was quite similar to that concerning extent of use (<b>Table 7</b>). In general, the evidence indicated somewhat easier operation of the program prostheses, although the improvement was by no means universal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those bilateral arm amputees who reported easier operation and more extensive use of their new prostheses attributed the improve- ments primarily to the more secure grasp permitted by the terminal devices prescribed in the Field Studies. Neoprene-lined hook fingers and the heavy-load feature of the Northrop-Sierra two-load hook contributed greatly to this improved grasp security. Other favorable aspects of the new arms, mentioned by different subjects, were lighter weight and better control (faster operation and lower force requirement). The one subject fitted with an above-elbow arm indicated that operation of his new elbow lock was simpler and more efficient.</p> <h5><i>New Wearers</i></h5> <p>The five amputees who had not worn prostheses bilaterally prior to the Field Studies rated their program prostheses quite useful (<b>Table 9</b>). For some reason, however, their ratings showed less enthusiasm than did those of the patients who had previously worn prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Specific Activities Performed</i></h5> <p>At Evaluation II (new prostheses), information on the specific uses to which bilateral arm amputees put their prostheses was obtained from all 10 subjects for each of the activity areas under study. The activities reported by the individual amputees were given as "free responses" (i.e., unprompted and unstructured), and hence the listings may be considered more representative than complete.</p> <p>The available data on the 10 bilateral subjects indicate that they used their prostheses extensively in eating and attained a relatively high level of independence. Two mentioned specifically that they performed all eating activities with their new prostheses (i.e., were completely independent). <b>Table 10</b> presents specific eating activities reported to be performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Only one of the 10 bilateral amputees claimed complete independence in dressing, although two other subjects reported the performance of all dressing activities except buttoning shirt sleeves. Two more persons performed all activities except fastening buttons, lacing shoes, and tying neckties. <b>Table 11</b> lists specific dressing activities reported as performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The employability or vocational-placement possibilities of bilateral arm amputees always hold considerable interest. Although the sample was in this instance exceedingly small, it may be worth noting that five of the 10 bilateral amputees were self-employed, that four worked for others, and that only one was unemployed. Of the nine employed subjects, one was a lawyer, one an engineer, one a forester, and one a quality-control inspector. Two were filling-station attendants, and three were farmers. The quality-control inspector, unemployed at the beginning of the program, obtained his position after receiving his new prostheses, and he credited the functional qualities of the limbs for his new employment.</p> <p><b>Table 12</b> lists specific activities reported by the nine employed subjects as being performed with their program prostheses at work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A listing of recreational activities performed by the bilateral amputees revealed that with their new arms most were able to drive a car independently and that most engaged in some form of active or passive recreational endeavor. <b>Table 13</b> lists specific activities mentioned by the subjects as being performed with their prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The pattern of home activities performed by bilateral amputees (<b>Table 14</b>) does not differ greatly from that of unilateral except that among bilaterals there is a lesser tendency to undertake tasks requiring fine manipulation. Even allowing for the smaller number of subjects involved, it is apparent that the home activities of bilaterals run more to gross tasks, such as pushing a lawnmower or handling a broom, than to precision activities, such as electrical or radio repairing. Since the absence of "at least one good hand" would be a major handicap in work requiring manipulation of small parts, such a situation is quite understandable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In summary, the comparative data on five bilateral arm amputees whose preprogram prostheses were replaced by program arms appeared to indicate that:</p> <ol> <li>The five subjects thought well of their old prostheses and used them extensively.</li><li>In four of the five cases there was slight but definite evidence of functional improvement over that provided by the old prostheses. Contributing largely to this improvement appeared to be the better grasp furnished by the Dorrance 5X and Northrop-Sierra two-load hooks, partly because of the neoprene-lined hook fingers and partly because of the heavy-load feature of the Northrop-Sierra device. Other favorable features mentioned by some of the subjects were lightness and ease of operation. The one amputee fitted with an above-elbow prosthesis felt that his new elbow was much more dependable and much easier to operate than the one previously worn. One subject in the group apparently had a left prosthesis very poorly fitted and functionally inadequate, a deficiency which, in view of the rigorous checkout procedures and the close control of fittings by the clinic teams, is hard to explain. Nevertheless, that particular patient was obviously fitted unsatisfactorily, and this circumstance affected his whole reaction to the prostheses provided.</li></ol> <h4>Discussion</h4> <p>An outstanding characteristic of the data thus far presented is general consistency. For all categories of daily-living activities considered (eating, dressing, work, recreational and social life, and home tasks), and for all criteria applied (general usefulness, level of usage, and ease of use), the evidence strongly indicates that the prostheses provided in the program were more useful than those previ- ously worn. But the material also raises a number of interesting questions of which only some can be answered satisfactorily by the available data. For example, the extent of improvement provided by the new prostheses varied considerably from amputee type to amputee type. It was least for the below-elbow subjects, and some few members of this group even expressed a preference for the old prosthesis. For the unilateral above-elbow and shoulder-disarticulation subjects, the increased usefulness of the new prosthesis was considerably more marked and dramatic.</p> <p>When one speculates on the reasons for these differences, it must be borne in mind that the so-called "old" prostheses exhibited a wide range of quality from very poor to excellent. A number of the preprogram arms, particularly those for below-elbow amputees, were probably as good as, in some few cases even better than, those provided in the study. Moreover, some of the below-elbow subjects whose old leather-socket arms had some of the comfort qualities of old shoes or slippers reacted unfavorably to the new plastic sockets. Whatever the reasons, it was evident that some of the old arms provided below-elbow amputees with a relatively high degree of usefulness and that the impact of the research program on these subjects was relatively small. The reverse appears to have been true of above-elbow and shoulder-disarticulation prostheses. Taken as a whole, the old arms for these cases were of comparatively limited usefulness, and hence considerable improvement was effected by the new prostheses. Thus it may be said that the prostheses provided in the field program made the greatest contribution where improvement was most needed.</p> <p>Another thought-provoking finding of the study was that the usefulness of the prostheses obviously varied from one activity area to another, sometimes quite significantly. All three unilateral groups rated their prostheses as being about equally useful in home, work, and social activities but considerably less useful in dressing and of least use in eating. An explanation of these differences may lie in the fact that eating and dressing involve a limited number of specific activities, particularly those which require bimanual effort, and that the majority of these are quite difficult to perform with an arm prosthesis. It may also be conjectured that, in the sometimes quite lengthy time lapse between amputation and receipt of an arm prosthesis, patients build strong habit patterns of one-handed eating and dressing and that these habits carry over after the prosthesis has been supplied. Work, leisure, and home tasks present a much wider and more varied range of activities. Presumably more of these require bimanual performance in which the prosthesis is of definite assistance. Bilateral arm amputees gave uniformly high ratings to their prostheses in all activity groups, but their performance problems are quite different from those of unilateral arm amputees.</p> <p>A third area of interest involves the matter of basic reasons for use or nonuse of the prosthesis. In numerous instances, a particular activity was performed with the prosthesis by a considerable number of amputees of a given type. Why, then, do not all amputees of that type perform that activity with the prosthesis? Here is a question with many implications. It has been suggested that of the factors determining prosthetic usage-such as ease and convenience of performance, motivation, habit patterns-the first named is of basic importance. If, for example, we consider some specific activity such as tying shoelaces, which with prosthetic help apparently can be performed by some amputees of all types, even including a few with shoulder disarticulations, we may assume that this activity presents a certain level of difficulty and inconvenience. For below-elbow subjects the level may be low enough not to discourage more than a few from performing the task with their prostheses. But it must also be high enough so that others, by reason of habit or lack of motivation or some other influence, will tie the laces one-handed, wear loafers or buckle shoes, or in some other fashion avoid use of the prosthesis. For above-elbow and shoulder-disarticu-lation amputees, of course, the difficulty in performing the activity rises progressively and markedly, so that even though the performance potential be available with the prosthesis fewer amputees would be inclined to avail themselves of it. Obviously, then, further study of the factors affecting prosthetic utilization is highly desirable.</p> <p>A fourth area of interest has to do with the vocational potential of arm amputees. The number and variety of tasks that amputees can perform with the aid of an artificial arm is quite surprising. Extensive use of the prosthesis on the job, in activities around the house, and in hobbies suggests for arm amputees a much wider employment potential than is generally recognized. This subject too is worthy of further investigation on a more intensive basis than was possible in the NYU Field Studies.</p> <p>In general, the relation between the pre-treatment (Evaluation I) and post-treatment (Evaluation II) conditions of the five bilateral amputees was quite similar to the corresponding relation for the unilateral below-elbow amputees discussed previously. Since the bilateral sample included predominantly below-elbow fittings (4 bilateral below-elbow, 1 bilateral below-elbow/above-elbow), the similarity is not surprising. The over-all performance patterns of the 10 bilateral subjects would indicate that as a whole these patients achieved a high level of performance in a wide range of tasks. To a very considerable degree they appeared able to operate their prostheses effectively and to meet independently a substantial number of the requirements of daily living.</p> <h3>Extent of Use of Arm Prostheses in Twenty Selected Bimanual Activities</h3> <p>In the preceding section, the evaluation of the utility of prostheses provided arm amputees was based upon an analysis of their usefulness in five key activity areas, changes in activity level, and ease of use. To gain further insight in this matter, additional study was made of how amputees use their prostheses in 20 selected activities which were considered significant on the basis of four criteria:</p> <ol> <li>The activities should be important ones drawn from all five of the areas of daily living previously discussed (i.e., eating, dressing, work, social life and recreation, and home tasks)</li><li>The activities should call for a range of work levels from floor to head.</li><li>The normal performance of the activities should be bimanual.</li><li>Prosthetic performance of the activities should be possible for all unilateral amputee types.</li></ol> <p>The tasks selected were:</p> <ol> <li>Cut food with knife and fork</li><li>Sharpen pencil</li><li>Sweep up dirt with brush and dustpan</li><li>File and clean fingernails</li><li>Tie necktie</li><li>Use telephone (particularly when taking notes)</li><li>Assist someone with coat</li><li>Take bills out of wallet</li><li>Unbutton shirt sleeve</li><li>Carry several packages</li><li>Use "Flit" gun</li><li>Open bottles, jars, and tubes</li><li>Put on glove</li><li>Use paper clip</li><li>Carry cafeteria tray</li><li>Use can or bottle opener</li><li>Tie shoelaces</li><li>Play cards</li><li>Rewire electric plug</li><li>Use hammer and nails</li></ol> <p>With regard both to preprogram and to program prostheses, the subjects were asked concerning each of the selected activities five questions:</p> <ol> <li>How often in your routine of living does the occasion arise for you to perform the activity? (Daily, weekly, monthly, other)</li><li>How important is the activity in your particular pattern of living? (Very important, important, of little or no importance)</li><li>How often do you perform the activity with your prosthesis? (Daily, weekly, monthly, other)</li><li>If you do not perform the activity with your prosthesis every time the occasion arises, why not? (Write-in)</li><li>If you never use the prosthesis to perform the activity, how do you perform it? (Write-in)</li></ol> <p>The material that follows presents amputee responses to these questions and from these responses seeks to determine the extent to which prostheses were meeting amputee needs. In the main, attention is directed toward the new prostheses provided in the study, that particular data being considered as indicative of present status and hence more meaningful. Only in regard to Question 3, and then with respect to unilateral cases only, is a comparison made between old and new prostheses.</p> <p>The subjects in this study were the same as those making up the sample for the previous series of questions. Again, the data on the three unilateral amputee groups are presented first, with those for the bilateral subjects in a separate section following.</p> <h4>Unilateral Subjects</h4> <p>As we have seen, the problem of restoring function to unilateral arm amputees varies from amputee type to amputee type, the extent of restoration generally being related inversely to the degree of anatomical loss. But all three types of unilateral arm amputees usually have left one normal arm and hand, and accordingly the prosthesis needs for the most part only to assist the remaining natural member.</p> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p>The purpose of the question "How frequently does the occasion arise to perform the activity?" was to ascertain how often amputees were called upon, or had the opportunity, to perform each of the 20 selected activities, regardless of whether they used the prosthesis in the performance of the activity or whether they even performed it at all. For instance, the question "How often do you have occasion to cut food with a knife and fork?" was interpreted as "How often do you have food which requires cutting with a knife?" Responses relative to each of the 20 activities were tabulated in four categories-at least once daily; at least once weekly; at least once monthly; and less than once monthly, or never. Separate tabulations were prepared for below-elbow, above-elbow, and shoulder-disarticulation amputees. On the basis of these tabulations, there was calculated the percentage of amputees (of each type) who reported once daily or oftener as the frequency of occurrence of a particular activity. The percentage figures were then used to arrange the 20 activities in order from those occurring most frequently to those occurring least frequently. It should be emphasized that "most frequently," as used here, means occurring on a daily basis to the largest proportion of amputees.</p> <p><b>Table 15</b> presents the results for the three groups of unilateral amputees. Since these data are based on unverifiable amputee statements concerning their activities, the information in <b>Table 15</b> cannot be considered as presenting any absolute answer. Nevertheless, the data are quite consistent. Percentages for the first nine activities are of the same order for all groups, and that for the tenth shows a slight variation for the shoulder-disarticula-tion subjects only. The 10 tasks on the lower end of the table were performed daily by the least number of amputees. These data showed similar patterns of occurrence for each of the three types of amputees. Thus it would appear that some of the activities on the "selected" list confront a large proportion of all types of amputees on a daily basis. Other activities affect relatively few amputees as often as this.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>How often an activity should occur, or how many people it should affect to be considered "significant" in the lives of amputees, is a philosophical question. On an arbitrary basis we might say that the first nine activities in <b>Table 15</b>, which occur daily in the lives of more than about half of the amputee population, are "significant" activities. Yet who can say that tying a necktie (occurring to one third of the group daily) or even using a hammer and nails (less than one fifth of the population affected daily) are "insignificant" activities? Obviously such tasks could be highly significant to the particular amputees involved.</p> <h5><i>Relative Importance of the Activities</i></h5> <p>In addition to the frequency of occurrence, the degree of importance subjectively attached to being able to perform a specific activity is a second significant factor in determining the usefulness of a prosthesis to its wearer. Accordingly, the ten subjects were also asked to rate each of the 20 selected activities as "very important," "important," or "of little or no importance" to them in their regular activity pattern.</p> <p><b>Table 16</b> presents the percentages of amputees rating the respective activities as either "very important" or "important," the activities being arranged in the approximate order of importance on the basis of these percentages. For example, "cut food with knife and fork" was rated "very important" or "important" by more amputees within each of the three unilateral amputee groups than was any other of the 20 selected activities. Tying a necktie was second in importance to above-elbow and shoulder-disarticulation amputees but fifth in importance to the below-elbow subjects. Thus the ranking of activities in <b>Table 16</b> may be thought of as indicating the general level of importance attached to the activities by the unilateral amputee population as a whole.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In these terms the 20 activities fall rather obviously into three levels of significance. The first 10 tasks are rated as important by two thirds or more of the sample, cutting food being by far the most significant activity (about 9 out of 10 subjects). The next three activities may also be considered quite significant, almost one in two amputees designating them as important. The final seven tasks may be regarded as having lower general significance, no more than one in three amputees rating them as important. With the possible exception of using a "Flit" gun, however, even these low-ranking activities cannot be considered as completely insignificant. For example, rewiring an electric plug, nineteenth in order on the list, is rated as an important activity by one in five unilateral amputees of all types, a fairly substantial number of people. We may conclude therefore that, while according to the criteria used in this study the 20 selected activities vary widely in importance, all, or almost all, have value to some significant proportion of unilateral arm amputees.</p> <p>It is of interest to compare the data on the importance of activities with those on the frequency of occurrence discussed earlier. <b>Table 17</b> presents the 20 activities in approximate order of frequency of occurrence (from <b>Table 15</b>) and also lists the approximate order of importance for the 20 tasks (from <b>Table 16</b>). A fairly consistent relationship between frequency and importance is apparent at once. Seven of the nine most important activities occur very frequently.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be inferred therefore that, in general, activities which occur most frequently are likely to be regarded as being the most important, but the instances where this principle does not hold are also of interest. Two out of three shoulder-disarticulation amputees said they had occasion to use a paper clip daily, but only one out of three considered the activity important. Less than one in six below-elbow amputees reported that they had occasion to use a hammer and nails on a daily basis, yet two out of three considered the activity important. While only one in three of the below-elbow subjects reported tying a necktie daily, about three in four considered it important to be able to do so. Thus, some activities that occur frequently may be relatively unimportant; others may occur only infrequently but still have great personal significance.</p> <h5><i>Performance of Activities with the Prosthesis</i></h5> <p>Having considered the frequency of occurrence of the 20 selected activities and the relative importance of these activities in the lives of amputees, we come now to the frequency of use of the prosthesis in the performance of the tasks, the point being to evaluate both the extent of prosthetic use and the relationship between this utilization and the two factors previously presented (i.e., frequency of occurrence and importance).</p> <p>Data on use of the prosthesis in the 20 selected activities, obtained from all amputees in the study, were organized to show the percentage of amputees who always, regardless of frequency, used the prosthesis in the performance of a particular activity, the percentage who sometimes used the prosthesis, and the percentage who never used it, a small number of amputees who claimed that they never had occasion to perform a particular activity being excluded. <b>Table 18</b> presents the incidence of use of the program prostheses as reported by the unilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of <b>Table 18</b> shows that the prosthesis is used extensively by below-elbow sub- jecls in performing the 20 selected activities, all tasks save one being performed by more than 50 percent of the group every time the opportunity arose. With rare exceptions (e.g., carrying packages), the utilization of the prosthesis in performing activities dropped off sharply and progressively from the below-elbow to the above-elbow to the shoulder-disarticulation groups. An intriguing and somewhat unexpected finding is the relatively small percentage of amputees reporting occasional use of the prosthesis. It would appear that amputee use of the prosthesis tends to be on an all-or-none basis. If an amputee uses his prosthesis to perform an activity at all, he tends always to use it for that activity. Even when this general tendency is violated, there are interesting areas for speculation. For example, cutting food with knife and fork has a relatively high incidence of "sometimes" responses. Since we know that cutting food is relatively difficult at all amputation levels, it seems probable that some amputees ignore the prosthesis under some circumstances (e.g., eating at home) but use it on other occasions (e.g., eating out or when they have company) in spite of the difficulty. The fairly general always-or-never use of the prosthesis in the performance of specific activities reinforces a conclusion presented earlier-that there is for each activity a certain threshold, or tolerance, level of difficulty associated with prosthetic performance, that this threshold varies from amputee to amputee and from activity to activity, that if the performance difficulty is within the individual's tolerance limits he will tend to use the prosthesis consistently, and that if the level of difficulty is above his limit he will tend not to use the prosthesis at all.</p> <p>The data in <b>Table 15</b>, <b>Table 16</b>, <b>Table 17</b>, and <b>Table 18</b> may also be viewed as an index of the relative usefulness of the prosthesis in the performance of the 20 selected tasks and, conversely, as a measure of the relative difficulty of the several activities from the standpoint of accomplishment by means of a prosthesis. For instance, the activity "sharpen pencil" appears to be performed (with help from the prosthesis) by 90 percent of below-elbow, 76 percent of above-elbow, and 62 percent of shoulder-disarticula- tion amputees every time the occasion arises. It would appear, therefore, that sharpening a pencil is not too difficult an operation for any type of unilateral arm amputee. The corollary conclusion is that, in pencil-sharpening, the prosthesis is a highly useful assistive device. On the contrary, activities such as cutting food or holding a telephone with the prosthesis appear to be quite difficult for arm amputees at all levels, and the prosthesis is then obviously of less value.</p> <p>If we extend this index-of-usefulness concept to the entire list of 20 activities, we obtain the results shown in <b>Table 19</b>, which presents the percentage of amputees reporting use of the prosthesis every time the occasion arose for performing the activities. If, further, it is assumed that those activities in which there is the highest degree of prosthetic utilization are activities for which prostheses are most useful (or, more simply stated, easiest to perform with a prosthesis), then <b>Table 19</b> indicates that the below-elbow prosthesis is highly useful or well adapted to performance in most of the 20 activities. For above-elbow and shoulder-disarticulation subjects, the usefulness or adaptability of the prosthesis drops off sharply (i.e., the prosthesis has a high level of usefulness for considerably fewer activities). Nevertheless, some consistency in pattern is evident for the three unilateral amputee types in that activities for which the prosthesis is most useful for the below-elbow group tend also to be easiest for the above-elbow and shoulder-disarticulation subjects. Similarly, the activities that are most difficult for below-elbow subjects also present the greatest difficulty for above-elbow and shoulder-disarticulation amputees. Not readily explained is the fact that the activities for which the prosthesis is apparently most useful generally rank low in frequency of occurrence or importance or both, while activities for which the prosthesis is least useful generally rank high in occurrence and importance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Old Versus New</i></h5> <p><b>Table 20</b> compares reports by unilateral arm amputees as regards the extent of use of the old and the new prostheses. It reveals a consistent but by no means universal trend toward greater utilization of the new prosthesis as compared with the old. It is most apparent in the above-elbow subjects (increase for 17 of the 20 activities), less apparent in the below-elbow and shoulder-disarticulation amputees. As regards specific activities, however, there appears to be no systematic pattern of changes in degree of prosthetic utilization, and hence the general evidence here is rather inconclusive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Reasons for Performing Activities Without Using the Prosthesis</i></h5> <p>In the foregoing material, consideration has been given to the matter of amputee utilization of prostheses in terms of their use always, sometimes, or never in performing each of the 20 activities under study. When an amputee always uses his prosthesis in the performance of a particular activity, some degree of adequacy of the limb for that task may be assumed. When, however, he "sometimes" performs a task without using his prosthesis, or when he "never" uses the artificial arm in the performance of that activity, prosthetic inadequacy to some degree would seem apparent. An understanding of the specific inadequacies of today's arm prostheses with respect to each of the 20 activities would be of great value in prescription and training as well as in planning research. Accordingly, each amputee who indicated less than full utilization of his prosthesis in a given activity was asked why he didn't use his prosthesis every time he had occasion to perform that task.</p> <p>The most specific, although not the most frequent, reason given for not using the prosthesis in the performance of particular activities was that the terminal device was inadequate. For instance, a given terminal device might be capable of holding a wallet or taking out bills but be ill-suited for holding a fork; it might be suitable for holding a necktie but not for handling a telephone. It may therefore be concluded that one major reason for not using the prosthesis in performing certain activities relates to lack of versatility in the terminal device.</p> <p>Another important reason advanced for failure to use the prosthesis was that the terminal device could not be brought to the appropriate functional position and operated there. Although the exact cause of this difficulty is not apparent from the data, it may be related directly to prosthetic inadequacies. As a matter of fact, not many amputees were able to give clear reasons for not using the prosthesis, so that it is possible only to speculate on the implications of the responses Some subjects stated simply that they "could not perform" the task in question. Since this kind of response may indicate either lack of training or genuine prosthetic deficiency or both, full interpretation requires further investigation. In the absence of a more complete examination, it may only be guessed that poor features in the available prosthetic equipment contributed in some way to its disuse.</p> <p>That an activity was "easier to perform without the prosthesis" was the reason given most frequently for failure to use an artificial arm. Although not especially revealing, such statements reaffirm the conclusion reached for other aspects-that for numerous amputees performance of certain activities presents such difficulty that it is "cheaper" in time, effort, and peace of mind to do without the prosthesis. A sharp rise in the number of "easier-without-prosthesis" responses was noted in the above-elbow amputees as compared with the below-elbow subjects-a result in keeping with earlier findings of decreasing prosthetic usefulness at the higher levels of amputation.</p> <p>A number of amputees reported that the prosthesis was not worn at the time a particular activity was performed. This circumstance may be considered as indicating either that the activity was easier to perform without the prosthesis or that performance without the prosthesis presented no particular problems. Were the prosthesis indispensable, it would be worn on almost all occasions when opportunity to perform the listed activities arose. Since it evidently was not, it must be assumed that some amputees could dispense with their prostheses without (to them) significant functional loss.</p> <p>Two other general observations can be made concerning the reasons for nonuse of the prosthesis. Both reinforce evidence presented earlier. One is that the number of "reasons" for nonuse of the prosthesis increased sharply for the above-elbow group as compared with the below-elbow subjects, which is only to say that more above-elbow amputees than below-elbow amputees report "sometimes" or "never" as regards use of the prosthesis. The other is that some "important" activities and some "occurring frequently" (such as cutting food, tying a necktie, using a telephone, taking bills out of a wallet, unbuttoning the shirt sleeve, tying shoelaces, and so on) are also reported by many amputees as being easier to perform without the prosthesis than with it.</p> <p>In summary, it would appear that in general the statements made by all amputee groups point, either directly or by implication, to functional inadequacies of the prosthesis as the basic reason for failure to make full use of it. The specific inadequacies, and the means of correcting them, are of course not directly or fully revealed by the present data. Even the seemingly straightforward problem of inadequate prehension in terminal devices cannot be solved simply by adding rubber bands or by providing a device with a stronger grasp. Experience has shown that for numerous amputees a lightly loaded hook is adequate for most needs and that they therefore prefer it. They object to the necessity for overcoming heavy resistance in every operation just to accommodate needs occurring infrequently. Nor is the voluntary-closing hook always the answer. Evidence presented in Section V of this series shows that such voluntary-closing devices as are currently available also are not without objectionable features. The solution of such problems must await further research into the total area of prosthetic utilization.</p> <h5><i>Manner of Performing Activities Without the Prosthesis</i></h5> <p>When, in a particular activity, an amputee regards the use of the prosthesis as either impossible or too difficult, awkward, or time-consuming, he is faced with the choice of excluding the activity from his routine of living or of finding some substitute means of accomplishing it. In the NYU Field Studies, those subjects who did not use the prosthesis in one or more of the 20 selected activities were asked what they did when confronted with the task or tasks concerned. By far the most frequent response by all classes of unilateral arm amputees was to the effect that they used the remaining hand, either alone or in combination with some other part of the body or some external object. About 3/4 of all responses told of one-handed performance, and the activities which are normally bimanual but for which performance was actually one-handed were essentially the same ones for all three classes of unilateral amputees. Moreover, activities so performed were for the most part the same ones as those reported to be "easier to perform without using the prosthesis" and also the same as those said to be most difficult to perform with a prosthesis (i.e., least facilitated by assistance from a prosthesis).</p> <p>A second alternative to use of the prosthesis, occurring in about 10 percent of the responses, was the use of substitute devices such as combination knife-forks, telephone holders, or playing-card holders-all simply aids to one-handed performance. As for other methods of accomplishing daily tasks without use of a prosthesis, some 15 percent of the subjects indicated that the services of another person were enlisted. Again, as in the case of one-handed performance, the activities most frequently cited were much the same ones for all three groups of unilateral amputees. Although there is no apparent reason behind the choice of activities for which outside help is to be sought, it is possible that the tasks selected are too difficult to perform alone, either with or without a prosthesis. But of course other factors-an overly solicitous wife, general dependency, lack of training- may well be involved.</p> <p>Two important goals in upper-extremity prosthetics are to help the amputee be independent in the performance of the tasks of daily living and to permit him to function bimanu-ally in as "normal" a fashion as possible. Obviously the final achievement level may be below that of a "normal" person, but nevertheless these goals remain the best standard of comparison. Prosthetic utilisation may be viewed as ranging from an optimum of complete independence and bimanual function to less independent performance with the sound arm alone, either with or without assistive devices, to a complete dependence on assistance from others. The employment of this scale of achievement along with additional measures of the quality or appearance of prosthetic performance should provide a useful basis for evaluating the degree of success obtained in amputee rehabilitation.</p> <p>From the material here presented, we may conclude that, in the 20 selected tasks, the most common substitution for prosthetic use involves use of the remaining "good" hand, either alone or in combination with some other part of the body or some external object. One-handedness, with or without the use of substitute devices, avoids the necessity of dependence on others, but it also leaves much to be desired from the standpoint of simulating "normal" performance. Moreover, one-handed performance of such activities as tying a necktie, or unbuttoning shirt sleeves with the teeth, is not easy. If these methods really are "easier" without a prosthesis, then prosthetic use must indeed be unattractive to the individuals concerned. The general findings of the whole study lead, however, to the obvious conclusion that a prosthesis is at best only a partial replacement for a lost limb. In unilateral arm loss, increased usage of the remaining arm and hand has unavoidably to make up, to greater or lesser degree, for existing prosthetic inadequacies.</p> <h4>Bilateral Subjects</h4> <p>As already pointed out (page 49), the 10 bilateral subjects in the Upper-Extremity Field Studies included 7 bilateral below-elbow and 3 bilateral below-elbow/above-elbow cases. Undoubtedly, the general performance level of the group as a whole was higher than it would have been had the sample included bilateral above-elbow and bilateral shoulder-disarticulation subjects. The extent of prosthetic utilization exhibited must therefore be interpreted accordingly. The responses of the subjects concerning frequency of occasion to perform the 20 selected activities, importance of the selected tasks, and frequency of actual prosthetic performance are presented in <b>Table 21</b>, <b>Table 22</b>, and <b>Table 23</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p><b>Table 21</b> presents the responses of the bilateral subjects as to the frequency of occasions for performing the 20 selected activities with prostheses. It will be apparent at once that the activities for which opportunity occurred to the majority of bilateral amputees daily were for the most part the same ones occurring most frequently for unilateral subjects.</p> <h5><i>Importance of the Activities</i></h5> <p>The ratings of the bilateral group as to the significance of the 20 activities are presented in <b>Table 22</b>. On the basis of a composite of the two ratings "very important" and "important," the activities most significant to the bilateral amputees were, with the single exception of sweeping up dirt, the same ones that rated high in importance for the three unilateral groups, and more than half of these were among the ones occurring most frequently. Thus the general pattern of relationship between frequency and importance observed with the unilateral groups appears to apply to the bilaterals also. And again, as with the unilateral cases, the activities of bilaterals that apparently do not conform to this pattern give rise to speculation. A case in point is the matter of using the telephone. Ostensibly an activity which confronts bilateral arm amputees rather infrequently (<b>Table 21</b>), it is rated as significant by all of the ten subjects involved. Either the activity is considered important in spite of infrequent occurrence or, more likely, bilateral amputees avoid use of the telephone because of difficulty in handling it with their prostheses. Avoidance could explain infrequent occurrence.</p> <h5><i>Performance of Activities</i></h5> <p><b>Table 23</b> summarizes the responses of the 10 bilateral amputees as regards utilization of the program prostheses in the performance of the 20 selected activities. The always-or-never characteristic of prosthetic utilization, described earlier for unilateral amputees, is even more evident in the bilateral group. At Evaluation II, only one bilateral amputee reported "sometimes" use of the prostheses in any of the 20 activities. Judging from the proportion that never perform a given activity, the tasks that are the most difficult for bilateral amputees are also among those occurring most frequently for them, or rated most important by them, or both, so that the situation noted earlier for unilateral subjects again applies to bilaterals also. If we take as a basis of comparison the percentage of bilateral arm amputees who always use the prostheses to perform an activity, then as a group bilaterals use their prostheses more extensively than do any of the unilateral groups. The comparative figures, including the apparent anomalies, lead to the logical supposition that, if they can, bilaterals will perform the most difficult tasks in order to be independent but that some tasks may be too complex for them to manage in spite of a strong desire to do so.</p> <h5><i>Reasons for Not Using the Prosthesis and Alternative Ways of Performing Activities</i></h5> <p>Because of the small number of cases involved, and because of the variety of body movements used by bilateral arm amputees to accomplish tasks without prostheses, a detailed analysis of substitution techniques is not warranted, but two general observations may be made nevertheless:</p> <ol> <li>Prosthetic deficiencies related to nonperformance were concerned with inadequate grasp by the terminal device and inability to operate it at the appropriate level.</li><li>The chief remedy for such deficiencies was to have someone else perform the task. Use of substitute devices was confined largely to unbuttoning shirt sleeves, presumably by use of a special buttonhook held in a prosthesis.</li></ol> <h4>Discussion</h4> <p>The NYU Field Studies reveal a number of interesting highlights regarding the utilization of prostheses reported by upper-extremity amputees. With only minor exceptions, the 20 bimanual activities, chosen empirically, occurred in every case with sufficient frequency, and/or affected a large enough proportion of the amputee population, to be considered significant. Among the various amputee groups (unilateral below-elbow, above-elbow, and shoulder-disarticulation cases and bilateral arm cases) there was considerable agreement as to the relative frequency of occurrence of the activities. It must also be noted, however, that among the bilaterals the frequencies of occurrence were much lower than among the other groups. For example, only 10 percent of the bilaterals carried a cafeteria tray as often as once a week, and none of them used a "Flit" gun or rewired an electric plug as often as once a week. Finding such agreement supports the selection of these activities as being highly significant in the activity patterns of upper-extremity amputees.</p> <p>As judged by amputee opinions concerning the importance of the 20 selected activities, the level of significance attached to the individual tasks varied considerably. For unilateral subjects, 10 of the activities were rated as important by 2/3 or more of the group, five were rated as important by 1/3 to 1/2, and five were significant to less than 1/3. For the bilateral group, 11 activities were rated as important by 2/3 or more of the sample. For all amputee types, even those activities rated as important by the least number of amputees could not be regarded as totally insignificant. On the basis of amputee judgments of frequency of occurrence and of importance, therefore, the tasks selected appear to have •constituted a sound basis for study of the patterns of prosthesis usage among arm amputees. Although significant exceptions were apparent, in general the activities occurring most frequently were also rated as the most important.</p> <p>In sum, the data on amputee use of prostheses in performance of the 20 selected activities revealed a number of interesting, if occasionally unexpected, findings. Among these were:</p> <ol> <li>A sharp drop-off in prosthetic utilization from below-elbow to above-elbow to shoulder-disarliculalion amputees, found in an earlier investigation (page 32), was confirmed. While over-all utilization of the prosthesis by all amputee types, including the above-elbow and shoulder-disarticulation cases, was quite remarkable, improved utilization was most striking among the below-elbow and bilateral amputees. More than 50 percent of all unilateral below-elbow subjects reported that they always used the prosthesis in the performance of 19 out of the 20 selected activities (<b>Table 18</b>), and at least half of the bilateral amputees reported 100-percent use in 13 out of 18 applicable activities (<b>Table 23</b>).<br /> Because heretofore prostheses for above-elbow and for shoulder-disarticulation amputees have sometimes been regarded as comparatively useless, the data relating to these types of amputees are perhaps even more dramatic than are the corresponding results for the other two types. In the above-elbow group, 50 percent or more of the sample reported that for widely diverse tasks they always used the prosthesis. In a number of "important" activities, a smaller but still significant proportion of above-elbow subjects always used the prosthesis. If we focus attention on what was done rather than on what was not done, there is considerable evidence that the prostheses had real value even for the shoulder-disarticulation group. Some 50 percent or more of the sample reported that in performing 8 of the 20 tasks they always used the prosthesis. In almost none of the activities could the prosthesis be considered useless. Even for the shoulder-disarticulation amputee, to whom a prosthesis offers the least functional replacement, the fitting and use of a modern artificial arm seems worth while. And a similar conclusion may be drawn from the data presented earlier concerning use of the prosthesis in eating, dressing, and vocational, recreational, and home activities by all classes of amputees, including above-elbow and shoulder-disarticulation cases.<br /> There are, then, two sides to the coin of prosthetic usefulness. One points to the inadequacies of even the most up-to-date equipment and emphasizes the need for much improvement. The other shows that, despite prevailing inadequacies, present-day upper-extremity prostheses are quite useful devices, particularly in those cases once thought incapable of deriving much benefit from any arm substitute.</li><li>An "all-or-none" type of phenomenon in amputee use of prostheses was noted. In any given activity, an amputee tends either always to use his prosthesis or never to use it. While not absolute or universal, the inclination was considered strong enough to be viewed as a general characteristic of prosthetic utilization.</li><li>Paradoxically, the prosthesis was most useful for many activities which occurred less frequently, or which amputees rated as less important. Some of the more frequently occurring, and more important, of the 20 activities, such as "cut food with knife and fork" and "unbutton shirt sleeve," were less frequently performed with the prothesis. This may indicate that the difficulty of performing the task with prothesis influences frequency of prosthetic use more than does the frequency of occasion for use or the importance of the task.</li><li>Although there were definite indications that the program prostheses were used more extensively than were their preprogram counterparts, the increase in utilization was neither universal nor particularly striking. The reasons given by arm amputees for not using their prostheses in the performance of activities pointed generally to prosthetic inadequacies as the basic cause. While lack of a suitable all-purpose terminal device was the only specific item identifiable from the data, it appears that the whole area of amputee use or non-use of an arm prosthesis calls for further and intensive study. Where arm amputees did not use their prostheses in activity performance, the most common substitution among unilateral subjects involved use of the remaining hand, either alone or in combination with some other part of the body or some external object. One-handedness replaced what would normally be bimanual performance. Among bilateral arm amputees, "someone else does it for me" was the most frequent compensation for failure to use prostheses.</li></ol> <p>In the final analysis, the value of any particular set of principles or procedures in upper-extremity prosthetics is reflected by the degree of acceptance and utilization afforded the wearer by the prosthesis after the novelty has worn off and routine operation is expected. As part of the NYU Field Studies, therefore, the opinions of a large and diversified group of arm amputees were obtained on widely separated occasions in response to a series of open-end and multiple-choice questions relating to five key areas of activity considered more or less common to all persons. These reactions, classified and analyzed in terms of amputation type, were augmented by interviewing the same group of subjects with regard to 20 bimanual activities selected empirically as being important and of frequent occurrence in the course of daily living.</p> <p>These two inductive approaches were selected from many possibilities for investigation as being the most practical and appropriate for determining amputee opinions as regards the utility and general value of their prostheses. Though the answers obtained do not provide a completely definitive method for grading success or failure in the rehabilitation of arm amputees, they have nevertheless furnished much useful information on a number of the factors influencing acceptance of prostheses by their wearers.</p> <p>As might have been anticipated, amputees with the more disabling conditions (that is, with higher levels of amputation) were able to employ their prostheses over a smaller range of activities. On the other hand, the greatest increases in prosthetic utilization were found among these very groups. Not anticipated, however, was the indication that, in general, amputees tend to use their prostheses every time they do a given activity or not at all. The frequency of occurrence and the importance of an activity to an amputee were not always indices of the utility of the prosthesis in the particular task. While there were definite improvements in the utilization of program prostheses, a great deal of room for improvement remains, particularly in the bilateral group. Although deficiencies in the prostheses may be responsible, other factors such as training and motivation may also be involved. New studies focused on these questions will be required to illuminate the specific relationships.</p> <h3>Part 2. Amputee Performance With Arm Prosthesis</h3> <p>Since arm amputees, like most people, are not generally capable of a completely realistic self-appraisal, there is an inherent weakness in data which derive solely from verbal reports. For this reason, a second method of evaluation was devised with the purpose of assessing prosthetic use on the basis of more objective information. Based on the assumption that proficiency in use also reflects the value of the prosthesis to the amputee, two types of prosthetic proficiency tests were developed. The first was designed to measure the amputee's skill in prehension and accuracy in positioning the terminal device for prehension. The second was concerned with evaluating skill in performing a series of common daily activities.</p> <h4>Test Rationale and Test Development</h4> <p>Methods of evaluating human performance in physical activities vary from the simple, relatively objective timing of a footrace to the more subjective assessment of figure-skating or fancy diving. In the footrace, effectiveness of performance is determined solely by measuring time, since speed of performance is the main factor. In rating activities of the second type, consideration also is given to such subjective features as timing, rhythm, grace, and form because here both effectiveness and appearance are matters contributing equally to the overall result. Since the total value of performance with a prosthesis involves these two factors, efforts to analyze the quality of prosthetic use in the NYU Field Studies sought information not only on the effectiveness with which the amputee used his prosthesis in activities of daily living but also on his appearance while performing them. In this sense, "effectiveness" refers to the ability to complete a task in a reasonable time. "Appearance" has to do with the relationship between the performance of the amputee and that typical of a normal person.</p> <h4>Abstract-Function Tests</h4> <p>Considering the uses arm amputees make of the various functions provided by modern arm prostheses, it is clear that all artificial arms are employed primarily as prehensile tools. But the ability to grasp with a hook or artificial hand would be extremely limited were the terminal device restricted to one plane or to a single area of operation. The value of other prosthetic functions, whether passively or actively controlled, lies in their usefulness as a means of positioning the terminal device so that work can be performed throughout a large operating sphere. It may reasonably be said that all the motions that can be provided in an upper-extremity prosthesis are capable of classification into one of two functional categories-those involved in the act of prehension itself and those which are used to position the terminal device so that meaningful prehension may be performed. Recognition of these functional divisions led to the development of two tests of abstract function-the prehension test and the positioning test-designed to permit study of some of the factors involved in prehension and positioning. They are tests of "abstract function" in the sense that no purposeful activity is involved and that only the bio-mechanical functions of positioning and operating the terminal device are analyzed. Tests of abstract function were, then, used to assess the amputee's ability to:</p> <ol> <li>operate and control his terminal device in grasping, transporting, and releasing objects.</li><li>position his terminal device accurately and operate it effectively in various places in front and to the side of his body.</li></ol> <h4>Practical-Activities Tests</h4> <p>Tests of practical activities, used in an evaluation of how the amputees performed meaningful activities of daily living, were designed to provide information concerning the facility and appearance of a total performance in order to measure the functional value of the appliance. Selection of the performance tests of practical function was based on three prime criteria-that the activities concerned should normally require bimanual performance, that the activities concerned should be those performed frequently by the subjects being tested, and that performance of the activities should be important to the amputee.</p> <p>Tests of practical function were, then, used to rate:</p> <ol> <li>the effectiveness with which amputees perform common, everyday tasks.</li><li>the naturalness of appearance while amputees perform daily activities.</li></ol> <h4>Standards Of Performance</h4> <p>In the choice of a yardstick with which to measure the quality of prosthetic performance, consideration was given to the purpose of fitting an amputee with an artificial arm. Since the obvious aim is to restore as much as possible of the function lost through amputation, the desired outcome is that the amputee accept and use his prosthesis as naturally and as "normally" as possible. For this reason, normal, two-handed performance of tasks appeared to be a valid criterion. Because, however, it is commonly recognized that an amputee can never attain a completely normal, two-handed pattern of performance, it may reasonably be objected that such a standard is to some degree unrealistic and that the rating of amputee performance in relation to that of other amputees would provide a more reliable comparison. Perhaps it would. But the absence of norms or standards of amputee performance at the time the NYU Field Studies were undertaken precluded any choice in the matter. Consequently, the normal performance pattern was selected as the standard.</p> <h3>Sample</h3> <p>The numbers of below-elbow, above-elbow, and shoulder-disarticulation amputees available for these performance tests varied considerably. Participating in the pretreatment tests were 80 below-elbow amputees, 57 above-elbow amputees, and 4 shoulder-disarticulation amputees representing, respectively, 48 percent, 36 percent, and 17 percent of each amputation type in the sample. Attrition during the pretreatment evaluation was due to nonfunctioning or malfunctioning of arms, amputees appearing for evaluation without prostheses, and breakdown of prostheses during use with consequent inability to complete the test. Owing to the generally better functional condition of arms during the course of the program and to the increase in the number of shoulder-disarticulation and above-elbow amputees wearing arms, the number of subjects available for post-treatment testing was substantially higher: 115 (68 percent) below-elbow, 111 (70 percent) above-elbow, and 17 (74 percent) shoulder-disarticulation cases. To provide the most rigorous analysis that the data will permit, only the performances of the patients available for both pre- and post-treatment evaluations are presented. This restricts the total sample to 75 below-elbow, 51 above-elbow, and 4 shoulder-disarticulation cases. Because there are so few shoulder-disarticulation amputees, their performance ratings are not treated statistically but are described in terms of impressions and trends.</p> <p>All of these amputees took the prehension test, the first to be administered, but somewhat fewer completed the positioning test and the practical-activities tests, either because of breakdown of prostheses during the course of the tests or because of indisposition on the part of the patients.</p> <h3>Procedures</h3> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>In utilizing his prosthesis in the activities of daily living, the amputee has occasion to grasp objects of various sizes, shapes, weights, textures, and degrees of fragility or hardness. This diversity was recognized by including, in the prehension test, objects which embody many of the variables normally encountered. Of the 12 objects used, six were of metal (five aluminum, one steel) and six of compressible rubber, and all were of one of four basic shapes-cylinders, spheres, prisms, and right-angled forms-in various sizes.</p> <p>In addition, the testing materials included a form board constructed of "Masonite" attached to a three-ply wooden board measuring 17 X 17 in. and into which were cut recesses corresponding to the shapes of the test objects but slightly (1/8 in.) larger. The test objects were arranged on a table near the board and in the same relative position as the recesses in the board so as to reduce the need to search for the proper recess. In the course of the test, the amputee transferred each of the objects from the table to the appropriate recess in the form board. Before the actual test, the amputee was given a trial run to familiarize himself with the objects and to give him an opportunity to decide upon the most efficient way to approach and grasp an object. The test was explained to the amputees as follows:</p> <p>"You are to place each of these objects in the appropriate recess in the form board. Start with the top row and work from left to right. Do each row in the same way.</p> <p>"Work as quickly as you can but also as accurately and neatly as you can; do not waste any time.</p> <p>"If you cannot handle any object after trying for 1 minute, leave it and go on to the next. You will be notified when you have been on any object for 1 minute.</p> <p>"Use only your prosthesis in handling the various objects.</p> <p>"Avoid compressing or distorting the shape of the rubber objects as much as possible.</p> <p>"You are being tested on your ability to grasp the objects and to release them into the recesses in the form board." <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of these tasks, the terminal device is first brought into a position which allows for grasp of the object. The next step, concerned with the grasp itself, involves operation of the prehension mechanism, placement of the fingers to obtain a stable grasp, and control of finger pressures to provide appropriate prehensile forces. To complete the activity, the amputee must transport the object and then position the terminal device so that the object is released at the intended place. The general impression that an amputee's performance makes upon the observer depends upon the body move- ments employed, the number of errors made, and the appearance of the control motion. In addition to these factors, the appearance of the total performance is related to the general ease, grace, and accuracy of movement.</p> <p>In an attempt to appraise in each activity both the functional and the appearance value of the amputee's performance, the significant parts of the performance were rated with regard to positioning movements for grasp and release, appearance and effectiveness of control motion, and control of finger pressure. The ratings were then combined in an over-all score on the basis of the following 10-point scale:</p> <p>Excellent (10). Graceful, rhythmic, fast, accurate performance closely approximating the cosmetic value of a performance by a normal person.</p> <p>Good (8). Smooth, rapid performance involving one or two errors and some slight body and limb distortion in several positions.</p> <p>Average (6). Uneven, somewhat inaccurate performance with occasional errors, some effort, and some body distortion.</p> <p>Fair (4). Slow performance marred by errors and uncosmetic limb and body positions.</p> <p>Poor (2). Awkward, strained, slow performance with fumbling, excessive movement, and many errors.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 when indicated.</p> <p>The ability of the arm amputee to grasp and hold objects securely with a prosthesis is dependent partly upon the amount of power the man-machine combination can furnish and partly upon the structure, size, and shape of the terminal device. The number of errors made during the test was recorded, two kinds of errors being considered-grasp errors and compression errors. A grasp error was counted when the amputee regrasped an object in an attempt to obtain a more secure grasp, when the object, once grasped, fell from between the fingers of the terminal device, or when the object slipped within the fingers to the extent that the amputee had to reduce his speed or otherwise interrupt his performance to avoid dropping it. The ability to control finger pressure was appraised by tallying the number of compressible objects distorted and judging the extent of the distortion.</p> <p>Considered alone, the time taken to perform a particular activity may not be a satisfactory indication of efficiency. When considered in relation to accuracy and appearance, however, it may be an important factor, particularly in view of frequent amputee complaints regarding inability to work rapidly. In the prehension test, the amputee stood at the table and began at his own volition, a stopwatch being started with his first movement. The watch was stopped as the last object was placed in the appropriate recess on the form board, and the elapsed time was recorded.</p> <h5><i>Positioning Test</i></h5> <p>Although prehension may be considered the primary function of both the normal hand and the prosthetic replacement, the ability to position the hand or its substitute in space is a key factor in utilization. The normal, two-handed person has occasion to reach for, grasp, and release objects in three planes. He commonly handles objects at the level of the mouth, the chest, and the mid-thigh, and objects at chest or waist level up to 1-1/2 feet on either side of him are usually within his reach. To study the ability of the amputees to employ their prostheses in these areas, use was made of the positioning test, which involved six common hand positions. The six exercises devised to assess the ability of an amputee to operate his terminal device at different positions required the subject to place a 6- X 3/8-in. dowel into a clip positioned on the wall and so arranged that release of the dowel was required in both vertical and horizontal positions. Before the actual tests, each amputee was given a trial run to familiarize him with the procedures and to let him decide upon the best approach to each of the test situations. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of this test, the amputee was required to remain within a rectangle drawn on the floor 18 in. wide and extending 36 in. from a wall. He stood outside this restraining area until, on the signal to begin, he stepped into it. Although he was required to remain there while performing each of the tasks, he was permitted to reach over the restraining lines. The patient was told:</p> <ul> <li>"Hold this stick in your sound hand and stand behind the restraining line."</li> <li>"When I say 'go,' grasp the dowel in your prosthetic hand (hook), step into the restraining area, and place the dowel in the clip on the wall."</li> <li>"Do this as quickly as you can after you receive the signal, but do it as smoothly and as accurately as you can."</li> <li>"If you drop the stick while trying to place it in the clip, or at any other time, pick it up and continue the test."</li> <li>"You are being tested on your ability to place the stick in the clip as quickly as possible with the least amount of excessive movement."</li> </ul> <p> Proficiency in this test depended upon maintaining a relatively normal posture and appearance while operating the terminal device at varying distances and angles from the body. The cosmetic value of the performance was related to ease, grace, and smoothness of body movements and to associated characteristics in prosthetic control motions, while effectiveness was reflected in the speed and accuracy of positioning the dowel in the clip. Rated individually were body- and limb-positioning movements, appearance of prehension control motion, and appearance of elbow-lock control motion. These were then consolidated into a rating of total performance by use of the same type of 10-point scale as in the prehension test: excellent, 10; good, 8; average, 6; fair, 4; poor, 2. Again, ratings of 9, 7, 5, 3, and 1 were interpolated as necessary. The time required to perform each positioning test was recorded by means of a stopwatch. <b>Fig. 19</b>, <b>Fig. 20</b>, <b>Fig. 21</b>, <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Practical-Activities Tests</h4> <p>The practical-activities tests called for each amputee to be tested in the performance of eight activities of daily living selected from the 20 common activities discussed heretofore. For each individual the activities varied in accordance with the criteria of frequency and importance previously mentioned (i.e., each amputee was tested on the eight activities he reported as occurring most frequently in his routine of living). In choosing between activities of approximately equal frequency, those regarded by the subject as of greater importance were selected for test.</p> <p>In the discussion of the temporal sequence of events during performance of the prehension test, it was pointed out that four phases of the performance could be isolated: the positioning movements for grasp, the grasp itself, the transporting of the object, and the positioning movements for release of the object. With one major exception, this breakdown served equally well as a guide to the more complex practical activities. Here, unlike the situation prevailing in the prehension test, the amputee must not only transport an object but must also make sure it arrives at a position where it can be used or manipulated purposefully. Moreover, the nature of the prehension test forced the amputee to pick up each object from the table without use of the sound hand, a feature that made it necessary to position the body and the prosthesis so that the object could be grasped with the terminal device. In routine practice, however, the amputee frequently picks up an object with his sound hand and places it in his terminal device, thus eliminating many of the positioning movements otherwise required for grasp.</p> <p>With special reference to practical-activities tests, therefore, we may speak of "positioning movements for use," as distinct from "positioning movements for grasp or release," to mean the sequence of motions adopted by an amputee to bring an object into position for the performance of a useful task. Each activity was rated according to the normalcy of the pregrasp positioning movements, the security of the grasp, and the adequacy of positioning for use. The first two were scored on the same basis as in the prehension test; the degree of awkwardness in the positioning movements was rated and the number of errors tallied.</p> <p>Positioning for use, however, refers to the manner in which an object is grasped as that relates to the intended manipulation or use of the object. For example, when the normal hand holds a telephone, both mouthpiece and receiver are positioned close to the face for ease and comfort in hearing and speaking. The artificial hand of an amputee may hold the telephone at some distance from the face, thus necessitating some undue amount of compensatory head-bending. Or the hearing end of the telephone may be held against the ear while the mouthpiece is at eye level rather than mouth level. Errors such as these in positioning an object for use may be due either to faulty judgment on the part of the amputee or to limitations inherent in the prosthesis. Whatever the cause, the adequacy of positioning in relation to ultimate use was rated in terms of the deviation from normal position and of the degree of compensatory movement necessitated by the position of the object in the appliance. These scores were then combined in an over-all rating of the functional and cosmetic value of the amputee's performance in each activity. Rating was accomplished on a 10-point scale as follows:</p> <p>Excellent (10). Object position does not deviate from position for normal use, nor are compensatory body and limb positions necessary.</p> <p>Good (8). Object deviates slightly from position in which the normal hand would use it; slight deviations in body and limb positions may also be present.</p> <p>Average (6). Object deviates somewhat from normal position, and some compensatory deviation in body or extremity position is necessary to use the object.</p> <p>Fair (4). Object shows marked deviation from normal position for use and necessitates somewhat awkward body and limb positions to accomplish the task.</p> <p>Poor (2). Object shows marked deviation from normal position for use, accompanied by strained, awkward, or obtrusive body and limb positions.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 whenever it was felt to be necessary. In the accompanying annotated illustrations are depicted the materials, instructions, and procedures utilized in the administration of the 20 activities comprising the test series. Every time the amputee began one of the practical tests, he was first requested to perform the task in his customary way. He was told that the series of tests was a means of determining how he performed those tasks normally as part of his activity pattern. It was pointed out that he was being rated on how well he did the entire task regardless of the specific use he made of the prosthesis. The basis for rating the over-all appearance of the performance was the same as that for the prehension test, and the time taken to complete each test activity was recorded. <b>Fig. 23</b>, <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Reliability And Validity</h4> <p>Fundamentally a test is an instrument for measuring the extent or absence of a trait or attribute. To be most meaningful, test results must be both reliable and valid.</p> <p>The reliability of tests which are scored by means of judgmental ratings depends upon the use of consistent standards in rating performances, and ordinarily precautions are taken to ensure a comparable frame of reference among the raters. During the course of these studies, the reliability of the raters' judgments was evaluated periodically and found to be reasonably satisfactory. A stringent statistical analysis at the completion of the studies (Appendix I) confirmed the reliability of the ratings on the abstract-function tests. But because too few practical-activity tests were scored by each rater, the reliability of the practical-activities ratings could not be assessed in the same way.</p> <p>The validity of a test rests upon the degree to which it actually measures what it is designed to measure. Selection of the abstract-function tests was based upon an analysis of the functional requirements of prosthetic utilization, the skills involved being those necessary to operate the prosthesis under any circumstances. Since these tests were designed to evaluate proficiency of prosthetic use by direct measurement of meaningful performance with prostheses, they have a certain amount of face validity. The validity of the practical-activities tests appears to be self-evident, since the amputee's ability to perform a given task was in this case determined by having him actually perform it in the presence of the raters.</p> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>As might have been anticipated, the ratings of below-elbow and above-elbow cases in the prehension test clearly indicated that performance was related to amputation level. That is to say, the average below-elbow performance level was consistently better than above-elbow performance in both pre- and post-treatment evaluations (<b>Table 24</b>). An important point reflected by these data is that the discrimination of differences by the prehension test may be regarded as evidence supporting the validity of the test. Experience indicates that the below-elbow amputee generally accomplishes more with a prosthesis and performs in a smoother and easier way than does the above-elbow amputee. Since it distinguishes these two groups clearly, the prehension test may be said to measure those qualities which distinguish the adequacy of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of performance ratings in the pre- and post-treatment evaluations, presented in <b>Table 24</b>, reveals a definite but not always statistically significant improvement in prosthetic function. For the 75 subjects comprising the below-elbow sample, the mean for the new arms was 5.8 as compared with 5.5 for the old. Although this difference is not significant statistically, closer study of the scores made at the two evaluations indicates a small but definite improvement in performance, especially through the middle of the score range, where there was a marked decrease in the number of amputees receiving ratings of 4 and 5 and a sharp increase in those receiving ratings of 6. It appears then that, although the treatment program had little effect on below-elbow amputees who exhibited very poor or very superior skills with their old arms, it did improve the "low-average" performers. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As reported in Part 1 of this Section, the below-elbow group as a whole felt that their new arms were somewhat more useful and easier to operate than the old. But this improvement was less marked than that at other levels of amputation, and some below-elbow subjects even felt that the new prosthesis was inferior to the old. The data thus tend to corroborate an earlier conclusion that for the less severely handicapped below-elbow amputee the improvement in prehension skill was not outstanding. By contrast, the 51 above-elbow cases showed a decided improvement in prehension performance with the prostheses fitted in the Field Studies. Statistically, the 4.9 average achieved with the program prostheses was significantly higher than the 4.0 average attained with the old arms. A comparison of the scores at the two evaluations revealed a clear-cut and consistent shift in the direction of improvement of performance. There was a marked decrease in the number of amputees scoring below 5 and a sharp increase in those scoring above 5. It may therefore be concluded that there was a general elevation of the level of above-elbow performance, the greatest improvement being evidenced among those of low and low-average skills. With only four cases available for analysis, the findings for the shoulder-disarticula-tion amputees are of limited significance, although among the four there was also a definite trend toward improvement in post-treatment performance.</p> <p>In general, the results obtained in the functional tests of the above-elbow and shoul-der-disarticulation amputees correspond to the verbal reports, which strongly indicated that the program prostheses were more useful, easier to operate, and more extensively used. Improvement in these two groups was more marked than in the below-elbow group, and it may therefore be concluded that the more severely handicapped segments of the amputee population derived the most benefit from the program prostheses and that the benefits accrued principally to the poorer performers. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed with which amputees performed the prehension test was also related to level of amputation, the below-elbow subjects taking significantly less time than the above-elbow cases to complete the test at both pre- and post-treatment evaluations. For no group (below-elbow, above-elbow, or shoulder-dis-articulation) did the average amount of time taken to perform the prehension test decrease significantly after treatment. The data for the below-elbow and above-elbow subjects are presented in <b>Table 25</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>According to these findings, improvement in performance skill was not reflected in an appreciable increase in performance speed, but the reasons for this apparent inconsistency are not clear. One possibility has to do with the increase in the number of subjects using APRL terminal devices at Evaluation II as compared with Evaluation I (below-elbow, from 14 to 37; above-elbow, from 8 to 31). The "double-shuffle" control motion involved in this type of device, and the consequent increase in the time required to operate it, may account for the failure to increase speed along with skill and ease of operation. At the same time, however, there is a suggestion that slower operation with APRL devices is accompanied by smoother and easier prehension.</p> <p>Two kinds of errors, grasp and compression, were recorded. Grasp errors were counted when an object slipped or fell from the terminal device or when it had to be regrasped. Compression errors were scored when the rubber objects were distorted by poor control of finger pressure. On both pre- and post-treatment evaluations, the below-elbow cases made fewer grasp errors than did the above-elbow amputees (<b>Table 26</b>). The shoulder-disarticu-lation cases made substantially more grasp errors than did either the below-elbow or the above-elbow subjects. The below-elbow subjects made fewer grasp errors after treatment (average: 8.0) than at Evaluation I (average: 9.2), but the difference was not significant statistically. There was little difference in the number of grasp errors made by above-elbow amputees before (10.0) and after (9.7) treatment. While the shoulder-disarticulation cases showed a stronger trend toward improvement in grasp security than did either of the other two groups, the result should be interpreted cautiously because of the small number of subjects involved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus it would appear that, despite the changes made in terminal devices, harnessing, and control-system alignment, grasp security was not greatly influenced by the treatment process. Perhaps the principal limitation was the lack of "all-purpose" versatility in the hook, its rigid structure preventing it from being completely suitable for handling a variety of objects.</p> <p>Unlike grasp errors, compression errors decreased in frequency among both below-elbow and above-elbow cases after fitting with program arms (<b>Table 27</b>), and the shoulder-disarticulation amputees appeared to follow the same trend. Below-elbow and above-elbow cases made the same number of compression errors (6.2) in the pretreatment evaluations. After the treatment procedure, there was again little difference between the scores of the two groups, the averages being 4.5 and 4.8 respectively. As one would expect, the shoulder-disarticulation cases made more compression errors than did either below-elbow or above-elbow subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Better control of finger pressure may be explained by the large proportion of APRL devices fitted in the treatment program and also by the contributions from improved harness and control systems. The apparent influence of APRL terminal devices in improving control of finger pressure without also improving grasp security suggests a deficiency in hook size or shape and perhaps also a general lack of emphasis on training for the proper approach in prehension activities.</p> <h5><i>Positioning Test</i></h5> <p>Skill in performance in the positioning test, as in the prehension test, was related to level of amputation, the below-elbow amputees making consistently higher scores, and the positions in which the below-elbow subjects performed best differed from those in which the above-elbow subjects were most effective (<b>Table 28</b>). The below-elbow amputees were most effective at mouth and waist levels in the centerline (Positions 1 and 2); at chest and waist levels toward the prosthetic side (Positions 4 and 5); somewhat less effective toward the sound side (Position 6); and poorest at mid-thigh level in the centerline (Position 3). Above-elbow subjects were most proficient at two waist-level positions (Positions 2 and 5); somewhat less effective at waist level on the sound side (Position 6), at chest level toward the prosthetic side (Position 4), and at mid-thigh in the centerline (Position 3); and poorest at mouth level in the mid-line (Position 1), all of which suggests that the most efficient use of the above-elbow prosthesis is to be had at 90 deg. of forearm flexion and that less efficient operation occurs when the forearm is flexed appreciably more or appreciably less than 90 deg. Shoulder-disarticulation subjects were most proficient in handling objects at waist level, either in the mid-line or toward the prosthetic side (Positions 2 and 5).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Among both above- and below-elbow patients, skill in operating the terminal device in different positions improved significantly after treatment, a result more positive than that obtained from the corresponding prehension test, where improvement was statistically significant for above-elbow amputees only. Analysis of the pre-and post-treatment ratings of the below-elbow amputees revealed significant improvements (<b>Table 29</b>) in the ability to operate their terminal devices in three positions-at waist level in the mid-line (Position 2), at chest level toward the prosthetic side (Position 4), and at waist level toward the sound side (Position 6).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The time required by the amputees to complete each of the six tests did not appear to be related to the particular position involved, nor did performance time seem to be affected by the treatment process (<b>Table 30</b>). For the below-elbow cases, mean performance times for all six tests varied between 5 and 7 sec. in both pre- and post-treatment evaluations. Similarly, the above-elbow cases performed each of the six tests in approximately the same average time (10 to 16 sec. at Evaluation I, 9 to 14 sec. at Evaluation II).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although by definition the positioning test is "abstract," the level of performance in the several positions bears a relationship to the ability that may be expected in the performance of practical activities in the same positions. Improved performance in the test should be reflected either in greater ease in use of the prosthesis or else in the ability to perform more activities with it. Since in all cases there was an improvement in test performance after treatment, there is strong indication that treatment resulted in im- proved skill in utilizing a prosthesis in the positions required for the pursuit of the normal pattern of daily activities. While the available evidence is not wholly definitive, the distinct shift toward higher scores after treatment must be taken as indicating a general improvement in achievement level.</p> <h4>Practical-Activites Tests</h4> <p>In contrast to the abstract tests of prehension and of positioning a prosthesis, the practical-activities tests were designed to evaluate the amputees' ability to integrate the mechanical operations of prehension and positioning into the efficient performance of a complete and meaningful task. From the list of 20 tasks there were selected for each amputee eight specific test activities which, according to the subject's own statements, occurred most frequently for him in his normal activity pattern and to which he himself attributed the most importance. By virtue of these criteria some tasks were tested less frequently than others. The present analysis involves only those activities performed by 10 or more subjects.</p> <p>On this basis, the below-elbow subjects received substantially higher scores than did the above-elbow cases, a fact which only substantiates the superior ability of the below-elbow amputee in coping with daily needs. The average, weighted, pretreatment performance rating was 6.4 in below-elbow cases, 5.0 in above-elbow cases. After the treatment program, the corresponding figures were 7.0 for the below-elbow and 6.2 for the above-elbow patients (<b>Table 31</b> and <b>Table 32</b>). The scores of the few shoulder-disarticulation cases tested were far below those of either below-elbow or above-elbow amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If we consider that a score of 10 represents normal nonamputee performance, then the average score of 7.0 obtained by the below-elbow population for all 20 activities represents a creditable performance. For some tasks, of course, the average was higher than 7.0, and certain individual amputees consistently outperformed the average. It may thus be con- cluded that below-elbow subjects generally perform common daily tasks in a smooth, relatively unobtrusive, errorless manner. Although they never attain a level of skill equal to that of the nonamputee, they (and particularly the better performers in the group) tend to approach that level of performance.</p> <p>The post-treatment skill of the above-elbow group, represented by an over-all weighted-average rating of 6.2, indicates a relatively high level of performance. While the need for an elbow-lock control motion, together with the greater body distortion that results from the lack of an anatomical elbow, reduces the functional level of the above-elbow amputee to less than that of the below-elbow group, the above-elbow patient is nevertheless capable of more or less skillful use of a prosthesis.</p> <p>In the post-treatment evaluation, the below-elbow subjects generally performed better in all of the 15 activities studied. Increases in the ratings ranged from a low of 0.1 point to a relatively significant 1.5 points. Although the average increase (0.6 point) was not substantial, all of the changes were in the expected direction, an increase of a full point or more being achieved in five of the activities. A similar trend characterized the performance of the above-elbow subjects, where improvement (ranging from 0.1 point to 2.8 points) occurred in all 11 activities studied. In eight of the activities there was a gain of at least one full point, the average for all 11 being 1.2 points. The magnitude of the gains and the number of activities in which significant improvement occurred were both greater than in the case of the below-elbow subjects.</p> <p>It should be noted that most of the 20 shoul-der-disarticulation amputees taking the test at the post-treatment evaluation were capable of performing six to eight of the 20 activities. Apart from considerations of the quality of performance, this outcome represents a significant increase in the number of activities those subjects were capable of performing.</p> <h3>Discussion</h3> <p>Proficiency in the use of arm prostheses is clearly related to level of amputation. The performance of the below-elbow amputees in the NYU Field Studies was found to be consistently better and faster than that of the above- elbow amputees, who in turn performed better and faster than did the few shoulder-disarticu-lation amputees involved. Differentiation of performance was apparent in all tests, both before and after treatment.</p> <p>The most important single reason for the superior performance of the below-elbow amputee lies in his retention of the natural elbow. The above-elbow amputee is required to operate a mechanical elbow scarcely designed to provide all the functions of the natural elbow. Coupled with this mechanical limitation is the relatively high degree of skill required to operate present-day mechanical elbows smoothly and unobtrusively. Together these two factors impose upon the level of above-elbow prosthetic performance an insurmountable upper limit. The difficulty is only magnified in the case of the shoulder-disarticulation amputee, who must operate both a terminal device and a mechanical elbow by scapular abduction, a motion more gross and yet more limited than the humeral flexion normally available to both above- and below-elbow amputees. Further development and refinement of existing elbows and an increased emphasis on amputee training could conceivably elevate the level of above-elbow and shoulder-disarticulation performance to some degree. But radical changes to bring the above-elbow or shoulder-disarticulation amputee functionally up to par with the below-elbow case must await new concepts and designs in the development of components and control systems.</p> <p>As a result of the treatment program in the NYU Field Studies, the ability of all the amputee subjects to use their prostheses improved to varying extent. The superiority of the newer components and newer fabrication procedures, and the systematic training given to each patient as a routine matter, contrived to produce a general benefit differing only in degree from subject to subject and from amputation level to amputation level. That the improvement in performance among the below-elbow amputees was relatively small indicates that as a group they derived the least benefit from the new developments, for the obvious reason that their relatively high level of proficiency prior to the studies discounted their ability to profit greatly from the program. The more significant gains made by the above-elbow and shoulder-disarticulation amputees identified these groups as the major beneficiaries of the Field Studies. Although as a group the above-elbow subjects never quite attained the achievement level of the below-elbow amputees, the gap between them was significantly smaller after the treatment program, and as individuals the few shoulder-disarticulation cases improved markedly.</p> <p>The prostheses prescribed in the program were designed to provide maximum comfort, freedom of movement, and optimal replacement of lost function. The more significant improvements included higher, better-fitting, and better-appearing sockets; more useful and more easily operating elbows; improved efficiency of force transmission through better cable alignment and use of more stable materials; lighter, freer, and more comfortable harnessing; and a marked increase in the use of terminal devices offering improved control of grasp force. The advantages offered by these features were apparent in the prehension test, in which the objects to be manipulated remained stationary and the amputee was required to place himself and his terminal device in the best position for grasp and release. The need for compensatory body movements, which tend to lower performance ratings, was clearly reduced by the increased freedom and mobility of the new arms. The increased control of finger pressure offered by the new devices was reflected in the general and significant decrease in the number of compression errors made at the second evaluation.</p> <p>The value of the newer elbows seemed to be demonstrated by the improvement in performance of the above-elbow cases in the positioning test. The higher scores on the second test were based on more accurate positioning of the terminal device with lessened body contortion-a function of the elbow unit. It is interesting to note that, while performance ratings improved after treatment, speed of performance remained static. With the wider use of APRL devices on the second evaluation, an increase in the time required might have been expected. Since operating time did not increase, improved control of finger pressure was achieved without a concomitant slowing of performance.</p> <p>The similarity in performance patterns in the abstract-function and practical-activities tests may have important clinical consequences. Further study is warranted to see whether proficiency in the practical utilization of a prosthesis is related to, and perhaps reflected by, performance in abstract-function tests. Should such a relationship be found, it would be possible to convert the easily administered abstract-function test from a research tool to a clinical instrument. A combination of the more sensitive and selective elements of the tests could provide the foundation for a reliable system of measuring achievement and proficiency in amputee training.</p> <p>As a result of the Upper-Extremity Field Studies, it is now possible to establish a set of proficiency norms based upon amputee per- formance but retaining as its main criterion the skill patterns of nonamputees. The therapist who trains an arm amputee to use a prosthesis could thus have available a realistic and relatively objective standard against which to evaluate the progress and achievement of each patient, since she would be comparing his performance with that of hundreds of amputees of a similar type. The resulting improvement in the evaluation of training effectiveness should permit a judicious allocation of training time and services. Despite its inadequacies of crude-ness and of administrative difficulty, the performance-evaluation system described here established for the first time a logical plan for ascertaining the degree of functional restoration offered amputees by modern prosthetics services, a problem heretofore frequently bypassed for lack of reliable and valid methods.</p> <h3>Concluding Remarks</h3> <p>Refinement of the existing research tools on the basis of past experience, reapplication of these methods in the light of present knowledge, and the further correlation of results may well make it possible to predict the anticipated outcome when specific prosthetic components are applied to a particular arm amputee. Such an eventuality may lead to major changes in the principles of arm prescription and fitting as currently embodied in the art-science of upper-extremity prosthetics.</p> <p>The results of these studies, which have been analyzed and interpreted in the discussion sec- tions on pages 54-61, 99-103, and 143-149, are not resummarized here by way of concluding this article. It is perhaps sufficient to close with the remark that there has been presented in this article a large volume of information providing new insights-some clear, some tentative-into the over-all problem of evaluating arm prostheses. The surface of this broad field has been partially mapped along with some scattered probings of the substrate; but certainly the way has been opened for those who may elect to pursue this problem a little further.</p> <h3>Appendix I Reliability and Validity of the Test Methods</h3> <h4>Reliability</h4> <p>It is well known that test results are subject to a variety of influences and that therefore errors of measurement are to be expected under the best of experimental conditions. The tests used in the NYU Field Studies were at the time in a developmental stage, and in anticipation of errors tending to reduce reliability several precautionary steps were taken.</p> <p>Three measures were employed in scoring the performance tests-performance rating, number of errors, and time. The reliability of the last two is not open to serious question, since such errors as are likely to occur in counting errors or in reading a stopwatch are not usually of significant magnitude or of a systematic nature and can be expected to vary randomly and "average themselves out." Performance ratings, being based on judgment, are more variable, so that errors tending to reduce reliability are to be expected. Some of the principal sources of bias in this study may have been:</p> <ol> <li>Errors of Leniency. Judges tend to rate higher in the desirable traits the subject they actually know.</li><li>Errors of Central Tendency. Judges hesitate to give extreme ratings and so tend to displace subjects in the direction of the average for the entire group, thus misrepresenting the true variation in the group.</li><li>Halo Effect. We tend to judge in terms of the general mental attitude toward the test situation. Knowing, for example, that a subject is being tested for the second time, with an intervening period of fitting and training, a judge may tend to upgrade the performance unduly.</li><li>Normal Variation in the Attitude of the Judge. As individuals, we are continuously influenced by our physical environment and emotional status, and the net effect may produce variability in judgment.</li><li>Variations in Judges' Values. A judge's preconception about the relative difficulty of activities, or of the value to be placed upon efforts in relation to achievement, may bias his judgment.</li></ol> <p>During the course of the studies, 12 NYU Field Representatives conducted the performance tests over a 3-year period between 1953 and 1956. At no one time were all of the judges active in the work, and as a result they did not conduct equal numbers of tests. Nor was it always possible for the pre- and post-treatment evaluation of a patient to be judged by the same rater. Steps were therefore taken to maintain the reliability of the ratings by familiarizing judges with probable sources of error and by firmly establishing the judgment criteria. In addition, all judges were highly qualified members of the NYU staff, with previous research experience in testing and assessment. All were either graduates of the course in upper-extremity prosthetics at UCLA or else had been given similar instruction at New York University. Moreover, the criteria for evaluating performance were carefully studied in formal sessions by all the judges to aid in the development of consistent standards of judgment. The effectiveness of these steps in maintaining reasonable reliability was gauged by statistical analysis.</p> <p>Evidence of reliability was obtained by comparing periodically the independent but simultaneous ratings of a single performance as arrived at by several judges. The ratings thus obtained were evaluated by means of a statistical procedure involving Kendall's Coefficient of Concordance,<a style="text-decoration:none;">*</a> which indicates the degree to which a number of raters are applying essentially the same standard. Kendall's coefficient (W) is used to evaluate the difference between the variability in a set of ratings actually obtained and the variability to be expected in a hypothetical set of ratings if there were perfect agreement among all the raters. The resulting single measure of the extent of agreement among several judges is usually expressed as a chi-square function [x2 = p(m - 1) W, where m = number of judges and p = number of scores]. If the difference (in degree of variability) between the obtained and the hypothetical sets of ratings is significant (by statistical test), we may assume that not all of the raters were applying the same judgmental standard. Since of the original 12 raters in the Field Studies only eight rated enough cases for the results to be valid, only these eight were included in this and succeeding analyses of homogeneity. The statistical findings (x2 = 14.47; df = 7; P &lt; 0.05) indicated that a hypothesis of no relationship between the sets of ratings given by each rater is untenable. This may, therefore, be considered as indicative of a satisfactory degree of consistency in the judgments of the raters at those times. To test the reliability of the scores given by the judges during the entire test period, another technique, "analysis of variance," was used.</p> <p>"Analysis of variance" is a statistical procedure by which a number of independent samples or sets of scores may be tested simultaneously to determine whether or not they are sufficiently similar to be pooled. It is an efficient method for evaluating inter-rater reliability when more than two raters are involved. The test is expressed in terms of a ratio, F, which describes the relationship between the variability of the scores among the several raters (between groups) and the variability of each rater's scores from the mean of all raters (within groups). Simply stated, it is a test of a hypothesis that the scores given by any one rater did not vary significantly from the average of the scores given by all the raters. As shown in the relationship the larger the variance from one rater to another (between groups) as compared with a single rater's variance from the common mean (within groups), the larger the fraction (F). A large F signifies a great difference between the raters; an F of low value indicates homogeneity in the group. A low ratio therefore indicates that performances were consistently rated, that the raters are therefore interchangeable, and accordingly that all the ratings may be considered as having been given by the same rater. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the small number of cases involved, this technique could not be applied to the data from the practical-activities tests or from the abstract-function tests for the above-elbow sample at the pretreatment evaluation. It was applied to the ratings given the below-elbow cases on administration of both the prehension and the positioning test and to the ratings given the above-elbow cases at the post-treatment evaluations (<b>Table 1</b>). There were thus 21 tests in which individual raters had scored enough cases for reliability studies to be made by this means. Used were only those ratings given to subjects evaluated on both pre- and post-treatment tests by the same group of raters. Which is to say that, although an individual rater may not have scored the same subject on both evaluations, he was a member of a group of raters who had given all the ratings.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the 21 tests, 17 were not significantly different (0.05 level). That is, the extent to which they varied is well within the relatively narrow limits of chance fluctuation, which indicates an acceptable degree of consistency and reliability among the raters. Four, footnoted in <b>Table 1</b>, were statistically significant beyond the 0.05 level of confidence (i.e., there was enough variation in the ratings in these tests to raise a question about the consistency of rating standards).</p> <p>Despite the significant F value obtained in the four questionable tests, all results were used in this report. While the lower statistical reliability of the four may indicate rater unreliability or instability due to smallness of the sample (which would suggest the possibility of eliminating either these tests or the extreme raters), they were retained because the results clearly followed the trend of those tests appearing more reliable statistically. Since, furthermore, all of the tests are, or were, in a developmental stage, no theoretical reason could be adduced for their low reliability. There seemed to be greater value in retaining all of the tests and analyzing the conditions affecting reliability than in discarding some tests on statistical grounds alone. Considering the implications of the findings from all 21 tests, the ratings seemed homogeneous enough to warrant pooling.</p> <h4>Validity</h4> <p>To establish the validity of a test on empirical rather than logical grounds requires a previously established independent criterion with which to compare the test in question. The degree of correspondence between the two (i.e., the extent to which the test measures the same variable as does the independent criterion) is the extent of test validity. External criteria usually are: a specific outcome or product of an activity (as, for example, the number of words typed by a typist in a specific time is a criterion of typing speed), or the activity itself (as illustrated by the speed of a runner as a criterion of fleetness of foot), or the judgment of persons qualified in a given field. The abstract-function tests-the prehension test and the positioning test-require activities which correspond closely to the skills being measured (i.e., to the ability to grasp a very wide variety of objects and to operate a terminal device in several useful planes). No other criteria appear more germane. The practical-activities tests derive their validity in the same fashion-each activity is a valid test since it is itself the skill being measured.</p> <p>To go a step further and to determine whether all or none of these tests are also useful measures of "prosthetic utilization" or of "extent of functional restoration" or of "rehabilitation" requires broader study and the use of other criteria. The presently available judgment of qualified clinic personnel may be the most useful criterion with which the tests may be compared. If, for example, the way in which amputees were classified on the basis of the test results was closely related to qualified judgment about amputee achievement, it would tend to establish the validity of the test as a measure of prosthetic utilization. Such an analysis is beyond the scope of the present work but remains as an interesting avenue for further study.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Siegel, S., Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The five kinds of tasks selected were considered as encompassing the major undertakings in which an arm amputee might use a prosthesis in the course of daily living.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Children's Prosthetic Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-027.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-029.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-030.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-028.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-031.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-032.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-033.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-034.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-035.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-036.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-037.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-038.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-039.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-040.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-041.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-042.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-043.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-044.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-045.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/88bef5d62a14398fc3a18bca7131f8d8.pdf 86d59bbde4b62c325ee0ebad480c4e5f https://staging.drfop.org/files/original/a84e8ce4eb14a01f0ef2b2853a788184.jpg 0a6c5befd14aa80990442ce44b52ab3b https://staging.drfop.org/files/original/086c58dc00817fa00adcb9085b4887ee.jpg 3c6699b65e4f90cf65ce688efeef8135 https://staging.drfop.org/files/original/9b7bcc17ba2e80fbdba893a929d85938.jpg 9ed6bb7ee61966d89d7987f935e7b034 https://staging.drfop.org/files/original/16080d78a84c16864ec113cd9ecacdf5.jpg b392c89f1756f04fe19a3ad6250113e2 https://staging.drfop.org/files/original/29997ac6960eedc1a118bddad0b95f7c.jpg 6c9a31a9af5ba3831ccdbeb8f4936c57 https://staging.drfop.org/files/original/5786b706e7e673ea58f74136b2873bd9.jpg 0cd440682c88a020c34584737b244d7d https://staging.drfop.org/files/original/9619f95ba15af83f199f79659e870183.jpg b4c873ee734251f9760a68756ee81e23 https://staging.drfop.org/files/original/98848e3c786b553e83ab938453172bb8.jpg 0c8c38b091e2db04fca212e6d969202b https://staging.drfop.org/files/original/156b8585b39aa6c343505e1dbb2319eb.jpg 473d661cc1700725a11f2a0801e2f0b4 https://staging.drfop.org/files/original/180831d52019c33f425c4abef213436c.jpg cb53f48a3e0b0aadd418c3f302efb8c8 https://staging.drfop.org/files/original/00d9d63023a6fe1b224f4e65f8f427d8.jpg d19eb70180882f9be9283cfe7c9fad7c https://staging.drfop.org/files/original/92cc21d0b179a43c17c8e2601b36face.jpg ef09bcbd71c9a5ab1946affdd2d3a1fb https://staging.drfop.org/files/original/84ed9b79ed6c37a2442937152385a670.jpg 96cc057c0c3752fe06400aaef020bf31 https://staging.drfop.org/files/original/02800ee7d2bcaf59054a58fa1a76f5f9.jpg bcd50bad74ee70aedc0c9fdd43ae2b78 https://staging.drfop.org/files/original/e83e8ff373a7a2161bce8c4e4b469c59.jpg e0815425b9120a70904cb54f6db154c4 https://staging.drfop.org/files/original/13e717b3a2917a1f960b337b564c1a2c.jpg 95b5a4e637a9579f4f7f1262bd8f9f93 https://staging.drfop.org/files/original/c7761c10dee8f20eb5989c636532dd48.jpg 16a76ccbb32f47d32cc0636dfe8b849c https://staging.drfop.org/files/original/de8c25414b9f0dc535a4ece8c2a3bc3c.jpg e42c82f4b353b2d82db9be8e58647298 https://staging.drfop.org/files/original/aae1935446e932da0d197817ff316667.jpg cdfce01bb2a2f3d62f09803a4399a4cd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_004.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 4 - 25 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_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Munster-Type Below-Elbow Socket, a Fabrication Technique</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Kevin A. Cody, M.A. <a style="text-decoration:none;">*</a><br />George Hartmann, C.P.O. <a style="text-decoration:none;">*</a><br />Dominick E. Casella <a style="text-decoration:none;">*</a><br /></h5> <p>The introduction of the Munster technique into the United States in 1958 generated considerable interest in the prosthetics profession, particularly for the management of amputees with short and very short below-elbow stumps. However, in spite of the enthusiasm for this technique, its application has met with varying success in this country. The dearth of precise instructional material has undoubtedly contributed to the lack of consistent results. Each prosthetist has improvised from the limited information available, sometimes successfully, sometimes unsuccessfully.</p> <p>The purpose of this article and the manual upon which it is based<a></a> is to present a detailed description of the Munster technique based upon the procedures utilized in the successful fittings performed in the New York University evaluations of 1963-1964.<a></a> But there can be no substitute for formal instruction and demonstration in the technique. This point is stressed because at least one critical procedure in the fabrication technique, that of cast taking, is quite difficult to learn by the written word and pictures alone.</p> <p>The procedures presented do not conform in every respect to those promulgated by the developers, Drs. Oskar Hepp and G. G. Kuhn.<a></a> However, it is believed they are a close approximation. For this reason the technique is referred to as the "Munster-type" fabrication technique. In choosing this title, it is intended to give appropriate credit to Drs. Hepp and Kuhn for the original development of the technique, without implying identity with their procedures.</p> <p>Short below-elbow stumps have always presented fitting problems for the obvious reasons of small attachment area, poor leverage, and a decreased range of useful motion. Split sockets and step-up hinges have commonly been used to provide a full range of elbow flexion (135 deg.) to amputees having very short below-elbow stumps. However, this system is characterized by several features which tend to reduce its over-all acceptability. Step-up hinges decrease the lifting power available to the amputee, increase the bulk of the prosthesis at the elbow and proximal forearm, and historically have lacked durability. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior-oblique and posterior-oblique views of the Munster-type prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the middle 1950's, Drs. Hepp and Kuhn of Munster, Germany, formulated a new approach to the prosthetic management of short upper-extremity stumps. They developed a technique for fabricating sockets for below-elbow and above-elbow amputations which provides a more intimate encapsulation of short slumps.<a></a> </p> <h3>Evaluation of Munster Fabrication Technique</h3> <p>New York University Adult Prosthetic Studies became interested in the Munster technique for amputees having short and very short be-low-elbow stumps, following the favorable experiences reported by amputee clinics in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children.<a></a> Under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development, New York University conducted an evaluation of what was considered the Munster technique in applications to adult amputees.<a></a> The general characteristics of the below-elbow sockets fabricated in this study were:</p> <ol> <li>The forearm was set in a position of initial flexion (average 35 deg.) in relation to the humerus. Because of the reduced range of useful motion, the socket was flexed to position the terminal device in the most generally useful area.</li><li>The anterior trim line extended to the level of the antecubital fold, with a channel provided for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket enclosed the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket. The trim line was just above the level of the epicondyles.</li></ol> <p>Because of the high anterior and posterior walls of the sockets, the range of motion for the average amputee was limited to approximately 70 deg. (from 35 deg. to 105 deg. flexion). The limited range of motion characteristic of Munster-type sockets bears emphasis (<b>Fig. 2</b> and <b>Fig. 3</b>). In current practice, the acceptable checkout standard for maximum elbow flexion with the prosthesis is that it should be within 10 deg. of stump flexion without the prosthesis. This standard is not applicable to the Munster-type prosthesis. Nevertheless, the decreased range of motion available has been found acceptable by unilateral amputees who typically use their prostheses as assistive devices and perform very few activities at the extremes of the flexion-extension range.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Maximum extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Maximum flexion, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results of the New York University study of Munster-type fittings cited earlier indicated that:</p> <ol> <li>Amputees reacted positively to the comfort and security of the socket.</li><li>The decrease in flexion range had no appreciable effect on the prosthetic functions of unilateral amputees. However, for bilateral subjects, modification of the anterior trim line and the provision of a wrist-flexion device were necessary for the performance of tasks close to the body.</li><li>Lifting and holding forces available to the amputee were generally superior.</li></ol> <p>(<b>Fig. 4</b> and <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Live lift"-resisting vertical downward force while maintaining the elbow flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Axial load"-resisting vertical downward force with the elbow extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following the favorable results obtained in fitting adult amputees, New York University Child Prosthetic Studies initiated a study of the applicability of these procedures to children with very short, short, and long below-elbow deficiencies. As of March 1965, ten successfully fitted children ranging in age from 20 months to 10 years had worn their prostheses for periods ranging from 4 to 14 months.</p> <p>Although the study of the children's fittings had not been completed at this writing, the indications are that fabrication procedures for adults, as described in this article, would be equally applicable to children.</p> <h3>Prescription Considerations</h3> <p><i>A priori, </i>this method of socket fabrication would appear to be of greatest potential benefit to amputees with stumps of the short and very short types. These are patients who, under current practice, would typically be fitted with metal elbow hinges-step-up, polycentric, or, at the longer limits of the range, single-pivot or flexible hinges. Prime beneficiaries might be amputees who normally would be fitted with split sockets and step-up hinges because of the inherent disadvantages in this type of fitting.</p> <p>In general, this hypothesis has been verified by fitting experience to date. In the NYU evaluations approximately 90 per cent of the stumps fitted fell into the short and very short below-elbow categories. Specifically, nine adults (including one bilateral amputee) with stump lengths ranging from l-1/2 in. to 5-1/2 in. (18 to 52 per cent) and eight children with stumps 2 in. to 3 in. long (25 to 40 per cent) were successfully fitted with Munster-type prostheses.</p> <p>The precise limits of applicability of the Munster-type prosthesis (that is, the minimum and maximum stump lengths) must be determined individually for each patient. However, based upon a somewhat limited investigation of these considerations, the following guidelines are offered:</p> <p><i>Minimum length: </i>Very short stumps virtually disappear at 90 deg. of elbow flexion. Hence, the maximum prosthetic flexion angle obtainable with stumps in this category is limited accordingly. The shortest stump fitted at NYU was 1-1/2 in. (18 per cent) in length. The maximum flexion angle obtained (with prosthesis) was 80 deg.</p> <p>Thus, fitting of Munster-type sockets to stumps as short as 1-1/2 in. depends upon the acceptability of a very limited amount of elbow flexion (usually less than 90 deg.).</p> <p><i>Maximum length: </i>With regard to maximum stump length, two limiting factors must be considered:</p> <ol> <li>Depending on the extent of the anatomical deficiency, stumps of mid-length and longer usually have some degree of residual pronation-supination which may be harnessed in a conventional below-elbow socket with flexible hinges. This active pronation-supination of the prosthesis is eliminated with the Munster-type fitting. The question to be decided is whether other advantages of the Munster-type prosthesis adequately compensate for the loss of rotation in a given case.</li><li>The configuration of the Munster-type socket (proximal opening at an angle to the socket) presents progressively increasing difficulty in donning and doffing the prosthesis as stump length increases. Absolute stump length rather than proportion of sound side remaining appears to be the prime determinant. The difficulties can be reduced by socket modifications, such as a looser fit or lowered trim line. Such modifications, however, progressively reduce control and retention of the prosthesis.</li></ol> <p>NYU has fitted several adult and juvenile amputees whose stumps fell into the long classification; that is, 55 per cent of sound side or longer. One adult at the borderline of the long classification (5-1/2 in.-56 per cent) and a child well within this category (4 in.-66 per cent) were not affected by the considerations mentioned above. In both cases residual pronation and supination were minimal, and no difficulty was experienced in putting on and taking off the prosthesis.</p> <p>However, an adult with a 7-in. stump (66 per cent) required considerable modifications to the proximal brim before the prosthesis could be delivered successfully. The anterior trim line was reduced approximately 1/2 in. below the cubital fold to facilitate passage of the stump. The subject had about 55 per cent of residual stump rotation; but, since this rotation had not been utilized in the previous prosthesis, no deprivation was imposed by the Munster-type arm.</p> <p>One child with a 6-in. (92 per cent) stump was also successfully fitted with two different modifications of the Munster-type prosthesis. In the initial prosthesis, the posterior trim line was reduced to just above the olecranon for manageable donning and doffing. In a second fitting, the standard trim lines were maintained, but the socket was made somewhat looser than usual. Both modifications produced sockets with slightly reduced but still very acceptable retention.</p> <p>Thus, the Munster-type prostheses can apparently be fitted without difficulty to stumps up to the limit of the short below-elbow classification (55 per cent). The fitting of longer stumps involves consideration on an individual basis of the factors discussed.</p> <h3>Bilateral Fittings</h3> <p>The question of fitting Munster-type prostheses bilaterally is not fully resolved. Two problems are inherent in such fittings:</p> <ol> <li>The difficulty in donning two closely fitting prostheses without assistance.</li><li>The limitation imposed by restricted elbow flexion, particularly on the dominant side.</li></ol> <p>NYU has had no experience in fitting children bilaterally but has successfully fitted one bilateral adult amputee (4-in. and 5-1/2-in. stumps). The inherent problems were resolved by:</p> <ol> <li>Fitting the sockets less snugly than usual to facilitate donning.</li><li>Lowering the anterior trim line and providing a wrist-flexion unit on the dominant side for activities close to the body.</li></ol> <p>It is probable that selected juvenile bilateral amputees might be successfully fitted with similar modifications.</p> <h3>Procedures</h3> <h4>Stump Eexamination and Measurements</h4> <p>Materials required for stump examination and measurements are:</p> <ul> <li>Measuring tape</li> <li>Ruler</li> <li>Goniometer</li> <li>Measurement form (<b>Fig. 6</b>)</li> </ul> <p>A thorough stump examination is an important prerequisite to any prosthetic fitting procedure. In the Munster-type fitting, a stump examination is even more critical than usual because of the intimate socket encapsulation of the stump. Skin irritations, painful scars, abrasions, and sensitive areas must be identified so that necessary socket reliefs maybe anticipated and provided.</p> <p>Consistent with sound prosthetics practice, it is advisable to follow the conventional measurement procedures described in the<i>Manual of Upper Extremity Prosthetics</i><a></a> so that a comprehensive record will be available for future reference. The appropriate below-elbow measurements are recorded on the modified Upper-Extremity Measurement Chart shown as <b>Fig. 6</b>. However, it should be noted that, since the plaster-wrap casts are used as check sockets in this technique and stump molds made from the wrap casts are not corrected to measurements, the only measure essential for fabrication is the length of the normal forearm to wrist and thumb tip.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Measurement form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should also be noted that stump and sound forearm lengths are pleasured from the olecranon rather than from the epicondvles, since the olecranon is more convenient to use as a reference point on the cast and socket. These measurements are described below.</p> <p><i>Stump length: </i>The stump length is measured from the posterior aspect of the olecranon (<b>Fig. 7</b>). If distal redundant tissue is present, the measurement should include the redundancy.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Measuring stump length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Forearm length: </i>With the patient's sound forearm flexed at approximately 90 deg., and held midway between pronation and supination, measurements are made from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid, and from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Measuring forearm length. A, Measuring from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid; B, measuring from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Wrap Cast</h4> <p>Materials required to take the wrap cast are:</p> <ul> <li>Cotton stockinette (appropriate size for stump)</li> <li>Dacron tape for temporary harness</li> <li>Yates clamps</li> <li>Indelible marking pencil</li> <li>Three rolls of plaster-of-Paris bandage (6 or 8 cm. elastic-type preferred)</li> <li>Pail of water</li> </ul> <p>A snug, form-fitting cotton stockinette is placed over the stump to insulate the skin and hair from plaster. The assistance of the amputee or a temporary figure-eight harness may be used to keep the stockinette free from wrinkles. The harness method is generally preferable for children.</p> <p>Application of the proper molding grip is essential to the success of the wrap cast and hence to the final outcome of the fitting. It is important, therefore, that the prosthetist practice this procedure on each amputee prior to the application of the cast. He will thus become familiar with the individual characteristics of each amputee's stump, and the possibility of erroneous molding once the stump is wrapped will consequently be reduced. Furthermore, the amputee will know what to expect during the casting procedure and be better able to cooperate.</p> <p>It is important to note that the prosthetist will be able to apply the molding grip more conveniently when his arms and those of the amputee are at the same level. It is suggested, therefore, that child amputees sit on a table or stand on a raised platform.</p> <p>In this article, the specific steps to be followed are described for a right below-elbow amputee (the hand positions are reversed for a left amputee). Because of the fundamental importance of the correct molding grip, this aspect of the fabrication procedure is illustrated with both photographs and drawings.</p> <p>With the amputee's stump flexed to 90 deg., the index and middle fingers of the pros-thetist's right hand are placed on the anterior surface of the stump. The prosthetist's right wrist should be in a neutral or slightly extended position. The two fingers should rest on either side of the biceps tendon and along the anterior surface of the slump. Moderate pressure is exerted (to the point of firm resistance) simultaneously into the cubital fold and downward on the anterior surface of the stump, but am concentration of pressure distally is avoided (<b>Fig. 9</b> and <b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Practicing the molding grip. The prosthetist exerts moderate pressure on either side of the biceps tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Another view of the prosthetist exerting pressure on either side of the biceps tendon, simultaneously into the cubital fold and downward on the anterior surface of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The dorsal aspect of the proximal ulna is distinctly wedge-shaped. The prosthetist's left hand is shaped so that the thenar and hypo-thenar eminences form a channel into which this wedge will fit (<b>Fig. 11</b>). The grooved hand is then positioned against the underside of the stump to provide stability and support without distortion. The metacarpal joints of the prosthetist's left hand should be located just below the amputee's olecranon (<b>Fig. 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Practicing the molding grip. A, The wedge-shaped ulna as viewed from the rear; B, channel formed in the prosthetist's hand; C, the ulna fitted into the channel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Practicing the molding grip; positioning the grooved left hand of the prosthetist against the underside of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The index, middle, and ring fingers of the prosthetist's left hand are cupped and positioned on the distal posterior surface of the humerus just above the level of the epicondyles (<b>Fig. 13</b>). Gentle downward pressure is applied with the pads of the fingers. Care must be taken to avoid pressure between the palm of the hand and the olecranon. Thus relief is automatically provided for the olecranon. The little finger and the thumb may be curled to make contact with the medial and lateral epicondyles, respectively. However, these digits should <i>not </i>exert any pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Practicing the molding grip; gentle downward pressure being applied by the pads of the index. middle, and ring fingers of the prosthetist's left hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In view of the intimate fit which characterizes the Munster-type socket, tender areas and bony prominences such as the olecranon and the epicondyles must be clearly defined for the provision of the necessary reliefs. While the stump is flexed at 90 deg., these areas are marked with an indelible pencil so that thev may be easilv identified on the wrap cast (<b>Fig. 14</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Marking tender areas and bony prominences </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A preliminary trim line is marked on the cast sock by drawing a line posteriorly connecting two points 1 in. superior to the medial and the lateral epicondyle, respectively; and the line is continued anteriorly so that it passes through a point 1/2 in. above the mid-cubital space (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Marking the preliminary trim line on the cast sock. A, A line is drawn posteriorly connecting two points 1 in. superior to the medial and the lateral condyles; B, the line is continued to pass anteriorly 1/2 in. above the mid-cubital space. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The critical relationship between the stump and the Munster-type socket cannot be overemphasized. Every effort should be made, therefore, to obtain a properly fitting cast. To this end, it is recommended that at least two, and preferably three, casts be taken so that the prosthetist and the patient together may choose the best of the series. Elastic or non-elastic plaster-of-Paris bandages may be used, but the elastic is preferable since it results in a more accurate configuration.</p> <p>While the stump is flexed at 90 deg. and the humerus is held midway between internal and external rotation, the wrap is commenced with two circular turns above the elbow joint (over the olecranon and the cubital fold). Only very slight tension should be applied to the plaster-of-Paris bandage (either elastic or nonelastic) in the process (<b>Fig. 16</b><i>A</i>). The wrapping proceeds to the distal end of the stump in a figure-eight or a spiral pattern (<b>Fig. 16</b><i>B). </i>The wrap is continued at least 1/4 in. above the reference marks made earlier.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Wrapping the stump. A, The wrap is begun with two circular turns around the elbow joint-over the olecranon and the cubital fold; B, the distal end of the stump is included in either a figure-eight or a spiral pattern; C, the wrap is continued at least 34 in. above the reference marks made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the wrapping has been completed, the molding grip practiced earlier is applied (<b>Fig. 17</b>). Finger pressure should be sufficient to displace all loose tissue (to the point where firm resistance is reached). Pressure is maintained until the plaster has set.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Application of the molding grip to the wrap cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened, the proximal end of the wrap cast is reinforced with several turns of nonelastic plaster-of-Paris bandage in order to minimize distortion. Then the stockinette is pulled down over the cast (<b>Fig. 18</b><i>A</i>). As the cast is gently worked off the stump, upward pressure is applied to the arm to increase skin tension at the proximal end of the cast in order to break the vacuum seal (<b>Fig. 18</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Removal of wrap cast. A, Pulling the stockinette down over the cast; B, applying upward pressure on the arm as the cast is gently worked off the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The stockinette is removed from the cast, and the indelible markings which have been transferred from the stockinette to the inner wall of the cast are accentuated (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Accentuating the indelible markings transferred from the stockinette to the inner wall of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These procedures should be repeated until a minimum of two, and preferably three, casts have been taken.</p> <h4>The Check Socket</h4> <p>Materials required to prepare the check socket are:</p> <ul> <li>Knife</li> <li>Scissors</li> <li>Fresh plaster</li> <li>Water</li> </ul> <p>All of the wrap casts taken should be prepared in accordance with the procedures described below and used as check sockets. The one agreed upon by both the prosthetist and the patient as providing the most comfortable fit and the greatest range of motion and maximum security is selected for use in the preparation of the positive plaster model.</p> <p>A hole is cut in the cast, just large enough to allow the passage of a stump pulling sock and as close to the distal end as possible so that shortening of the cast is minimized (<b>Fig. 20</b><i>A</i>). The final trim lines for every socket must be determined individually for each amputee. However, as an initial step, the proximal end of the cast is trimmed to the level of the reference line made earlier (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Trimming the cast. A, The hole cut in the distal end should be just large enough to permit passage of a stump pulling sock; B, trimming the proximal end at the level of the reference line made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is then moistened, and the inside of the cast is smoothed with fresh plaster to remove all gauze marks, except in the area of the epicondyles and the olecranon (<b>Fig. 21</b>). <i>No </i>plaster should be added in these critical areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Smoothing the inside of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting The Check Socket</h4> <p>Materials required for fitting the check socket are:</p> <ul> <li>Cotton stockinette (stump pulling sock)</li> <li>Indelible marking pencil</li> </ul> <p>A length of stockinette is placed on the amputee's stump, and the distal end of the stockinette is drawn through the hole in the check socket. The stump is pulled into the socket, care being taken that all flesh is drawn inside the cast (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pulling the stump into the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the check socket on the amputee, the usual tests are made for adequacy of fit, comfort, and range of motion by having the amputee exert force against resistance in elbow flexion, extension, and rotation (<b>Fig. 23</b>). Although the stump cannot rotate the socket, there may be some undesirable rotation of the stump within the socket. If the fit of the check socket is not satisfactory, the socket should be rejected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Determining the adequacy of the fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the check socket causes any pain or discomfort, the appropriate area should be marked on the outside of the socket so that relief can be provided (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Marking an area which requires relief. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The same procedures are repeated with the other check sockets and the best socket is selected for use in completion of the prosthesis.</p> <h4>Establishing The Range of Motion in Check Sockets</h4> <p>The maximum forearm flexion and extension positions attainable with the Munster-type prosthesis will be significantly less than those achieved in conventional prostheses. Experience has shown that the maximum flexion range for the typical short below-elbow stump fitted with a Munster-type socket is approximately 70 deg. (from 35 deg. initial flexion to 105 deg. maximum flexion).<a></a> A range of motion of this magnitude is not always achievable but should be the initial goal of the fitting.</p> <p>The principal factors limiting the range of motion are:</p> <ol> <li>Restriction in the maximum flexion angle obtained attributable to one or more of the following conditions: <ul> <li>Insufficient relief for the olecranon</li> <li>Too small a channel for the biceps tendon</li> <li>Too high an anterior wall</li> </ul> </li><li>Restriction in extension attributable to too high a posterior trim line.</li></ol> <p>However, it must be emphasized that lowered trim lines or loose fit will adversely affect the retention of the socket on the stump. Hence, the initial trim lines need to be closely maintained in order to provide maximum socket retention. They should be reduced only when absolutely necessary to provide greater comfort or increased range of motion, or both.</p> <p>Materials required in establishing the range of motion are:</p> <ul> <li>Indelible pencil</li> <li>Scissors or knife</li> <li>Goniometer</li> <li>Ruler</li> </ul> <p>A line is drawn on the lateral side of the check socket coincident with its long axis (from the lateral epicondyle to the mid-distal end) to serve as a guide in measuring flexion and extension (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Drawing a line on the check socket coincident with its long axis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The center of the goniometer is placed on the lateral epicondyle. The lower arm of the goniometer is placed on the long axis line, and the upper arm of the goniometer is lined up with the acromion (<b>Fig. 26</b>). Maximum flexion and extension angles are measured from these points of reference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Placement of goniometer to measure maximum flexion and extension angles </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If motion is restricted, the specific cause for the restriction should be determined and corrective action should be taken (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Trimming the check socket to provide increased range of motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee cannot achieve the proposed 35 deg. of initial flexion in the check socket, the discrepancy is compensated for in the alignment of the forearm shell. Therefore, while the stump is maintained in an actively extended position, a second line is drawn on the check socket at an angle of 35 deg. between the humerus and the stump (<b>Fig. 28</b>). This line will serve as a guide in aligning the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Drawing a second line at a 35-deg. angle between the humerus and the stump to serve as a guide in aligning the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The adequacy of the proposed initial flexion angle is tested by placing a ruler along the <i>35 </i>deg. line drawn on the check socket (<b>Fig. 29</b>). The ruler is placed to correspond to the intended length of the finished prosthesis; that is, the olecranon-to-thumb-tip measurement recorded on the Upper-Extremity Measurement Form (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Placing a ruler along the 35-deg. line to test the adequacy of the proposed angle of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee should flex and extend this improvised forearm composed of the check socket and the ruler (<b>Fig. 30</b>). Maximum flexion should be about 105 deg., except for very-short stumps, where it probably may not exceed 90 deg. Because of the inherent limitation of motion associated with the Munster-type prosthesis, the usual test of having the amputee bring his terminal device to his mouth is not applicable. The goal is to provide the maximum flexion angle possible compatible with a cosmetically acceptable initial flexion position and socket retention.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Checking the flexion and extension of the improvised forearm composed of check socket and ruler. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the maximum flexion angle obtained with 35 deg. of initial flexion is not acceptable, the angle of the ruler is adjusted to provide greater initial flexion. Initial flexion angles to a maximum of 45 deg. have been used, but at the expense of decreased cosmesis (<b>Fig. 31</b>). If less than 35 deg. of initial flexion is desired for cosmetic or other reasons, the angle is decreased accordingly. Such reduction also decreases the maximum flexion angle obtainable. The selected angle of initial flexion is indicated on the check socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Alternative angles of initial flexion: 30 deg., increased extension, decreased flexion; 40 deg., increased flexion, decreased extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Preparation of the Positive Model</h4> <p>Materials required for the preparation of the positive model are:</p> <ul> <li>Plaster-of-Paris bandage</li> <li>Talcum powder</li> <li>Hollow pipe (approximately 12 in. in length and 1/2 in. in diameter)</li> <li>Awl</li> <li>Two roundhead screws</li> <li>Fresh plaster</li> <li>Water</li> <li>Sanding screen</li> <li>Indelible marking pencil</li> <li>Vaseline or other parting agent</li> </ul> <p>The distal end of the check socket is closed with plaster-of-Paris bandage or with masking tape (<b>Fig. 32</b>) and a small extension (approximately 1 in.) is constructed at the proximal end of the check socket (<b>Fig. 33</b>), again with plaster-of-Paris bandage or with masking tape. This extension will provide the prosthetist with a margin of safety in smoothing the positive stump model without disturbing the desired trim line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Closing the distal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Construction of extension at proximal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the inner surface of the check socket has been sprinkled with talcum powder, the check socket is filled with liquid plaster of Paris (<b>Fig. 34</b>). Before the plaster hardens, a hollow pipe is inserted into the plaster. A recess approximately 1 in. to 1-1/2 in. deep is made in the plaster at the proximal end of the mold. A small hole, approximately 1/4in. in diameter, should be drilled in the pipe toward the bottom of the recess to facilitate vacuum lamination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Check socket filled with liquid plaster of Paris and a hollow pipe inserted into the plaster. The small hole drilled in the pipe will facilitate vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the positive model has hardened, the check socket is punctured with an awl at the proximal and distal ends of the forearm-extension reference line (<b>Fig. 35</b>). The punctures should penetrate into the positive stump model. An indelible pencil is inserted into the holes to mark the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Puncturing the check socket with an awl in order to mark on the positive model the proximal and distal ends of the forearm extension reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster wrap (check socket) is removed, and major irregularities, for example, superfluous plaster, are trimmed from the positive model (<b>Fig. 36</b>). All reference marks should be accentuated on the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trimming irregularities from the positive stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The junction between the positive model of the stump and the mold extension is faired with liquid plaster of Paris to provide a smoothly curved radius (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Fairing the juncture between the positive model and the mold extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The olecranon area on the positive stump model is built up approximately 1/16 in. with liquid plaster of Paris (<b>Fig. 38</b>). This build-up will provide additional relief for this bony prominence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Building up the olecranon area on the positive model to provide relief for this bony prominence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal end of the positive stump model is built approximately 1/2 in. with liquid plaster of Paris. This build-up will increase the length of the socket slightly and provide space for the hole through which the stump sock is pulled (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Building up the distal end of the positive model to increase the length of the socket slightly and to provide space for the hole through which the stump sock is pulled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The positive model is sanded smooth, and roundhead screws are inserted into the two reference holes made on the lateral side of the model. These screws will produce projections on the laminated socket through which a line will be drawn to align the forearm extension cone.</p> <h4>Lamination</h4> <p>Materials required for lamination are:</p> <ul> <li>Drill with 1/8-in. bit</li> <li>PVA sheets</li> <li>Dacron blanketing</li> <li>Nylon stockinette</li> <li>Polyester resin</li> <li>Promoter</li> <li>Masking tape</li> <li>Vacuum pump</li> <li>Wrist unit</li> <li>Manila paper</li> </ul> <p>The socket and forearm shell are laminated in accordance with standard procedures.<a></a> Vacuum lamination<a></a> is recommended to provide a truer reproduction of the model.</p> <p>Holes 1/8 in. in diameter, are drilled through the undercut areas at the proximal end of the positive model in order to draw the PVA bag into those areas during vacuum lamination (<b>Fig. 40</b>). The holes should exit in the vicinity of the previously mentioned hole in the pipe.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Drilling 1/8-in. holes through undercut areas at proximal end of the positive model to draw in PVA bag during vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the stump model has been lubricated, the inner PVA bag, dacron blanketing (for a smoother inner surface), the nylon stockinette, and the outer PVA bag are applied in the usual manner<a></a>, under a vacuum pressure of 12 in. of mercury (<b>Fig. 41</b>). (This is equivalent to 5.9 psi.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Inner PVA bag, dacron blanketing, nylon stockinette, and outer PVA bag ready for lamination on lubricated stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Polyester resin is applied in the standard manner.<a></a> Special attention should be paid to working the resin into the undercut areas (<b>Fig. 42</b>). The layup is oven-cured as usual.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Working resin into undercut areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has cured, an opening is cut in the extreme distal end of the socket (<b>Fig. 43</b>). The hole should be of sufficient diameter to allow the passage of the stump pulling sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Cutting an opening in the distal end of the socket to allow passage of the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A reference line is drawn on the outer wall of the socket by connecting the two screwhead projections. A forearm extension cone is applied in the usual manner, with the long axis of the cone coincident with the reference line (<b>Fig. 44</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Forearm extension cone aligned with reference line established by screwheads on socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lamination procedure for the forearm is the same as for the socket, except that dacron blanketing is not used (<b>Fig. 45</b>). The forearm extension may be laminated as a separate section or directly over the socket, using a wax melt-out. Both procedures work satisfactorily. After the forearm laminate has been cured, the prosthesis is cut along the proximal socket brim and the mold is broken out.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Forearm extension laminated over socket and cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting of the Prosthesis</h4> <p>A 1-in. hole is drilled through the medial wall of the forearm shell close to the distal end of the inner socket to permit passage of the stump pulling sock. The edges of the hole are polished with a grinding cone (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Polishing the edges of the hole tor the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Wearing a length of stockinette (approximately 8 to 10 in.) as a stump sock, the amputee inserts his stump into the socket and pulls the distal end of the sock through the hole (<b>Fig. 47</b>). The application of tension on the stump sock facilitates the complete insertion of the stump into the socket. The sock is left on the stump and the end of the sock is tucked into the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Application of tension on the stump sock facilitates the complete insertion of the stump into the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is checked for the adequacy of its fit. Reliefs are provided and trim lines are modified (<b>Fig. 48</b>) where necessary for comfort and range of motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Checking the adequacy of socket fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnessing</h4> <p>Three different harness arrangements have been used successfully at New York University with the Munster-type sockets.</p> <p>Initially, the arms were fitted with a conventional figure-eight harness with triceps pad, flexible hinges, and inverted Y-strap. However, the intimate stump encapsulation, flexion attitude, and high trim lines of the Munster sockets provide excellent retention and security, and in most cases obviate the need for suspensory apparatus to maintain the socket on the stump. Without harness, the majority of subjects in the Xew York University stud}' with adult amputees were able to resist high axial loads (in the order of 50 lb.) with negligible socket displacement. In the fitting of child amputees, the same results obtained with axial loads up to one-third of body weight. Hence, the two simplified axilla-loop harness systems which will be described have proved adequate for most patients.</p> <p>The conventional harness is fabricated according to standard prosthetics practice.<a></a> However, because of the integral security of the socket, the size of the triceps pad may be reduced.</p> <p>In the New York University fittings a triangular triceps pad constructed of light-gauge aluminum covered with leather was used exclusively (<b>Fig. 49</b>). The general pattern of the templates used as a guide in shaping this pad is shown in <b>Fig. 50</b>. The exact size of the template for each subject is determined as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. View of conventional harness showing triceps pad fabricated of light-gauge aluminum covered with leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Pattern of template for triceps pad (not actual size). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The width is equal to one-half the circumference of the arm measured just above the epicondyles.</li><li>The length is three-quarters of the width.</li></ol> <p>There is no significant functional difference in the two simplified axilla-loop harness systems. In one system the reaction point is located at the proximal socket, while in the other it is located over the triceps. The choice between the two systems depends upon the amputees' preferences regarding the position of their control cables.</p> <p>To locate the reaction point on the proximal socket, a standard housing crossbar assembly is riveted to the <i>midline </i>of the posterior wall of the socket approximately 1/2 to 3/4 in. distal to the proximal brim (<b>Fig. 51</b>). The crossbar portion of the loop is directed upward.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Simplified axilla-loop harness with reaction point on proximal socket. Upper, standard housing crossbar assembly riveted to the midline of the posterior wall of the socket. Lower, harness completed with an axilla-loop arrangement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal retainer base plate is located on the lateral side of the forearm in the usual manner so that it produces as direct a line of pull as possible between the crossbar and the terminal device.</p> <p>The cable-housing assembly is attached in the usual manner. The cable should be maintained as short as possible without interfering with function in order to reduce the incidence of the cable rubbing on the flesh or clothing.</p> <p>The harness is completed with an axilla-loop arrangement (<b>Fig. 51</b>). An additional suspensory strap (that is, a front-support strap) or flexible hinges are not needed.</p> <p>The simplified axilla-loop system is appropriate for most patients. But some patients will object to the low position of the control cable, which may interfere with the sleeves of shirts or blouses. To meet such objection, the reaction point may be located on a small leather triceps pad (3 in. x 3 in.)(<b>Fig. 52</b>). A small strap, preferably Velcro, is sewn across the middle of the posterior surface of the triceps pad to provide a means of securing the pad to the arm. A standard housing crossbar assembly is attached over the strap and centered on the triceps pad. The distal retainer base plate is placed on the forearm in the same manner as described in the previous system. The cable housing assembly is attached in the usual manner. The harness is complete with an axilla-loop arrangement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Reaction point on small triceps pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Checkout Procedures</h4> <p>Standard below-elbow checkout procedures<a></a> are applied to the Munster-type prosthesis and the usual requirements should be met except for the following:</p> <ol> <li>Since prosthetic forearm rotation is eliminated, the pronation-supination measure is not applicable.</li><li>Since a decreased flexion range is an integral feature of the socket, the checkout standard of a 10-deg. loss of flexion with prosthesis does not apply. Maximum flexion for most amputees will range between 100 deg. and 115 deg., which may be approximately 30 deg. less than stump flexion with the prosthesis off.</li><li>Because of the decreased elbow flexion, the requirement for opening of the terminal device at the mouth may not apply. However, full opening of the terminal device should be available at maximum flexion of the elbow.</li></ol> <p>In following the checkout procedures, particular attention should be paid to the unique features of these sockets; namely, the critical importance of the fit of the socket around the epicondyles and olecranon and the built-in suspension of the sockets. The application of compression and torque forces (particularly a vertical downward force at the terminal device with the elbow flexed at 90 deg.) should indicate the presence of any pressure areas around the elbow. Additionally the axial-load test<a></a> -application of a vertical downward force at the terminal device with the elbow fully extended-should reveal any deficiencies in the suspension feature of the sockets.</p> <p>It must be recognized, however, that, because of the close fit of the socket over the epicondyles and olecranon, some adults will not be able to tolerate the accepted axial-load standard of 50 lb. (or, for children, one-third of the body weight). Special caution to avoid injury to the amputee should be taken when applying the axial-load force. Failure to meet the 50-lb. standard should not in itself be sufficient cause to reject the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</li> <li>Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The "Muenster" type fabrication technique for below-elbow prostheses, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the "Muenster-type" below-elbow prosthesis, April 1965.</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</li> <li>University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster-type' below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Dominick E. Casella </b></td></tr><tr><td class="clsTextSmall">Research Administrative Assistant, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>George Hartmann, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Kevin A. Cody, M.A. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant 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/1965_02_004/autum65-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_004/autum65-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_004/autum65-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_004/autum65-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_004/autum65-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_004/autum65-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_004/autum65-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_004/autum65-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_004/autum65-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_004/autum65-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_004/autum65-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_004/autum65-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_004/autum65-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_004/autum65-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_004/autum65-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_004/autum65-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_004/autum65-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1965_02_004/autum65-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1965_02_004/autum65-19.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 The Munster-Type Below-Elbow Socket, a Fabrication Technique Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Kevin A. Cody, M.A. * George Hartmann, C.P.O. * Dominick E. Casella * https://staging.drfop.org/files/original/f73009e86594dcca75541df0a12e99d0.pdf 1889f60a10577651577742fa073f3c95 https://staging.drfop.org/files/original/290830ff921d3225c71b7da047de3c91.jpg 604673b43d699b8dd0e4e40b2ebc2915 https://staging.drfop.org/files/original/a35ba394e727d7f97890d44e3b4bc8f8.jpg d1d8235db6501bdc2e847d0aa6325edc https://staging.drfop.org/files/original/64c3f030f117136789588247cc666446.jpg 4f2e2336c57ccb9972606fa34fc39784 https://staging.drfop.org/files/original/80a7da92cda87b5b46d4629f021c8c94.jpg dbe15132b2e8b0856e434023c45cafd3 https://staging.drfop.org/files/original/5c1001c8613c3cdbbbeaec4168327017.jpg a0568a7d77d908e3e116118e815c1508 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_010.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 10 - 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/1966_01_010.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_010.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>Preliminary Design Analysis of Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Nancy V. Appoldt, B.A. <a style="text-decoration:none;">*</a><br /></h5> <!-- <sup Note="1">*Based upon a report entitled <i>Preliminary Design Analysis of Linkage Feeders, </i>published by Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, New York, N. Y., in May 1965. The report was prepared under the general supervision of Sidney Fishman, Ph.D., Project Director, Prosthetic and Orthotic Studies, New York University. The study reported upon was supported by funds from the Vocational Rehabilitation Administration, Department of Health, Education, and Welfare.</sup> --> <p>In 1962 the Committee on Prosthetics Research and Development authorized a survey of current orthotics research and development in a number of selected centers as an initial step in a proposed orthotics evaluation program. A prime purpose of the survey was the identification of orthotic devices and procedures as suitable subject matter for the evaluation program.</p> <p>One of the devices selected as meeting the requirements for inclusion in the evaluation process was the linkage feeder designed at the University of Michigan. However, it was apparent that this device, plus a number of others, was essentially a variant of the ballbearing feeder designed and developed two decades ago by the Georgia Warm Springs Foundation. Hence, a review of existing feeder designs was undertaken as a prelude to any formal evaluation program.</p> <p>The systems involved were those currently in use at the Georgia Warm Springs Foundation, Rancho Los Amigos Hospital, the University of Michigan, the Texas Rehabilitation Center, and the Texas Institute for Rehabilitation and Research. Two prefabricated units that were available commercially were also reviewed, but these units resemble the Rancho Los Amigos Hospital feeder so closely that separate consideration is not warranted.</p> <p>Ideally, a feeder supports the weight of the arm and permits the patient with severely weakened or paralyzed upper extremities to position the hand with a minimum of muscular effort. The extent of a patient's performance with a feeder and his method of performance are, of course, contingent on the nature and extent of his disability.</p> <p>The feeders considered in this article have numerous structural features and operational principles in common. An aluminum forearm trough and two stainless-steel swivel arms that rotate on ball or needle bearings support the weight of the upper extremity and provide useful motion when activated by a slight residual motor power in the head, neck, trunk, or arms. The joint cylinders may be rotated to bring the feeder assembly into an inclined plane which provides gravity assistance to the horizontal motions of the extremity. The trough pivot may be positioned to give a bias to both vertical motions of the forearm, namely, raising the hand to the head or lowering it to the table top.</p> <p>A number of accessory components may be attached to a feeder to adapt the equipment to individual requirements without modifying the basic design. Among these are metal clips, straps, and foam-rubber liners to prevent slippage <!--Page 11--> of the forearm; horizontal and vertical stops to restrict feeder motions to a controllable range; elastic-band and supinator assists to aid motion; and double T-bars to support the hand and provide attachments for self-help devices.</p> <p>The basic principles of the various feeders being the same, a matter of interest is the significance of the points on which they differ. In Appendix A the distinctive features of each of these systems are identified and illustrated in detail. The Georgia Warm Springs Foundation model is presented as the basic design, with its apparent advantages and disadvantages. The other four designs are then compared with the Georgia Warm Springs Foundation item.</p> <h3>SUMMARY AND CONCLUSIONS</h3> <p>Linkage feeders were received from the Georgia Warm Springs Foundation, the University of Michigan, Texas Rehabilitation Center, the Texas Institute for Rehabilitation and Research, and Rancho Los Amigos Hospital. With the Georgia Warm Springs Foundation balanced forearm orthesis as the frame of reference, the design and operational features of each feeder were subjected to critical examination. In summarizing the findings of the examination, two points must be emphasized:</p> <ol> <li>All feeders are in current and apparently successful use at the centers from which they were obtained.</li><li>The feeders were not applied to <i>bona fide </i>patients, but were analyzed in relation to use by a normal adult.</li></ol> <p>Thus the validity of the advantages and disadvantages cited in this report might require further verification.</p> <p>It is of value, however, to identify the <i>apparent </i>strengths and weaknesses of each feeder in relation to the Georgia Warm Springs Foundation balanced forearm orthesis. This feeder was the first of its kind, and its basic design served as a model for the subsequent feeders. The question that this review attempts to answer is: In what respects do the features of the other feeders appear to be superior or inferior to those of the Georgia Warm Springs Foundation Feeder?</p> <h3>UNIVERSITY OF MICHIGAN</h3> <p>The multiple adjustment features of the University of Michigan feeder appear to make it the most versatile of those reviewed. Moreover, this adjustment capability is maintained throughout the life of the feeder, in contrast to the reduced adjustability of the "permanent" feeder which is the end product in some of the other designs.</p> <p>The significant additional adjustment involves the rocker-arm assembly and allows the trough, and consequently the forearm, to be raised or lowered with respect to the trough pivot. The fore-and-aft adjustment found in other feeders is also available. Thus the forearm may be balanced against gravity in two dimensions, permitting maximum control of the forces acting about the trough pivot in horizontal, vertical, and intermediate positions of the forearm. The use of ball bearings in the distal link and trough pivot, as well as in the first and second joints, minimizes frictional forces in the system. The screw-adjustment system permits precise adjustment without the use of tools. The lateral location of the rocker-arm assembly, combined with the use of a triceps strap, permits a closer relationship between table top and trough, while the lateral space required for feeder operation is reduced by the use of a relatively short proximal link.</p> <p>The prime limitations of the University of Michigan feeder are:</p> <ol> <li>It is bulky and has a nonaesthetic appearance.</li><li>The nondetachable proximal link imposes the necessity for removing the entire feeder from the wheelchair when it is to be collapsed, transported, or stored.</li><li>The triceps strap may bind, reducing or eliminating elbow support.</li></ol> <h3>TEXAS REHABILITATION CENTER</h3> <p>The outstanding characteristic of the Texas Rehabilitation Center feeder is its simplicity. The adjustability of link lengths should also be useful for applications to children during the growth years.</p> <p>The absence of ball bearings in the proximal joint makes this feeder more difficult to maneuver in horizontal motions. The short swivel arms and stationary elbow dial restrict extension of the arm and thereby limit function to a reduced zone of motion. Contact of the elbow dial with the distal link obstructs lateral trough motion, while the rocker-arm assembly restricts the upward tilt of the trough. Because the trough is offset from the distal link vertically, <!--Page 12--> placement with relation to a table top is more distant than with the Georgia Warm Springs Foundation, University of Michigan, or the Rancho Los Amigos Hospital system, each of which has horizontally offset troughs. In order to change tilts at the first and second joints, the device must be returned to the orthotics shop.</p> <h3>TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH</h3> <p>The Texas Institute for Rehabilitation and Research model is notably streamlined in appearance. Frictional resistance is minimized in horizontal feeder motions by the use of needle bearings at the end of the distal link.</p> <p>As with the Texas Rehabilitation Center feeder, an orthotist must make any tilt adjustments. This lack of ready adjustment might tend to hinder a patient's performance if his wheelchair were on uneven terrain. It might also delay accommodation to improvement or regression of his disability. The trough's vertical offset from the distal link and relatively long vertical rod limit the closeness of trough placement to the table top. Moreover, to bring the trough as close as possible to the table top, clearance of the distal link is minimized (1/2 to 1 in.) and the link may strike objects on the table.</p> <h3>RANCHO LOS AMIGOS HOSPITAL</h3> <p>In the Rancho Los Amigos Hospital feeder a unique tilt adjustment is provided at the distal end of the proximal link. Adjustment of the second joint, therefore, is easier and more precise. The rocker-arm assemblies permit greater ranges of motion at the trough pivot than those of the Georgia Warm Springs Foundation model. The outside rocker-arm assembly, which has a ball-bearing unit at the trough pivot similar to that of the University of Michigan feeder, minimizes friction in vertical motions and permits two-dimensional adjustment of the pivot relative to the forearm. A ball-bearing unit may also be added to the joint at the end of the distal link to minimize friction in horizontal feeder motions.</p> <p>Each of the feeders, when compared with the Georgia Warm Springs Foundation system, appears to have both positive and negative features. On the basis of the available data, resolution of the various pros and cons as to which feeder is the best is not feasible. Certainly the thought that the most advantageous characteristics of the five feeders might be combined in one superior system has appeal.</p> <p>However, selection of the optimal feeder for a particular patient depends primarily on the purpose for which the device is prescribed. Purposes may range from support of the arms in a comfortable position for the most severely disabled to increased functional independence and participation in vocational activities for others. Thus a single feeder, even one incorporating the best elements of the various designs, may not serve the needs of all patients.</p> <p>Nevertheless, the similarities and differences of the five feeders identified in this review, and particularly the significance of the differences, are worthy of further study. If patients' needs in relation to the functions offered by the various components could be precisely defined, an individual's requirements might best be met by using selected components from one or more of the available feeders.</p> <!--Page 13--> <h3>Appendix A</h3> <h3><i>A Detailed Comparison of Five Feeders</i></h3> <h4>GWSF Balanced Forearm Orthesis</h4> <p><b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Georgia Warm Springs Foundation (GWSF) balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>attaches to the chair upright <i>2. </i>Two screws <i>3 and 4 </i>extend from the clamp to provide attachment for, and anteroposterior angular adjustment of, a ball-bearing tube 5.</p> <p><i>Advantages - </i>The proximal joint may be independently tilted anteroposteriorly and rotated mediolaterally to provide a gravity assist or to compensate for an inclined chair upright or for slopes. There is minimal joint friction.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable swivel arm 6 terminates distally in a ball-bearing tube <i>7. </i>Length of proximal link is adjustable during fitting, nonadjustable in the finished unit. The proximal link is either a drop-type <i>6 </i>or straight (not shown). Accessory collars (not shown) may be used to raise the proximal link. The distal link 8, curved approximately 90 deg., terminates in a vertical tube or post <i>9, </i>the height of which may be increased by height extenders (not shown).</p> <p><i>Advantages - </i>The feeder may be removed from the chair upright without disturbing the base assembly. Minimal friction is present between proximal and distal links. Drop-type proximal link is useful in obtaining proper feeder height for short patients (without clamp adjustment). The straight proximal link may be used with collars to provide elevation of the feeder for taller patients. The curved distal link reduces interference between elbow and distal link. Height extenders are useful for gaining additional trough height and increasing elbow-distal link clearance.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A drop <i>10 </i>or straight (not shown) offset rod inserted in the tube permits rotation of the trough. Accessory collars <i>11 </i>increase rod height. The distal end of the rod fits into two sleeves <i>12 </i>which rotate on the rod. The sleeves are brazed to a 1-in. flat bar with threaded holes for attachment to the underside of the trough <i>13. </i>An L-shaped bar <i>14 </i>soldered to the rod between the sleeves holds the movable sleeve unit on the rod.</p> <p><i>Advantages - </i>The offset rod provides additional trough-link clearance. Additional height adjustment is useful in accommodating tall patients.</p> <p><i>Disadvantages - </i>The L-shaped bar imposes a "down" stop on trough motion.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>15 </i>has prepunched holes interiorly for anteroposterior adjustment on the sleeve bar. The elbow dial is stationary (not shown) or hinged <i>16 </i>to the stem of the cradle and connected to the rocker-arm assembly by a linkage rod <i>17.</i></p> <p><i>Advantages - </i>The hinged dial permits full elbow extension.</p> <p><i>Disadvantages - </i>The stationary dial restricts elbow extension.</p> <!--Page 14--> <h4>The University of Michigan feeder.</h4> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The University of Michigan (U of M) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>similar to the GWSF item attaches to the chair upright <i>2. </i>An adjustment assembly connects the clamp with a ball-bearing cylinder <i>3 </i>and allows positioning anteroposteriorly by screw <i>4 </i>and mediolaterally by screw 5. Feeder height may be regulated by an adjusting nut <i>6 </i>incorporated into the ball-bearing tube.</p> <p><i>Advantages - </i>Greater precision in mediolateral, anteroposterior,and height adjustments than the GWSF feeder. No tools are required for adjustments. Minimal joint friction.</p> <p><i>Disadvantages - </i>Bulky, conspicuous. Weight of unit must be supported when attaching clamp to wheelchair.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The vertical portion <i>7 </i>of a straight swivel arm is threaded to accommodate the height-adjusting nut. The proximal link, which terminates distally in a ball-bearing tube <i>8, </i>is relatively shorter than the GWSF item. The distal link is angled distally 90 deg. and has a ball-bearing tube <i>10 </i>attached. The distal link is proportionally longer than the GWSF item.</p> <p><i>Advantages - </i>Short proximal link decreases space required (laterally) for feeder excursion. Minimal friction present at second ballbearing joint. Angled distal link provides trough-link clearance. Minimal friction present between distal link and rocker-arm assembly.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint. Linkage is not readily detachable from the wheelchair assembly.</p> <!--Page 15--> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A short vertical rod fits into the ball-bearing tube to permit horizontal rotation of the trough. Affixed to the superior end of the rod is a U-shaped housing <i>11 </i>which supports a ballbearing unit <i>12. </i>Extending from this unit is a threaded shaft which is mounted by a grooved block and adjusting screw <i>13. </i>Affixed to the block is a curved supporting arm <i>14 </i>which extends under the trough and attaches to another grooved block and screw assembly on the inferior lateral aspect of the trough <i>15.</i></p> <p><i>Advantages - </i>Minimal friction present in vertical motions of the trough. Screw-type adjustments permit finer control of elbow-hand balance. Balance of the feeder may be adjusted in two planes, vertical as well as anteroposterior. No tools are required for adjustments.</p> <p><i>Disadvantages - </i>Conspicuous, crude appearance.</p> <p><b>Trough</b></p> <p><i>Description - </i>A triceps strap <i>16 </i>has hinged attachments to two outriggers <i>17 </i>and <i>18 </i>which are riveted to the inferior and lateral aspects of the forearm cradle <i>19.</i></p> <p><i>Advantages - </i>Triceps strap permits full elbow extension. Posterior protrusion of elbow is less with triceps strap than with elbow dial.</p> <p><i>Disadvantages - </i>Triceps strap may be displaced from support position with repetitive motion.</p> <!--Page 16--> <h4>The TRC Feeder</h4> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Texas Rehabilitation Center (TRC) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly One arm of a U-shaped rod <i>1 </i>inserts into the round clamp <i>2. </i>The other end is brazed to a vertical tube <i>3 </i>so that bending of the U-rod tilts the tube anteroposte-riorly. Rotating the rod within the clamp tilts the joint mediolaterally.</p> <p><i>Advantages - </i>Simple and inconspicuous. The effect of increased friction from absence of ball bearings in the proximal joint is uncertain. Some friction at this point may be advantageous, for example, to lend stability at the shoulder so that motion imparted to the feeder will occur at the elbow first. It may, however, be disadvantageous if the impedence cannot be readily overcome, particularly in the zone of hand motions about the head.</p> <p><i>Disadvantages - </i>Benders must be used to obtain anteroposterior tilt adjustments.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>A detachable straight swivel arm <i>4 </i>is adjustable in length from 4 3/4 to 8 in. and terminates in a ballbearing tube 5. The distal link <i>6 </i>is a straight swivel arm, adjustable in length from 4 3/4 to 8 in., and terminates in a vertical tube <i>7.</i></p> <p><i>Advantages - </i>Feeder can be removed from chair without disturbing the base assembly. Ball bearings reduce joint friction. Short proximal link reduces lateral space required for feeder excursion.</p> <p><i>Disadvantages - </i>Short linkage lengths limit reach and permit joint toggle. As with the GWSF unit, benders must be used on the proximal link to obtain tilts at the second joint without affecting the plane of motion of the first joint. When the forearm is inclined vertically, the distal link interferes with horizontal excursion of the dial.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A rod, Y-shaped distally <i>8, </i>swivels within the tube and articulates with pre-drilled holes in the trough fenders <i>9 </i>to form the trough pivot.</p> <p><i>Advantages - </i>Pivot joints are easily adjusted on the trough without tools. The location of the trough pivot, being higher with respect to the trough than that of the GWSF feeder, more closely approximates the center of gravity of the forearm.</p> <p><i>Disadvantages - </i>Y-shaped rod imposes "up" stop on trough.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>10 </i>has anteroposterior adjustment on pre-drilled holes. Forearm cradle as stationary dial <i>11.</i></p> <p><i>Disadvantages - </i>As with the GWSF stationary dial assembly, elbow extension is limited.</p> <!--Page 17--> <h4>The TIRR Feeder</h4> <p><b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The Texas Institute for Rehabilitation and Research (TIRR) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly A round clamp <i>1 </i>is attached to the chair upright. An offset plate <i>2 </i>affixed to the clamp provides the mounting for the needle-bearing tube <i>3, </i>which is adjustable anter-oposteriorly in the trial feeder, nonadjustable in the permanent model (not shown). The tube is tilted mediolaterally by rotation of the round clamp.</p> <p><i>Advantages - </i>Smaller tube with needle bearings reduces bulk of unit and provides an unobtrusive appearance. Minimal joint friction.</p> <p><i>Disadvantages - </i>In the permanent feeder, mediolateral adjustments cannot be made without affecting anteroposterior tilt which has been established.</p> <!--Page 18--> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The proximal and distal links are straight and terminate in needle-bearing tubes 5 and <i>6. </i>The proximal link is detachable and the length of the links is adjustable in the trial model, nonadjustable in the permanent model.</p> <p><i>Advantages - </i>Feeder may be removed from the chair without disturbing the base assembly. Minimal joint friction.</p> <p><i>Disadvantages - </i>As in the GWSF unit, benders must be used to effect tilts at the second joint without altering the base assembly.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A relatively long vertical rod <i>7 </i>terminates superiorly in a clevis hinge <i>8. </i>A rectangular bar <i>9 </i>bearing two threaded holes for trough attachment is brazed to the movable portion of the hinge.</p> <p><i>Disadvantages - </i>The length of the vertical rod is not sufficient to prevent interference of the distal link with the lateral excursion of the elbow dial when the trough is in the "up" position. This means of offsetting the trough from the distal link positions the terminal end of the link approximately 1/2 in. above the table top. The path of feeder motion is obstructed by objects on the table.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>10 </i>and hinged elbow dial <i>11 </i>are similar to the GWSF unit's trough. The linkage rod <i>12, </i>which is adjustable for fitting purposes, is nonadjustable in the permanent feeder (not shown).</p> <p><i>Advantages - </i>Permits full elbow extension.</p> <!--Page 19--> <h4>The RLAH Feeder</h4> <p><b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The Rancho Los Amigos Hospital (RLAH) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>As in the GWSF unit, a round clamp <i>1 </i>attaches to the chair upright. An L-shaped bracket <i>2 </i>extends from the clamp to provide attachment for and anteroposterior angulation of an adjusting plate <i>3. </i>A ball-bearing tube <i>4 </i>is soldered to the posterior lateral aspect of the plate.</p> <p><i>Advantages - </i>As with the GWSF unit, the proximal joint may be tilted mediolaterally by rotating the wheelchair clamp and anteroposte-riorly by a separate adjustment. The plate simplifies anteroposterior adjustment.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable drop swivel proximal link 5 is similar to the GWSF item and terminates distally in an adjustable ball-bearing tube <i>6. </i>A small hinge unit <i>7 </i>permits anteroposterior tilting of the tube. The selected tilt position is maintained by set screws <i>8. </i>The distal link, similar to the GWSF item, is curved 90 deg. and terminates in a vertical tube <i>9. </i>An alternate unit (not shown) for patients with limited motion in the horizontal plane replaces the vertical tube with a ball-bearing unit. Post height extenders, like those of the GWSF system, may be fitted into the vertical tube to elevate the trough.</p> <p><i>Advantages - </i>The tilt adjustment for the second joint permits greater ease and precision in providing assistance to horizontal motions of the forearm. As with the GWSF distal link, the curved offset permits adequate horizontal rotation of the rocker-arm assembly when the trough is in the "up" position. Ball bearings used at the end of the distal link reduce friction between the distal link and the rocker-arm assembly. Additional feeder height may be desirable for tall patients or for specific activities (for example, combing the hair).</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>The standard assembly consists of a vertical rod which swivels within the tube and is surmounted by a U-shaped hinge unit <i>10. </i>Fixed to the movable portion of the hinge is a 1-in. rectangular bar <i>11. </i>Threaded holes in the bar can be aligned with drill holes in the underside of the trough for attachment and anteroposterior adjustment. The outside rocker-arm assembly incorporates a height-adjusting collar <i>12 </i>on a longer vertical rod and a ball-bearing trough pivot <i>13. </i>A clamp anchored to the hinge axis medially, attaches to an offset rod <i>14 </i>to permit vertical adjustment of the trough with respect to the hinge.</p> <p><i>Advantages - </i>The outside rocker-arm assembly reduces friction in vertical motions and permits greater control of elbow-hand balance by means of placing the trough pivot closer to the center of gravity of the forearm.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>15 </i>and dial <i>16 </i>are similar to but not identical with the GWSF forearm cradle and stationary dial.</p> <p><i>Disadvantages - </i>Stationary dial restricts elbow extension.</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>Nancy V. Appoldt, B.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-005.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 Preliminary Design Analysis of Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Nancy V. Appoldt, B.A. * https://staging.drfop.org/files/original/befcb86fff74a058e93e3af03fca5cb4.pdf 039187c0f904a1046950d24faf81834e https://staging.drfop.org/files/original/789116c760951063d9ff4663d56ebf11.jpg a9aab0226d3064cf534e81cdf298f8d4 https://staging.drfop.org/files/original/1d6f583a27b50e7e028c417b897f6e7b.jpg 15aa793539956fd62a25423d3bce7777 https://staging.drfop.org/files/original/9a407e0949fb0cacc06278d12c150165.jpg 2d7e8e8f2c1dc9463620a612fc5ec1ba DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_004.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Past and Present Medical Significance of Hip Disarticulation</h2> <h5>Henry E. Loon, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Hip disarticulation, or amputation through the hip joint, is one of the most drastic surgical removals known to medicine. It is seldom justified as other than a last-resort, lifesaving measure and, as compared to other amputations, is seldom performed. Because of its severity, and because it has been used only for patients already on the verge of medical disaster, it has been attended by discouragingly high mortality rates throughout its 200-year history. By the same token, however, the record of the changing need for hip disarticulation is a record of medical progress against fatal disease and trauma of the lower extremity. Whereas hip disarticulation was first used extensively against gangrene or the ever-present threat of generalized infection, it is now most frequently one of the ultimate weapons against cancer. Moreover, the operation has lost much of its fearsomeness as general medical knowledge and surgical skill have increased and as the hope for prosthetic rehabilitation of these patients has become brighter.</p> <p>By presenting the medical aspects of hip disarticulation in historical perspective, it. is hoped to show here how the pathological conditions indicating hip disarticulation have changed as medical science has progressed, how the operative dangers of hip disarticulation have been largely overcome, and how the surgical fashioning of the stump (within the limits imposed by injury or disease) has helped in the prosthetic rehabilitation of patients. Finally, there is appended a discussion of the recent interest paid to systemic effects that may accompany any major loss of limb.</p> <h4>Historical Beginnings</h4> <p>Until the mid-eighteenth century, surgeons considered themselves helpless to treat complicated fractures or suppurative diseases of the upper part of the femur, let alone malignant growths in this region. Death from septic complications, gangrene, or, in the case of cancer, metastases, was the almost inevitable outcome of these conditions.</p> <p>Surgical disarticulation of the hip was apparently first conceived by Sauveur Francois Morand, a leading French surgeon of the early eighteenth century, and was formally proposed in 1739 by two of his pupils.<a></a> Long before the first true surgical disarticulation, however, the hip of a boy of 14 was nearly disarticulated by gangrene which resulted from his having eaten diseased rye. Observing the thigh to be connected to the trunk only by the round ligament, the sciatic nerve, and some shreds of tissue, the French surgeon Lacroix<a></a> cut these with scissors. The other leg, similarly affected, was cut from the hip in the same manner four days later, and the patient survived another 11 days. This case gave a great impetus to discussion of the matter. In 1759, the Royal Academy of Surgery offered a "double prize" for the best essay on the following subject: "Dans le cas ou l'amputation de la cuisse dans l'article paroitroit l'unique ressource pour sauver le vie a un malade, determiner si l'on doit pratiquer cette operation, et quelle seroit la methode plus avantageuse de la faire."<a style="text-decoration:none;">*</a> Of 44 essays submitted, 30 were in favor of performing the operation.<a></a></p> <p>Not until 1774 was it proved that death on the operating table was not a necessary consequence of this formidable operation. In that year, the first true surgical disarticulation of the hip was performed by William Kerr,<a></a> of Northampton, England, on an 11-year-old girl who had a tumor of the thigh and symptoms of pulmonary tuberculosis.<a style="text-decoration:none;">*</a> The disarticulation had probably not greatly influenced the course of the disease, and Kerr concluded his presentation optimistically (p. 342): "With regard to the expediency of the operation, I am so much convinced of it in certain cases, that in such I shall not, for the future, hesitate to perform it when they occur."</p> <p>Another disarticulation said to have been performed at about the same time by Henry Thomson at the London Hospital apparently terminated fatally<a></a> , and the operation was not reported again for nearly 20 years. The Wars of the French Revolution and the Napoleonic Wars brought with them a new series of hip disarticulations.</p> <h4>Shifts and Changes in Indication Over Two Centuries</h4> <p>Although the earliest hip disarticulations were performed for disease, in the following 100 years many more were done for gunshot wounds than for any civilian cause. Up to the end of the American Civil War, nearly two and a half times as many military as civilian operations had been reported from Europe and America, as recorded by Otis in <i>The Medical and Surgical History of the War of the Rebellion . </i><a></a> Since that time, the situation appears to have been reversed again owing to the decreased necessity for the operation fol- lowing battle injuries and its increased use to remove malignant growths. It would be instructive to be able to compare hip disarticulations of military and of civilian origin—as to exact incidences and indications—throughout the history of the operation, but unfortunately information is incomplete and many difficulties of interpretation arise. Nevertheless, a comparison of the indications given for each group points up the necessity of considering the two categories separately.</p> <h4>Indications in Military Surgery </h4> <p>The military surgeon has always been concerned mainly with trauma and ensuing infection, although infection plays a progressively less important role than formerly. In 1812, Dominique Jean Larrey,<a></a> the famous French surgeon and personal physician of Napoleon, who himself (Larrey) performed seven of the early disarticulations, stated the indications for the operation in military surgery as follows:</p> <ol> <li>A torn-off limb, or great laceration of the limb so close to the upper articulation that amputation in continuity would not be possible.</li><li>Fracture of the femur in the vicinity of the trochanters, accompanied by a rupture of the femoral artery or of the sciatic nerve.</li><li>Massive gangrene of the lower extremity extending to the vicinity of the upper articulation, as a result of extensive wounds of the soft tissues.</li></ol> <p>At the time of the American Civil War, these indications were still considered valid, and Otis<a></a> repeated the first two almost verbatim. Today, however, most severe fractures, and even many comminuted fractures, of the upper end of the femur, if not associated with irreparable vascular damage, can be treated conservatively. Most of the major amputations of extremities in World War II were the result of such extensive traumatic injury that no improvement in surgical technique could hope to effect repair. According to DeBakey and Simeone,<a></a> 69 percent of the 3177 major amputations performed in the European and Mediterranean Theaters were due to extensive trauma (by which was meant complete or nearly complete severance of the limb or part of the limb), 12 percent to infection, and 19 percent to major arterial injury.</p> <p>The relatively small percentage of amputations due solely to major arterial injury could probably now be reduced still more because of new techniques of repair and grafting of blood vessels. Some successful cases were reported from the Korean War, and knowledge is further advanced today.<a></a></p> <p>Statistics on the specific indications for the 56 recorded cases of hip disarticulation from World War II<a></a> are at present not available. The implications of the records seen is that the majority were traumatic amputations. For instance, of the 154 wounds of the hip joint observed between D-Day and VE-Day at the 802nd Hospital Center, none was treated by disarticulation. Regarding the incidence of infection, there was no report of rapidly spreading hemolytic streptococcic or staphylococcic infection, such as still occurred in World War I <a></a>. At the 802nd Hospital Center, infection occurred in 9 of 29 injuries of the femoral head or neck. Although these were cases of persistent, long-lasting infection, leading in two cases to death, no hip disarticulation was performed. Usually this tendency toward conservatism was justified, but in looking back, the Office of the Surgeon General has modified this attitude in the following statement:<a></a></p> <ol> <li>When there has been great mechanical destruction of the bone and soft parts and when retained foreign bodies carrying fragments of clothing cannot be removed, foci of infection are maintained for indefinite periods of time.</li><li>A prolonged delay before amputation merely results in exhaustion of the patient, so that, when the operation is eventually performed, it often poses a serious threat to life. ... It must be assumed that patients with large areas of mixed, penicillin-resistant infection deteriorate every day that they live and that their chances of survival after major surgery become progressively less as time passes. . . .</li><li>Observation of numerous instances of pyoarthro-sis of the hip joint at United States Army amputation centers made it clear that when the sciatic nerve is lacerated the indication for early disarticulation of the hip is particularly strong.</li></ol> <p>Fulminating gas gangrene is still an indication for amputation, but its incidence has been tremendously reduced by the employment of prompt and thorough debridement and the administration of antibiotics. It is impossible to determine from the available statistics whether any hip disarticulations were performed because of this infection.</p> <p>To sum up, in military surgery hip disarticulations-like other major amputations- appear to be performed today primarily when the limb is completely or almost completely severed from the trunk. To these traumatic amputations must be added those cases in which disarticulation is necessitated by major injury to the blood vessels or to the main nerve trunks (particularly the sciatic) and those in which multiple foci of antibiotic-resistant infection cannot otherwise be eliminated. That the number of hip disarticulations has not been greatly reduced in comparison with former wars is testimony to the increased destructiveness of modern weapons; the type of injury which used to necessitate hip disarticulation can usually be treated conservatively today.</p> <h4>Indications in Civil Surgery</h4> <p>The civilian surgeon has also always been concerned with trauma, but disease, and especially malignant disease, has played an increasingly important role. In 1839, Velpeau<a></a> stated the indications for hip disarticulation in peacetime as follows:</p> <blockquote><p>A comminuted fracture, a necrosis, caries, osteosarcoma, spina ventosa, or any incurable degeneration whatever, of the femur, extended above its shaft, or gangrene, or any other disease in fact which has progressed nearly as high up as the haunch, and which is of such serious character as to demand amputation, will claim disarticulation provided the cotyloid cavity and the bones of the pelvis are not affected.</p> </blockquote> <p>The major change in indications from the nineteenth to the twentieth century is best seen from a comparison of nonmilitary hip-disarticulation cases. It may be seen from <b>Fig. 1</b> that, although many of the conditions listed by Velpeau might today be considered indications for hip disarticulation, they do not in practice occur very often. Cancer is <i>the </i>indication now, whereas in the early period it was one among a number of causes. The indications given by Smith<a></a> for his historical survey of cases fall into the following categories: malignancy, 13; severe crushing injuries, 8; suppurative diseases of the femur, 7; tuberculosis, 4 (tubercular lesions of the bones, 3; tuberculoma of the thigh, 1); gangrene, 3; miscellaneous causes ("diseases of the femur," "coxalgia," pain, exostoses), 7.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Comparison of early and recent indications for hip disarticulation in peacetime. Data for the early period were taken from a compilation by Stephen Smith<a></a> of all known cases of hip disarticulation to 1852. Wartime operations and those for which the indication was not known were eliminated. Data for the recent period were derived from articles indexed under <i>Amputations </i>in the <i>Quarterly Cumulative Index Medicus </i>from 1935 through 1951 and in the <i>Current List of Medical Literature </i>from January 1952 through August 1957. Again, wartime operations and those for which the indication was not stated were eliminated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four of the tumors which Smith gave as indication were not classified by him as malignant. But from the description of the course of the disease they appear to have been, and they are therefore here grouped under malignancy. This is only one example of how difficult it is to determine with any certainty what the true indications for these early operations were. Another example is Kerr's case (page 5). Smith, following Kerr's own diagnosis, recorded the indication as tuberculosis; yet from the description of the case it seems conceivable that the patient had a malignant growth in the upper end of the femur and the innominate bone with metastases to the lungs.</p> <p>Methods of diagnosis are greatly improved today, but it is no less difficult to obtain reliable statistics on recent hip disarticulations. Cases that do not present striking medical or surgical aspects are no longer reported in the literature. In this country, unfortunately, no survey of the total number of amputees has ever been made, but even in countries like Germany or Great Britain, where the government has made such surveys for the larger categories of amputations, no information of the incidence of hip disarticulations, let alone the indications for them, seems to be available. </p> <p>In a literature survey covering the period from January 1935 through August 1957, there were reported (<b>Fig. 1</b>) 146 civilian hip disarticulations for which the indications were malignancy.<a></a> Two were done for tuberculosis<a></a> and one each for osteomyelitis following an injury<a></a>, phlegmon of thigh and general septicemia following an injury, <a></a> a suppurative process (etiology not stated) of the coxo-femoral articulation,<a></a> actinomycosis, <a></a> gangrene caused by thrombosis, <a></a> and paralysis and contracture caused by an extradural abscess. <a></a> It is a little surprising that, of all the reported civilian hip disarticulations, none was done primarily for trauma. I have myself seen one patient whose hip was disarticulated because of injuries in peacetime, and I am certain that there must have been a few others.</p> <p>Fortunately, not all malignant growths, even in the upper part of the thigh, call for such drastic treatment as disarticulation of the hip. In some cases wide excision of the neoplasm suffices to remove it entirely. The decision as to whether or not to disarticulate depends upon the site and the type of the neoplasm. The indications upon which modern surgeons agree are well stated by Pack and Ehrlich<a></a>, and the reader interested in these details is referred to that excellent paper.</p> <h4>Incidence Relative to All Leg Amputations</h4> <p>Comparison of the number of hip disarticulations with total numbers of lower-extremity amputations shows still more clearly how seldom hip disarticulation is performed. It has now become much rarer in military than in civilian practice. During the American Civil War<a></a> 86,413 wounds of the lower extremities were recorded. In 12,605 of these cases (less than 15 percent), the wounds resulted in major lower-extremity amputations. Of these, 66, or 0.5 percent of the amputations, were hip disarticulations (<b>Fig. 2</b>). In World War II<a></a>, 248,000 wounds of the lower extremities were recorded. Of these, 12,612 (5 percent) are estimated to have resulted in major amputation. Fifty-six, or 0.4 percent, of the amputations are estimated to have been hip disarticulations. Thus the percentage of hip disarticulations in relation to total lower-extremity amputations has changed very little; it has remained small. Both the number of hip disarticulations and the number of lower-extremity amputations have, however, decreased greatly relative to the number of wounded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. One of the few survivors of disarticulation of the hip during the American Civil War. Note the large amount of soft tissue in the stump. From Otis<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In civilian cases the ratio of the number of hip disarticulations to all major lower-extremity amputations is probably somewhat higher but still less than 2 percent. Thus, of 70 lower-extremity amputees who underwent amputation or were treated at the University of California Medical Center from 1941 to 1955, only one had had a hip disarticulation.<a></a> Of 663 patients with major lower-extremity amputations who have passed through the Veterans Administration Hospital in Oakland since the end of World War II, eight have had hip disarticulations.<a></a> Even the records of an institution treating predominantly cancer patients show a very small number of hip disarticulations. The Bone Tumor Service of the Memorial Center for Cancer and Allied Diseases in New York City reported only 15 hip disarticulations from 1930 to 1946,<a></a> a fact which suggests that even today this operation is done only to forestall certain death.</p> <h4>The Long Struggle to Reduce Mortality </h4> <p>There was good reason why hip disarticulation was not attempted, or even conceived, until the eighteenth century. The surgical skills which had been developed up to that time were still grossly inadequate for an operation attended by so much danger of hemorrhage and shock.</p> <h4>Operative Mortality </h4> <p>When we consider that the operation had to be done as fast as possible, without benefit of anesthesia or knowledge of asepsis, it is surprising how many of the earliest patients survived even a few days or weeks. Larrey, <a></a> who was probably one of the most skilled surgeons of his time, has recounted cases in which, after ligating the femoral vessels together, he completed the procedure in 14 to 15 seconds. To achieve this speed, he used only four knife strokes. He drove a blade perpendicularly between the base of the femoral neck and the tendinous attachments of the lesser trochanter until it emerged posteriorly and, with an oblique downward stroke, cut the medial flap; raised the flap proximally to expose the articulation and with a stroke of the bistoury cut the articular capsule; abducted the thigh (nearly dislocating the head of the femur) and in a stroke cut the interarticular ligament; and with a downward and outward stroke of a small straight knife cut the lateral flap. The remaining arteries were then ligated. Larrey did not consider it necessary to suture the muscles. If there was no "irritation," the subcutaneous tissues and the skin were approximated with a few retention sutures. The edges of the wound were further drawn together by compresses dampened with red wine, and a large bandage was applied.</p> <p>Larrey reported that his first patient survived the operation well but a few hours later had to follow the army in a 24-hour forced march in winter, so that he died presumably of cold and exposure. His second patient also seemed well on the road to recovery when, six days postoperative, a soldier with the plague was bedded on the same straw mat with him. Larrey's patient became infected and died within 24 hours.</p> <p>The fate of these patients, who died not as a result of the operation itself, shows how difficult it is to establish the date of the first "successful" hip disarticulation. These two, together with others in which death occurred within a year after operation, were in early mortality statistics classed as fatalities.<a style="text-decoration:none;">*</a> On the other hand, there are no verifiable records of several of the early hip disarticulations claimed by later authors to have been successful. Otis on whose two works<a></a> the early figures given here are based, pointed to other frequent sources of fallacies in surgical statistics. He said:<a></a></p> <blockquote><p>The desire for distinction of ambitious operators sometimes tempts them to report successful results prematurely, and to fail to record unfortunate cases. Feverish partizans of particular operative procedures, in accumulating statistics, not unfrequently evince an unpardonable disregard for the fundamental rules of evidence, and admit testimony abounding in transparent fallacies. Some writers, in their zeal to gather together numerous observations, group those that are very dissimilar, and deduce inferences from the collection that are pertinent only to particular cases.</p> </blockquote> <p>He stated that in his own report the authenticity of cases was scrutinized and that doubtful cases were rigidly excluded.<a></a> Insofar as the records of earlier operations Otis recorded have been checked, he was indeed conscientious; yet in evaluating his figures it is essential to bear in mind all the limitations of this early material.</p> <p>According to Otis <a></a>, 111 known civilian cases of hip disarticulation were reported from Europe and America to the end of the American Civil War. Of these, 46 were considered successful and 65, or 59 percent, terminated fatally. In military surgery <a></a>, 254 authenticated hip disarticulations were reported, with 28 recoveries, 225 deaths, and one result unknown-a mortality rate of 89 percent. Of the 187 patients who underwent hip disarticulation prior to the American Civil War, 17 survived, giving a mortality rate of 91 percent. In the 67 cases occurring during the Civil War, 11 of the patients recovered-a mortality rate of 84 percent.</p> <p>In spite of this extremely high mortality rate, disarticulation gave better results than did more conservative methods of treatment for complicated fractures of the upper end of the femur. Of 252 patients with intracapsular shot fractures who were treated conservatively during the American Civil War, three recovered, giving a mortality rate of 99 percent.<a></a> Fifty-five excisions of the femoral head resulted in a mortality rate of 91 percent.<a></a> The mortality rate did not improve materially until well after the general introduction of asepsis in the 1880's. In 1878, Farabeuf,<a></a> when presenting his method of disarticulation to the Societe de Chirurgie in Paris, cited a still-persisting death rate of 75 percent. The American surgeon Wyeth,<a></a> writing in 1890, mentioned "the terrible death-rate after hip-joint amputation."</p> <h4><i>Improvements in Surgical Technique</i></h4> <p>After deaths from complications of infectious processes had been somewhat brought under control by the general introduction of aseptic surgical procedures, surgical shock still accounted for a large number of the operative deaths. A main contributing factor was hemorrhage.</p> <p><i>Reduction of Hemorrhagic Shock. </i>The arteries to the upper part of the thigh and the gluteal region branch out from several main trunks (<b>Fig. 3</b>), so that it is much more difficult to control the flow of blood for a hip disarticulation than for a thigh or leg amputation. Methods attempted for control ranged from a high tourniquet placed about the upper end of the thigh to compression of the aorta.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Arterial system in the hip and upper part of the thigh. Redrawn, by permission, from <i>Gray's Anatomy, </i>26th ed., Lea &amp; Febiger, Philadelphia, 1954. The original appeared in Eycleshymer and Jones' <i>Hand Atlas of Clinical Anatomy, </i>Lea &amp; Febiger, Philadelphia, 1925. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An ordinary touniquet is difficult to apply satisfactorily for a hip disarticulation. Placed about the thigh at the groin, it not only does not control bleeding from a number of the main vessels but it also slips out of place easily after enucleation of the promixal end of the femur. For this reason, there were developed various devices for holding a tourniquet in place, the best known being Trendelenburg's<a></a> and Wyeth's<a></a> systems of pins. In both procedures, long steel pins were driven through the soft tissues to prevent slippage of rubber tubing used to constrict the tissues.</p> <p>Of the more radical methods for compression of the parent trunks, some, such as a Davy's lever introduced through the rectum for the compression of the aorta, were dangerous, and they were not always reliable.<a></a> Other authors recommended making an abdominal incision and temporarily compressing<a></a> or lifting<a></a> or even permanently ligating<a></a> the common iliac artery. The latter procedure has been recommended as recently as 1954, <a></a> but it is not commonly used today. Many surgeons hesitate to add to the system an additional shock by making an incision into the abdominal cavity.</p> <p>In general, more conservative measures are and have been advocated. Although initial ligation of the femoral vessels does not provide a completely bloodless field (because of the many anastomoses from the obturator and gluteal arteries), it has usually been considered the most satisfactory method. As we have seen, Larrey in his early operations recommended preliminary ligation of the femoral artery and vein, and regardless of the type of incision this has been common practice to the present day. Farabeuf,<a></a> whose procedure is still widely used, especially in Latin American countries, recommended an anterior racquet incision. The stem of the inverted <i>Y</i> should be over the point at which the femoral vessels pass under the inguinal ligament, and the artery and vein are sectioned and ligated before proceeding with the operation. Farabeuf claimed that other arteries could satisfactorily be cut and compressed by assistants as they were encountered and then ligated before closing the wound. Marquardt<a></a> in a recent book stated that in Germany it is considered best to follow Angerer's two-stage procedure,<a></a> in which ligation of the femoral artery and vein is done through an incision in Scarpa's triangle one or two days before the proposed hip disarticulation. This expedient allows the vessels to become thrombosed so that there is little loss of blood during the disarticulation itself.</p> <p>Finally, blood may be conserved if, after ligation of the artery, the leg is elevated for several minutes to allow maximal drainage to the trunk before ligation of the vein.<a></a></p> <p>In addition to careful hemostasis, it is helpful to section the muscles, wherever possible, in the avascular areas close to the tendinous origins or insertions rather than through the muscle bellies. This principle, proclaimed by Callander<a></a> in 1935 for his amputation just above the knee, has been applied to hip disarticulations by Leriche,<a></a> Boyd,<a></a> Slocum,<a></a> and Piquinela.<a></a> In the days when speed of operation was the primary consideration, the principle was necessarily violated. If guillotine operations are excluded, it is hard to imagine a faster method than Larrey's, but cutting each flap with a single stroke, as Larrey did, meant sectioning the muscles through the richly vascularized bellies, thus contributing greatly to hemorrhage and shock. He was, of course, caught on the horns of a dilemma for those times, because speed, too, was essential to lessen shock.</p> <p><i>Other Techniques for Avoiding Shock. </i>Even in cases in which there has been no infection or excessive hemorrhage, shock often occurs. Bustos<a></a> gave this as reason for believing that conditions which could cause pain played the major role in causing shock. Gentle handling is considered essential by most modern surgeons. Layer-by-layer dissection, using a scalpel, was recommended by Petrovskii.<a></a> Caprio<a></a> recommended the use of an electric scalpel, with which he claimed that he could carry out the whole operation without even turning the patient over, as is usually done.</p> <p>Many surgeons have taken precautions to avoid shock that might result from overstimulation of the sciatic nerve. Since this large nerve trunk runs through the posterior portion of the thigh, it is ordinarily not sectioned until the latter part of the operation and is in the meantime subjected to a variety of tensions, particularly after the dislocation of the femoral head, when the half-severed limb hangs from the trunk, connected only by this nerve and associated soft tissue. Various methods for overcoming this problem have been suggested -proper support of the limb throughout surgery to avoid these tensions<a></a> ; injection of the nerve with procaine before sectioning it;<a></a> and even, in a debilitated case, section of the sciatic nerve (after injection with procaine) almost at the start of the operation<a></a>. In 1917, Morris, <a></a> using spinal anesthesia, began his operation by injecting the sciatic nerve with procaine through a small posterior incision and then proceeded through anterior incision with what is usually the first part of the operation. He stated that no shock was observed during the ensuing disarticulation.</p> <p>Recently, the use of spinal anesthesia has been questioned<a></a> on the grounds that hypotension results, which could be dangerous in view of the seriousness of hip disarticulation. However, hypotension does not occur routinely when the level of spinal anesthesia is so low that the splanchnic nerves are not anesthetized. <a></a> Injecting the sciatic nerve may appear superfluous if spinal block has been performed prior to the operation. It seems to be done as an additional precaution and as a means of blocking any afferent fibers that, traveling via the sympathetic chain, may enter the cord above the level of spinal anesthesia.</p> <p>A two-stage operation is sometimes advisable for patients who are in very poor condition. We have already mentioned Angerer's procedure of ligating the femoral vessels one or two days before the disarticulation, a method which aids in avoiding shock by reducing blood loss. Even a three-stage procedure has been recommended. <a></a> In most cases today, however, the operation is performed in one stage only.</p> <h4><i>Improvements in Adjunct Therapy</i></h4> <p>In the first quarter of the twentieth century, great progress in several fields decreased the risks of serious operations such as hip disarticulation. More careful debridement of wounds was supplemented by chemotherapy and the use of tetanus antitoxin. By the end of World War I, shock occurring in American Army soldiers was treated by fluid replacement and whole-blood transfusion.<a></a> Knowledge of the physiology and technique of blood transfusion was greatly advanced in the second quarter of the century. Methods of preserving whole blood and plasma were developed, although such problems as the occurrence of homologous-serum hepatitis virus in stored plasma remained unsolved and caused considerable damage. Surgical knowledge of the repair of fractures and of replacement of hopelessly damaged parts of bones by grafts of various types made conservative treatment possible in many more cases than before. The use of sulfa drugs and antibiotics greatly reduced the incidence of infection after severe wounds. Finally, psychotherapeutic measures to prevent psychic trauma and to facilitate recovery became an important adjunct to surgical care.</p> <p>Operative death has become rare, <a></a> but the extent of shock and the resulting damage to the system continue to deserve study.</p> <h4>Mortality From Cancer</h4> <p>Another mortality rate is, however, a matter of much greater concern today. As we have seen, most modern civilian hip disarticulations are performed for cancer. Since at the present time hip disarticulation is commonly not resorted to until other measures (radiation, wide excision) have failed, it often has only a palliative effect. The mortality, if studied for the 5-year-cure rate, is extremely high. Of a series of 52 patients operated upon at the Memorial Cancer Center in New York from 1926 to 1948, 44 (85 percent) died of cancer within five years.<a></a> Pack<a></a> and others<a></a> have emphasized that, if disarticulation is resorted to only at this late stage, the mortality rate in such cases will continue to be high. In a recent study of patients with malignant disease who underwent hemipelvectomy (an operation comparable to hip disarticulation for the purpose here), Lewis and Bickel<a></a> observed:</p> <blockquote><p>Twelve of the 18 patients who had had symptoms less than six months at the time of operation are still living (two with metastases), and 4 of the 6 who had had symptoms for six months to one year are still living (one with metastases), while only 8 of the 25 patients who had had symptoms for more than one year have survived the present follow-up periods, and one of these has evidence of metastases.</p> </blockquote> <p>Although there is sometimes justification for disarticulation as a palliative measure, it would be much more desirable to employ it as a cure. Disarticulation as a curative measure will, however, be possible only when surgeon and patient alike are willing to take this radical step at an early stage of the disease.</p> <p>To what extent will hip disarticulation be replaced by the even more drastic operation of hemipelvectomy? Hemipelvectomy is indicated if malignancy (or, for that matter, a severe crushing injury or a suppurative process such as that mentioned on page 8) has involved the tissues proximal to the coxofemoral joint. Leriche<a></a> went beyond this in 1937 when he predicted that hemipelvectomy would one day be considered the operation of choice for malignant growths of the upper part of the thigh. Lee and Alt<a></a> in 1953 compared hip-joint disarticulation with hemipelvectomy from the point of view of anatomy and surgical technique, extent of postoperative disability and use of prosthesis, and therapeutic effectiveness. They found that under modern conditions there was no great difference between the two operations so far as surgery or postoperative disability are concerned, whereas hemipelvectomy definitely offered better hope of a cure. They therefore considered hemipelvectomy the procedure of choice for high-grade soft-tissue or osteogenic malignant tumors of the upper thigh as well as of the pelvis.</p> <p>Not all modern surgeons go so far as this. Coley<a></a> has emphasized that it is essential to discriminate between cases, the decision depending upon the site and grade of malignancy of the tumor. Osteosarcomas and chondrosarcomas of the lower fourth of the femur do not call for hip disarticulation and are better treated by high thigh amputation, since then considerably less disability results.</p> <p>In sum, allowing a wider margin between the tumor and the incision is now generally recognized to be necessary to ensure elimination of all malignant cells. This means that the level of amputation has tended to move in a proximal direction. While some hip disarticulations have been replaced by hemipelvectomy, high thigh amputations have also been replaced by hip disarticulation, so that no appreciable decrease in the number of hip disarticulations is to be expected as a result of this trend.</p> <h4>Surgical Fashioning of Stumps</h4> <p>The surgical techniques of hip disarticulation practiced today have evolved as a result of this many-faceted experience. Throughout the history of the operation, the sequence of procedures has been dictated primarily by cumulative experience in combating hemorrhage and shock. The shape of the resulting stump has been affected primarily by the change in indication for the operation from predominantly traumatic to predominantly malignant cases. To a lesser degree, the shape has been affected by considerations of healing and subsequent fitting with a prosthesis.</p> <h4>THE LARGE SOFT-TISSUE STUMP</h4> <p>The large soft-tissue stump popular during the early history of hip disarticulation (<b>Fig. 2</b>) may originally have been developed through association with a high-thigh stump. Surgeons first experimenting with the dangerous operation of hip disarticulation may well have been loath to cut away too much soft tissue. But many of the early operations were actually done by first performing a circular high thigh amputation and then disarticulating the head of the femur through a lateral incision.<a></a></p> <p>During the latter half of the nineteenth century, many experiments were carried out with various kinds of subperiosteal amputations, in which a cuff of periosteum was left overlapping the end of the bone stump. Difficult as it was to perform, a subperiosteal hip disarticulation was done several times. Originally devised by Oilier of Lyons in 1859, it was carried out by James Shuter<a></a> of London in 1881. A circular amputation was first performed at the junction of the middle and upper thirds of the thigh. The vessels were ligated, and through a longitudinal incision on the lateral aspect of the thigh the remaining portion of the femur was dissected out, leaving the periosteum (peeled off up to the intertrochanteric line) in the flaps.</p> <p>The advantage of this method, according to Shuter and others who observed the patient over a year after operation, was that the residual periosteum provided a point of attachment for the muscles and caused a growth of what Shuter termed "new bone" but which other observers described as "a firm resisting cord",<a></a> cartilaginous rather than bony in character. Observers testified that this "cord" provided such a good attachment for the muscles that they were "in a high state of nutrition" and that the patient not only could flex, extend, adduct, and abduct the stump powerfully but also could communicate all these movements to the artificial limb. Durand<a></a> of Lyons had a woman patient who, more than four years after a similar operation, had a regenerative process resembling a tough fibrous stalk, which also provided an excellent attachment for the muscles. She was able, he stated, to lift a weight of 15 kg. with her flexed stump.</p> <p>In a modern case<a></a> the patient, although apparently not operated upon subperiosteally, was said to have had a stump with many of the characteristics claimed for the subperiosteal stumps. Disarticulation was done for osteomyelitis of the femoral shaft, trochanter, and neck, a sequel to extensive injuries of the thigh. The femur was carefully dissected out from the surrounding tissues, leaving a soft-tissue stump measuring 6 in. when relaxed. It was reported that "The muscles had become attached to each other by scar tissue, so that there was actiye flexion and extension of the stump if one grasped the muscles with his hands." The patient was able to wear a suction-socket prosthesis, which he could flex and extend at the hip joint "because of the fixation of the skin and muscles to the side of the socket by the suction exerted upon the distal end of the stump." This method of activating the prosthesis was compared to that used by crustaceans in activating their exoskeletons, and a point was made of the importance in this case of designing the socket so that, upon weight-bearing, the contracted muscle mass would be properly positioned on the ischial seat beneath the ischial tuberosity.<a style="text-decoration:none;">*</a> About the turn of the century, subperiosteal amputations were gradually abandoned, mainly because of the frequency of undesirable growths of new bone emanating from the periosteal cuff. Apparently only a few subperiosteal hip disarticulations were performed. In addition to the uncontrollability of new bone growth, other, even more important, reasons prevented the operation from becoming popular. One was the difficulty of stripping the periosteum from a healthy bone. Shuter's subperiosteal operation was done for a suppurative process of the femur, in the course of which the periosteum had already achieved a considerable degree of natural separation from the bone. Durand did not mention a similar condition in his patient, but his operation was done for tuberculosis, and possibly a suppurative process was present. Another reason, much more significant today, was that the retention of the periosteum made the procedure unsuited for any disarticulation done because of a malignant neoplasm.</p> <h3>The Compact Stump</h3> <p>After disarticulation for malignancy, the hip stump commonly fashioned today is compact, with the soft tissues reduced to a minimum. When involvement of the inguinal nodes is proved, or, in certain disease, even suspected, a radical groin dissection is also done, thus removing even more tissue from the body.</p> <p>Most incisions today, whether of the anterior racquet or semioval type, start just below the inguinal ligament and thus provide immediate access to the femoral vessels and nerve in Scarpa's triangle. These incisions create a long posterior flap and leave an anterior scar that is well removed from terminal and lateral pressure areas and from any possibility of fecal contamination before wound-healing is complete. The semioval incision has the advantage of eliminating the "handle" of the racquet, which, if carried too far, may easily invade a pressure area under the pelvic corset of the prosthesis. For this reason, it would seem to be the incision of choice for the use of the Canadian-type hip-disarticulation prosthesis, as may be seen from Fig. 11, page 37. This prosthesis is, however, very adaptable and can easily be modified to accommodate a larger or smaller amount of soft tissues (even dog-ears). Bony prominences are not necessary to anchor it. If the wound has healed by first intention, it is no longer critical whether the scar lies under a pressure area.</p> <p>For further information on the modern technique of hip disarticulation, the reader is referred to Slocum's procedure, which is detailed on pages 242-244 of his work, <i>An Atlas of Amputations .</i><a></a> The muscles are sectioned in the avascular areas close to their tendinous origins or insertions. Some additional precautions against shock, as already discussed, may be found desirable in certain cases. For cases in which involvement or suspected involvement of the inguinal nodes necessitates radical groin dissection, Pack and Ehrlich's standard method<a></a> can be followed. A racquet incision, with the handle of the inverted <i>Y </i>extending proximally, is recommended for this procedure, which is carried out before the hip disarticulation. The only problem here is that the large skin flaps, denuded of all underlying subcutaneous fat, lymphatic tissue, and fascia, are susceptible to necrosis and sloughing along their edges. Not much can be done about this, since in order to be effective the procedure has to be thorough. Since the wound does not ordinarily heal by first intention, the scar, extending as it does well above the line of the inguinal ligament, may present problems in the fitting of the Canadian-type hip-disarticulation prosthesis.</p> <h3>Possibility of Short Thigh Stump</h3> <p>Most cases of malignancy, as we have seen, require radical removal not only of the bone but also of as much soft tissue as possible. When the amputation follows trauma or disease other than cancer, however, the question may arise as to whether to disarticulate or to leave a very short thigh stump. The improvement of artificial limbs, as well as of surgical techniques, has made it possible to fit above-knee amputees of higher and higher amputation level with thigh prostheses rather than with hip-disarticulation prostheses. In 1930, Verrall<a></a> stated that any stump measuring less than 5 in. below the greater trochanter had to be fitted with a tilting-table (hip-disarticulation) prosthesis. In 1949, Slocum stated<a></a> that "When amputation approaches the level of the lesser trochanter, the function of this [hip] joint is nullified ..." and that therefore a patient with an amputation at this level or higher had to be fitted with some type of hip-disarticulation prosthesis. The possibility of fitting a suction socket depends, however, not only on the length of the residual bone but also on the volume of the soft tissues which provide the seal for holding suction. Indeed, in the case of the man with a completely boneless stump (cf. p. 14), the soft tissues alone enabled him to wear a suction-socket prosthesis.</p> <p>The leverage provided by even a small segment of the femur is, of course, a great advantage in activating a prosthesis. Tikhonov<a></a> reported interesting experiments to lengthen a short residual femur by bone grafts. He said that it was not possible to give an absolute measurement for the shortest thigh stump which could activate a thigh prosthesis, since this length depended also on the volume of soft tissues, which varied from stump to stump. Instead, he gave a formula based on the relation of length to circumference. He also noted that except for extreme cases a stump should measure somewhere between 8.5 and 13.5 cm. (3.3 and 5.3 in.) from the perineum in order to allow for piston action of 2 to 3 cm. (about an inch) yet still permit the prosthesis to be moved in any direction. For the patient with other handicaps in addition to the very short thigh stump (such as amputation of the contralateral extremity or an upper-extremity amputation), Tikhonov and his co-workers recommended that surgical lengthening of the short stump be considered as a means of increasing the patient's ability to get about.</p> <p>Tikhonov reported on the lengthening of three short thigh stumps by from 3 to 6 cm. (1.2 to 2.4 in.). A homoplastic graft, taken from the diaphysis of the fibula, was inserted into the medullary canal of the femur. After a maximum period of observation of 10 months, he reported that bony union had already been achieved in two of the lengthened stumps and that these were providing satisfactory additional leverage for activating a prosthesis.</p> <h4>Possible Systemic Effects of Major Loss of Limb</h4> <p>As more patients have survived these drastic operations and have become subjects for rehabilitation, increasing attention has been paid to the possible medical consequences of the loss of so large a part of the body. The entire limb can now be removed without great risk of operative death, the patient can be fitted successfully with a prosthesis, and appropriate attention can be given to his psychological and vocational readjustment. Then this question arises: What is the <i>medical </i>outlook for such a patient? The same kind of question has been raised in regard to many diseases and disabilities to which corrective measures have been applied. Frequently, all of the medical consequences of a selected course of therapy cannot be foreseen. The physician asks himself: Am I doing the right thing? Will the radiation therapy that appears so beneficial now give rise to untold medical harm later? In the recent literature of several European countries, there have been raised questions about possible systemic aftereffects of major amputation which could hold much significance for the rehabilitation of amputees. The answers have proved difficult. Many of the opinions expressed have been supported only by clinical impressions or by studies lacking in desirable controls. Many have been accompanied by enthusiastic but untested hypotheses. It appears that, before this mass of information can be evaluated properly and before definitive answers can be obtained, the questions may need to be rephrased and made the subject of carefully controlled studies.</p> <p>In their examinations of amputees, many physicians have observed signs and symptoms and have obtained in clinical tests results which have led them to suspect that amputation is followed by an increased incidence of systemic disease. The review of published observations made by Schulze in Germany in 1942 shows that major limb amputations had at that time already been thought capable of leading to a rather startling list of disorders, including obesity, abnormally increased perspiration, arteriosclerosis, enlargement of the heart, damage to the heart muscle, hypertension, pulmonary tuberculosis, aggravation of bronchial asthma, various disturbances of the digestive system, kidney disease, deformities of the healthy leg and foot, joint deformities, and worsening of varicose veins.<a></a> Some of these conditions are more likely to occur after major amputation than are others. Aside from further changes in the musculoskeletal system, the most frequently claimed effects have been cardiovascular disease- especially hypertension-and changes in the regulation of body heat-in particular, excessive perspiration. German authors have advanced hypotheses to explain the development of these clinically observed phenomena.</p> <p>Sturm appears to have been interested in these problems since 1940 and has published recently, with two colleagues,<a></a> a report of detailed clinical studies on 150 amputees. Of these patients, 130 were at Bad Nenndorf for a "cure." Medical histories were elicited from them by means of a questionnaire and were amended through interview and examination. In addition, various tests of cardiovascular function were made, with amputees appropriately grouped, in order to show that the incidence of cardiovascular abnormalities increases with the length of time since amputation. In an earlier paper, Sturm<a></a> described a syndrome characteristic of a few patients with long-standing amputations of the thigh and with a history of severe suppuration of the stump. Examination of such a patient showed a pale angiospastic face, a definite lability of pulse rate and blood pressure, marked dermographism, increased reflex activity, fine tremor of the hands, moist skin, and increased luster of the sclera. Most of Sturm's observations were offered in support of his hypothesis that "vegetative regulatory disturbances" in amputees result from chronic hypothalamic irritation, which in turn arises (by a stated neuro-physiological mechanism) from prolonged infection, pain, and vasoconstriction of vessels of the stump.</p> <p>Schneider, <a></a> who observed an increase of systolic pressure to over 140 mm. Hg in 20 percent, and of diastolic pressure to over 100 mm. Hg in 5 percent, of 67 amputees, developed Sturm's thesis further. He hypothesized that pain (triggered by a neuroma, long-lasting suppuration, deep-tissue scars, or even the pressure of the prosthesis) could, in constitutionally predisposed patients, excite the central sympathetic area of the hypothalamus and eventually create a central lesion with resulting hypertonia. Schneider also pointed out that the role of psychosomatic factors should not be underestimated. The frustration and resulting emotional conflicts experienced by amputees who were attempting to compete with normal individuals could contribute to an early development of essential hypertension.</p> <p>Another hypothesis concerns the heat-regulating mechanism of the body and the changes which result in it from the loss of a leg. Excessive perspiration in high-thigh and hip-disarticulation amputees has been frequently observed on a clinical basis. Schroder<a></a> com- mented on the role played by the extremities in the cooling system of the body in providing arteriovenous shunts to direct the flow of blood into deep or superficial vessels as needed and in providing a large surface area for evaporation. To him, the loss of a whole lower extremity would appear to mean the loss of a valuable part of the cooling system at the same time that extra demands on energy are being made, with resulting excessive production of heat. Such phenomena would indicate an unusual burden on the circulatory system.</p> <p>These views have excited interest and aroused controversy. Although clinicians may observe in amputees pathological conditions which strongly suggest themselves to be the aftereffects of amputation, analyses of government health records, and clinical studies based on them, have failed thus far to confirm these observations in amputees as compared with equivalent nonamputee populations.</p> <p>The difficulties of assessing the aftereffects of amputation are well reflected in the reports, annotated in <i>Lancet, </i><a></a> of the committee of the Ministry of Pensions in England which in 1950 was asked to find whether amputation of a limb, and subsequent wearing of a prosthesis, could initiate or aggravate cardiovascular disorder and whether such amputation reduces the expectation of life. The interim report of this committee in 1951, termed "somewhat inconclusive," revealed in living amputee pensioners a slight elevation of the mean blood pressure but no abnormal incidence of cardiovascular disease. A more detailed study of death certificates suggested, although not to the point of statistical significance, that patients with leg amputations died earlier, and more commonly from cardiovascular disease, than comparable pensioners with leg wounds not requiring amputation. The majority report of the committee in 1953 introduced a new factor—calling for further committee investigation—by suggesting that men who have suffered major sepsis, with or without amputation, have a higher late incidence of cardiovascular disease and an earlier average death. The committee then arranged for the medical examination of 5500 pensioners, of whom 4500 were to be amputees and 1000 were to be controls, but unfortunately so many of this sample "failed to attend" that no firm conclusions could be drawn. In 1955, however, the committee, after reviewing all of its evidence, made the following statement:<a></a></p> <blockquote><p>Limb amputations, and the subsequent wearing of a prosthesis do not, in time, produce effects on the body as a whole which may initiate, or aggravate, cardiovascular disorders to any significant extent. There is no material difference between the mortality rates of amputees, by reason of amputation, and that of the corresponding rates for pensioners who have suffered wounds not leading to amputation. Such excess as there is in both classes over that in the general population is quite small.</p> </blockquote> <p>For the German regional government of Schleswig-Holstein, Meyeringh and Stefani<a></a> sought to determine the incidence of hypertension in 794 above-knee amputees. They found a resting systolic blood pressure of over 150 mm. Hg in 9 percent, which they compared with an incidence of over 10 percent in the "average German population."</p> <p>In reviewing the articles pertinent to this controversy, one begins to suspect that a single careful distinction might do much to resolve it. This distinction would be between <i>(a) </i>asserting that systemic disease does occur in amputees and is due at least in part to the fact of amputation and <i>(b) </i>asserting that systemic disease occurs more frequently in amputees than in other persons. Conceivably, the same person who develops high blood pressure owing to physiological stresses imposed by amputation could also have developed high blood pressure for different reasons of physiological stress had he retained his leg. Whereas this explanation would seem too simple, it is not too difficult to imagine a complex of factors at work that could mask from certain types of statistical examination a true relation between amputation and subsequent disease.</p> <p>It would seem a pity should too much energy be expended in statistical quibble. The question of relative incidence of systemic disease in amputees and in normals is an important question for practical reasons-such as life insurance, pensions, and the allotment of research funds. Of more moment, however, to researcher, practitioner, and amputee alike, is the question of how and why systemic disease develops in amputees and whether it can be averted in rehabilitation. Furthermore, far from being dispensable, statistical analyses of data obtained from groups of amputees and from appropriate control groups would be a tool valuable to this elucidation.</p> <p>Many factors offering clues to the situation have been taken into consideration to a greater or lesser extent by individual authors-predisposition to hypertension, prolonged suppuration associated with amputation, difference in level of amputation or amount of body mass lost, age at amputation, and obesity. Owing to the differences-or obscurities-regarding the selection of subjects, the use of controls, and the criteria for systemic disease, the results of these authors cannot be compared satisfactorily or generalized. The possible importance of activity or inactivity, the wearing of a prosthesis, and the stresses attached to home and work environments has hardly begun to be considered from the medical viewpoint of systemic disease! Investigation into the systemic effects of amputation could lead to conclusions beneficial not only to amputees with hip disarticulations and high thigh amputations but also to amputees with less serious disabilities and even to persons suffering from other disorders.</p> <h4>Summary</h4> <p>Hip disarticulation is a drastic amputation used almost exclusively as a last-resort or life-saving measure. A review of the medical history of the operation during the last 200 years shows a number of changes. The one with the most far-reaching implications has been the major shift from operations indicated by injury or by disease other than cancer to operations indicated by malignant growth. Better methods for controlling hemorrhage and shock, together with progress in adjunct therapy, have reduced operative deaths from as high as 91 percent in pre-Civil War military cases to none in a recent American series done for malignancies. But the postoperative mortality in cancer cases continues to be extremely high (in the aforementioned recent series, 85 percent within five years of operation). For this reason some hip disarticulations, when indicated at all for cancer, may well be indicated much earlier in the course of the disease if the operation is to be therapeutic rather than merely palliative.</p> <p>The shift in indication has also influenced the surgical shaping of the stump to the extent that today, in contrast to earlier methods, a maximal removal of soft tissues as well as bone is considered essential in cases of malignancy. In the rarer cases in which the indication for operation is trauma or some other type of disease, it is advantageous to leave, whenever possible, a small segment of the femur and additional soft tissues in the stump, thus making possible the use of an above-knee rather than a hip-disarticulation prosthesis. With the Canadian-type hip-disarticulation prosthesis, the shape of the stump is not critical, because this device can readily accommodate any irregularities of body form.</p> <p>Whether disturbances of cardiovascular function, or of other functions such as thermoregulation, occur as a result of the loss of so large a part of the body is today a controversial subject. Although systemic disease has been noted frequently in amputees with major loss of limb, no controlled studies have demonstrated convincingly that the incidence of systemic disease is greater in amputees than in comparable nonamputees. Similarly, hypotheses that have been advanced to explain how systemic disease develops as a result of amputation are interesting but still without substantial verification physiologically. This area should be an attractive one for further research.</p> <h4>Acknowledgment</h4> <p>The author wishes to express his gratitude to the many members of the Biomechanics Laboratory whose generous help and cooperation made this paper possible. A particular debt is owing to our staff writer, Jean C. Lieberman, Ph.D., who was responsible for much of the historical research basic to the paper and for assistance in its composition.</p> <p><b>References:</b></p> <ol> <li><i>An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, </i>M. &amp; Philos. Commentaries, 6:337 (1779).</li> <li>Angerer, H., <i>Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, </i>Zentralbl. Chir., 69:1647 (1942).</li> <li>Beebe, Gilbert W., and Michael E. DeBakey,<i>Battle casualties: incidence, mortality, and logistic considerations, </i>Thomas, Springfield, Ill., 1952.</li> <li>Bolot, F., and P. Merz, <i>Disarticulation de la hanchepour un osteosarcome du fimur ayant envahi les parties molles et provoque une himorragie grave, </i>Maroc. med., 31:560 (1952). (Only title seen.)</li> <li>Boyd, Harold B., <i>Anatomic disarticulation of thehip, </i>Surg., Gyn., &amp; Obstet., 84:346 (1947).</li> <li>Brooks, Barney, <i>Exarticulation of the hip joint;with preliminary ligation of the common iliac artery, </i>J.A.M.A., 76:94 (1921).</li> <li>Bustos, Fernando M., <i>Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), </i>Bol. y trab. Acad, argent, cir., 32:195 (1948).</li> <li>Callander, C. Latimer, <i>A new amputation in thelower third of the thigh, </i>J.A.M.A., 105:1746 (1935).</li> <li>Caprio, Gerardo, <i>Grandes desarticulaciones en laraiz de los miembros, </i>Bol. Soc. cir. Uruguay, 22:518 (1951).</li> <li>Coates, John Boyd, ed., <i>Orthopedic surgery in theEuropean Theater of Operations, </i>Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</li> <li>Coley, Bradley L., <i>Neoplasms of bone, </i>Hoeber,ew York, 1949.</li> <li>DeBakey, Michael E., and Fiorindo A. Simeone,<i>Battle injuries of the arteries in World War II, </i>Ann. Surg., 123:534 (1946).</li> <li>Durand, M., <i>De la disarticulation sous-periostee dela hanche et de ses avantages sur la methode ordinaire, </i>Rev. chir., Paris, 17:646 (1897).</li> <li>Farabeuf, [L. H.], <i>Communication orale sur ladisarticulation coxo-femorale, </i>Bull, et mem. Soc. de chir., 4:180(1878).</li> <li>Farabeuf, L. H., <i>Precis de manuel operatoire, </i>4thd., Masson, Paris, 1893-1895. pp. 648-678.</li> <li><i>The fate of the amputee </i>(Annotation), Lancet, 1:633 (1953).</li> <li>Ghitzesco, C. I., <i>La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, </i>Presse meU, 43:243 (1935).</li> <li>Giles, Roscoe C, and William T. Keig, <i>The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, </i>Illinois Med. J., 106:209 (1954).</li> <li>GUlis, Leon, <i>Amputations, </i>Heinemann, London, 1954.</li> <li>Grey, Jorge de Moraes, <i>Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, </i>Rev. brasil. cir., 11:159 (1942).</li> <li>Gross, S. D., <i>Report of the committee on surgery,</i>rans. Kentucky State Med. Soc, 2:99 (1853).</li> <li>Halsted, W. S., <i>The effect of ligation of the commoniliac artery on the circulation and function of the lower extremity. Report of a cure of ilio-femoral aneurism by the application of an aluminum band to that vessel, </i>Bull. Johns Hopkins Hosp., 23:191 (1912).</li> <li>Huard, P., <i>Etudes sur les amputations el disarticu-lations des membres, </i>Masson, Paris, 1940.</li> <li>Hutter, Charles G., <i>Suction-socket prosthesis for ahip-disarticulation amputee, </i>J. Bone &amp; Joint Surg., 35A:230 (1953).</li> <li>James, Arthur G., and Wesley Furste, <i>Radicalsurgery for cancer of the extremities, </i>Am. J. Surg., 85:503 (1953).</li> <li>Katz, Elias, Private communication.</li> <li>27. Kirk, Norman T., and Leonard T. Peterson,<i>Amputations, </i>Chapter 10 in Lewis' <i>Practice of surgery, </i>Prior, Hagerstown, Md., 1944. Vol. 3, pp. 84-87.</li> <li>Larrey, Dominique Jean, <i>Memoires de chirurgiemilitaire, et campagnes, </i>J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</li> <li>Lee, C. Marshall, Jr., and Lewis P. Alt, <i>Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, </i>Ann. Surg., 137:704 (1953).</li> <li>Leriche, Rene, <i>A propos de 13 cas de disarticulationde la hanche, </i>Mem. Acad, chir., 63:1435 (1937).</li> <li>Lewis, Royce C, and William H. Bickel, <i>Hemi-pelvectomy for malignant disease, </i>J.A.M.A., 165:8 (1957).</li> <li>McBurney, Charles, <i>Direct intra-abdominal finger-compression of the common iliac artery during amputation at the hip-joint, </i>Ann. Surg., 25:610 (1897).</li> <li>Marquardt, Wolfgang, <i>Gliedmassenamputationenund Gliederersatz, </i>Wissensch. Verlagsges., Stuttgart, 1950. pp. 82-85.</li> <li>Maynard, R. L., <i>Hip-joint disarticulations, </i>Trans.ew England Surg. Soc, 24:248 (1941).</li> <li>Meyeringh, H., and H. Stefani, <i>Besteht nach einerAmputation des Oberschenkels eine Neigung zur Adipositas und zur Hypertension?, </i>Deutsche med. Wchnschr., 81:10 (1956).</li> <li>Morand, Sauveur Francois, <i>Opuscules de chirurgie,</i>esprez, Paris, 1768. Vol. 1, pp. 176-228.</li> <li>Morris, Robert T., <i>Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, </i>West. M. Times, 37:1 (1917).</li> <li><i>Outlook for the amputee </i>(Annotation), Lancet, 1:89 (1955).</li> <li>Pack, George T., <i>Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, </i>J. Bone &amp; Joint Surg., 38A:249 (1956).</li> <li>Pack, George T., and Harry E. Ehrlich, <i>Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), </i>Ann. Surg., 123:965 (1946). Parts I &amp; II.</li> <li>Petrovskii, B. V., <i>Method of disarticulation of thehip, </i>Vestnik khir., 72:50 (1952). In Russian.</li> <li>Piquinela, Jose A., <i>Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, </i>Arch. urug. med., 48:191 (1956).</li> <li>Pitkin, George P., <i>Conduction anesthesia, </i>2nd ed.,ames L. Southworth, Robert A. Hingson, and Winifred M. Pitkin, eds., Lippincott, Philadelphia, 1953.</li> <li>Richerand, cited in <i>60, </i>p. 8.</li> <li>Saltzstein, Harry C, <i>Osteogenic sarcoma of upperthird of femur; well ten years after disarticulation at the hip joint, </i>J. Michigan Med. Soc, 43:145 (1944).</li> <li>Schneider, K. W., <i>Zur Frage der Plethora und Hy-pertonic bei Amputierten, </i>Klin. Wchnschr., 31:697 (1953).</li> <li>Schroder, Joachim, <i>Zur Frage einer besonderenKreislaufbelastung bei Gliedmassenamputierten infolge einer Mehrbeanspruchung ihrer War-meregulation, </i>Deutsche med. Wchnschr., 81:1620 (1956).</li> <li>Schulze, Karl, <i>Uber den Einfluss grosser Amputa-lionen auf den Gesamtorganismus; eine Studie zur Frage der Spatschaden bei Oberschenkelampu-tierten, </i>Arbeit u. Gesundh., No. 41:69 (1942).</li> <li>[Shuter, James], <i>Subperiosteal amputation at thehip-joint, </i>Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</li> <li>Shuter, James, <i>Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, </i>Trans. Clin. Soc. London, 16:86 (1883).</li> <li>Slocum, Donald B., <i>An atlas of amputations,</i>osby, St. Louis, 1949. pp. 239-247, 402-410.</li> <li>Smith, Beverly Chew, <i>Disarticulation of the hip forendothelioma (Ewing's tumor): 31-year follow-up, </i>Ann. Surg., 115:318 (1942).</li> <li>Smith, S., <i>Statistics of the operation of amputation atthe hip-joint, </i>New York J. Med., 9:184 (1852).</li> <li>Stajano, C, <i>El mecanismo del "choc" en la desar-ticulacion de la cadera, </i>Arch. urug. med., 10: 642 (1937).</li> <li>Strauss, Kurt, <i>Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, </i>Miinchen. med. Wchnschr., 86:1751 (1939).</li> <li>Sturm, Alexander, <i>Hochdruck nach Oberschenkelam-putation, </i>Med. Klin., 48:197 (1953).</li> <li>Sturm, A., W. Frisch, and H. W. Griinewald,<i>Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, </i>Medizinische, No. 35:1132 (1954).</li> <li>Thomson, John, <i>Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, </i>Blackwood, Edinburgh, 1816. pp. 259-279.</li> <li>Tikhonov, V. M., <i>Short thigh stump in children, itslengthening and preparation for prosthesis, </i>Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</li> <li>Tixier and Arnulf, <i>Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, </i>Lyon chir., 32:443 (1935).</li> <li>Trendelenburg, F., <i>Ueber Exarticulation des Ober-schenkels, </i>Arch. klin. Chir., 26:858 (1881).</li> <li>U. S. Surgeon General's Office, <i>Circular No. 7: areport on amputations at the hip-joint in military surgery </i>[By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</li> <li>U. S. Surgeon General's Office, <i>The medical andsurgical history of the War of the Rebellion (1861-1865), </i>U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: <i>Surgical history. </i>pp. 88, 89, 127-168.</li> <li>U. S. Surgeon General's Office, <i>The Medical De-partment of the U. S. Army in the World War, </i>U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, <i>Surgery, </i>Part 1 <i>{General surgery, orthopedic surgery, neurosurgery).</i></li> <li>Velpeau, Alf. A. L. M., <i>New elements of operativesurgery, </i>1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp; W. Wood, New York, 1847. Vol. 2, pp. 637-653.</li> <li>Verrall, P. Jenner, <i>Some amputation problems,</i>roc. Roy. Soc. Med., 24:183 (1930).</li> <li>Wyeth, John A., <i>Bloodless amputation at the hipjoint, </i>New York Med. J., 61:528 (1890).</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>35.</b> </td><td class="clsTextSmall">Meyeringh, H., and H. Stefani, Besteht nach einerAmputation des Oberschenkels eine Neigung zur Adipositas und zur Hypertension?, Deutsche med. Wchnschr., 81:10 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">The fate of the amputee (Annotation), Lancet, 1:633 (1953).</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Schroder, Joachim, Zur Frage einer besonderenKreislaufbelastung bei Gliedmassenamputierten infolge einer Mehrbeanspruchung ihrer War-meregulation, Deutsche med. Wchnschr., 81:1620 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Schneider, K. W., Zur Frage der Plethora und Hy-pertonic bei Amputierten, Klin. Wchnschr., 31:697 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Sturm, Alexander, Hochdruck nach Oberschenkelam-putation, Med. Klin., 48:197 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Sturm, A., W. Frisch, and H. W. Griinewald,Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, Medizinische, No. 35:1132 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Schulze, Karl, Uber den Einfluss grosser Amputa-lionen auf den Gesamtorganismus; eine Studie zur Frage der Spatschaden bei Oberschenkelampu-tierten, Arbeit u. Gesundh., No. 41:69 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Tikhonov, V. M., Short thigh stump in children, itslengthening and preparation for prosthesis, Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Verrall, P. Jenner, Some amputation problems,roc. Roy. Soc. Med., 24:183 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Cf. discussion of very short thigh stumps, page 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Durand, M., De la disarticulation sous-periostee dela hanche et de ses avantages sur la methode ordinaire, Rev. chir., Paris, 17:646 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>21.</b> </td><td class="clsTextSmall">Gross, S. D., Report of the committee on surgery,rans. Kentucky State Med. Soc, 2:99 (1853).</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Lewis, Royce C, and William H. Bickel, Hemi-pelvectomy for malignant disease, J.A.M.A., 165:8 (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>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The Medical De-partment of the U. S. Army in the World War, U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, Surgery, Part 1 {General surgery, orthopedic surgery, neurosurgery).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Huard, P., Etudes sur les amputations el disarticu-lations des membres, Masson, Paris, 1940.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Pitkin, George P., Conduction anesthesia, 2nd ed.,ames L. Southworth, Robert A. Hingson, and Winifred M. Pitkin, eds., Lippincott, Philadelphia, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (1947).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (1917).</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (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>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Callander, C. Latimer, A new amputation in thelower third of the thigh, J.A.M.A., 105:1746 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">GUlis, Leon, Amputations, Heinemann, London, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">27. Kirk, Norman T., and Leonard T. Peterson,Amputations, Chapter 10 in Lewis' Practice of surgery, Prior, Hagerstown, Md., 1944. Vol. 3, pp. 84-87.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Angerer, H., Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, Zentralbl. Chir., 69:1647 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Marquardt, Wolfgang, Gliedmassenamputationenund Gliederersatz, Wissensch. Verlagsges., Stuttgart, 1950. pp. 82-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire, 4thd., Masson, Paris, 1893-1895. pp. 648-678.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Brooks, Barney, Exarticulation of the hip joint;with preliminary ligation of the common iliac artery, J.A.M.A., 76:94 (1921).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Halsted, W. S., The effect of ligation of the commoniliac artery on the circulation and function of the lower extremity. Report of a cure of ilio-femoral aneurism by the application of an aluminum band to that vessel, Bull. Johns Hopkins Hosp., 23:191 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">McBurney, Charles, Direct intra-abdominal finger-compression of the common iliac artery during amputation at the hip-joint, Ann. Surg., 25:610 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Farabeuf, [L. H.], Communication orale sur ladisarticulation coxo-femorale, Bull, et mem. Soc. de chir., 4:180(1878).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Thus the figures that follow are not statistics of operative or even hospital deaths alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Strauss, Kurt, Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, Miinchen. med. Wchnschr., 86:1751 (1939).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bolot, F., and P. Merz, Disarticulation de la hanchepour un osteosarcome du fimur ayant envahi les parties molles et provoque une himorragie grave, Maroc. med., 31:560 (1952). (Only title seen.)</td></tr><tr><td class="clsTextSmall"><b> 9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b> 17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr><tr><td class="clsTextSmall"><b> 18.</b> </td><td class="clsTextSmall">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (1954).</td></tr><tr><td class="clsTextSmall"><b> 20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b> 29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr><tr><td class="clsTextSmall"><b> 30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b> 34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b> 39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr><tr><td class="clsTextSmall"><b> 41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (1956).</td></tr><tr><td class="clsTextSmall"><b> 45.</b> </td><td class="clsTextSmall">Saltzstein, Harry C, Osteogenic sarcoma of upperthird of femur; well ten years after disarticulation at the hip joint, J. Michigan Med. Soc, 43:145 (1944).</td></tr><tr><td class="clsTextSmall"><b> 52.</b> </td><td class="clsTextSmall">Smith, Beverly Chew, Disarticulation of the hip forendothelioma (Ewing's tumor): 31-year follow-up, Ann. Surg., 115:318 (1942).</td></tr><tr><td class="clsTextSmall"><b> 54.</b> </td><td class="clsTextSmall">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (1937).</td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Tixier and Arnulf, Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, Lyon chir., 32:443 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">DeBakey, Michael E., and Fiorindo A. Simeone,Battle injuries of the arteries in World War II, Ann. Surg., 123:534 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Thomson, John, Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, Blackwood, Edinburgh, 1816. pp. 259-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Or possibly a metastatic cancer of the lungs. At her death, 18 days after operation, an autopsy showed them to be almost totally reduced to matter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, M. &amp; Philos. Commentaries, 6:337 (1779).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In a case in which amputation of the thigh at the articulation with the hip bone appears to be the last resort for saving the life of a sick man, to determine whether this operation should be performed, and what would be the most advantageous method of doing it.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Richerand, cited in 60, p. 8.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry E. Loon, M.D. </b></td></tr><tr><td class="clsTextSmall">Research Orthopaedist, Biomechanics Laboratory, University of California Medical Center, San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-003.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Past and Present Medical Significance of Hip Disarticulation Creator An entity primarily responsible for making the resource Henry E. Loon, M.D. * https://staging.drfop.org/files/original/e52cf9eac794bb9024231c39d7c2f051.pdf 413a609559c66e9af1293680829afbfb https://staging.drfop.org/files/original/166a665a9fc23bfb942fb45a0d328add.jpg c4cee2dc30891c4dbd453a9ff9e9011d https://staging.drfop.org/files/original/dbcd7e754b0a7ca302d6404ea3eb5802.jpg bdcfd7fbb9809d59b822c0d8ec33038f https://staging.drfop.org/files/original/f9037b7cea4f85149601c702a1aa5701.jpg d55cef0a8d268de336576c39f462689a https://staging.drfop.org/files/original/de19e93c24849987f2b78a59293b0356.jpg 1f2ce2deb67ef8d12a9c28e3c40958b6 https://staging.drfop.org/files/original/3f2cc93e4e236d72d78c81efe84fc44a.jpg d7b29c791929c0956a546a4a68f9d629 https://staging.drfop.org/files/original/af1b7b176b3438b5f1ae452d9e41bdf6.jpg dd70ef09a9e9d539df70116c0d4bd9ea DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_031.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 31 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Method for Location of Prosthetic and Orthotic Knee Joints</h2> <h5>Henry F. Gardner <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, JR, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>When it is necessary to use a mechanical knee joint, whether it be in a below-knee prosthesis or a long-leg brace, ideally there should be no relative motion between the patient's limb and the appliance during its use. Because the human knee is not a single-axis joint, analogues of the human knee employing more than one axis of rotation have been developed but none have proven practical, owing largely to bulki-ness, but to some degree to cost. At this time, therefore, we are faced with the problem of determining a method of placing the center of rotation of a single-axis mechanical knee joint with respect to the knee so that the least amount of relative motion will occur between the patient and the appliance.</p> <p>This article describes a method of determining the optimum location of single-axis knee joints, based on data accumulated recently from X-rays and from cadaver dissection.</p> <h3>Functional Characteristics of the Knee</h3> <p>Both the medial and lateral condyles of the femur appear as helical curves, the radii of which become progressively smaller from anterior to posterior. Only a small portion of the surface of the femur is in contact with the tibia at any given moment. Weight, however, is distributed over a larger area by the menisci, which provide smooth contact at any position.</p> <p>The knee structure is stabilized by cruciate and collateral ligaments, which control the range of motion of the joint and the relative positions of the articulating condylar surfaces. Because the medial and lateral condyles of the femur are not the same size, a transverse rotation of the femur takes place as the knee approaches full extension, causing the collateral and cruciate ligaments to tighten, and binding the femur and tibia tightly together in the weight-bearing position. Thus, as the knee begins to flex from the extended position and the femur rolls on the head of the tibia, the medial condyle rotates approximately 15 deg while the lateral condyle rotates approximately 20 deg. Then a slipping or gliding motion begins. Although the total flexion-extension range of the knee is approximately 160 deg, the first 110 deg is the most useful segment for prosthetic application, since this arc includes the full range required for walking (70 deg) and for sitting (100 deg).</p> <p>The numbered references if <b>Fig. 1</b> show the areas and the femoral condyle and the tibial plateau where contact is made successively as the knee is flexed or extended. Points "0" on the femur and tibia indicate the contact relationship between the bones when the knee is in 5 deg hyper-extension. During the first 20 deg of knee flexion, the condylar surfaces of the femur roll posteriorly on the tibia from point "0" to point "1." The greatest migration of the instantaneous center of rotation takes place during the first 15-20 deg of flexion. During the latter portion of the first 20 deg of knee flexion, a progressive sliding begins (between points "1" and "2"). Once the center of rotation reaches point "2," it remains relatively fixed during the remainder of the flexion range. This point is considered to be the optimum location for single-axis mechanical joints, especially if the knee is not permitted to extend fully. However, the usefulness of this point depends on one's ability to locate it by reference to external bony landmarks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Points of contact between the femoral condyle and the tibial plateau during knee flexion and extension. The majority of translation occurs in the first 15 deg of knee flexion from a position of hyper-extension (point "0"). Successive flexion beyond this point concentrates the point of articulation between points 1 and 6. In prosthetics application, restriction of the knee to 10 deg before full extension confines the instantaneous center of femoral rotation between points 1 and 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>X-ray Studies of the Knee</h3> <p>X-ray studies of knee motion were undertaken in an attempt to find landmarks that had a constant relationship to the optimum center of rotation. Analysis of over 500 X-rays of the knee, such as those shown in <b>Fig. 2</b>, taken in various phases of extension and flexion revealed that the posterior femoral condyles, the posterior tibial condyles, and the posterior border of the head of the fibula are in approximately vertical alignment throughout the useful range of flexion-extension (lines 1, 2, and 3). Although the patella and the anterior fleshy-knee outline appear to recede posteriorly under the tensions exerted by the quadriceps, the posterior aspects of the femoral and tibial condyles and the posterior border of the fibula remain in the same relative posterior vertical alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical transverse soft-tissue X-ray views of a normal knee showing the vertical relationship of the posterior borders of the major bony knee segments with the knee in the extended position and in 90 deg of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because there is only very thin tissue covering the anterior border of the tibia and the tibial tubercle, they are easily palpable, and therefore should make better reference points than the poples.</p> <h3>Analysis Of The Knee Joint By Diissection</h3> <p>The knee-joint measurements obtained from 21 adult cadavers are given in <b>Table 1</b> and <b>Fig. 3</b>. An analysis of these measurements indicates that the difference between the anterior-posterior measurements of the stump and the actual bone dimensions is approximately 3/4 in. The medio-lateral dimensions vary approximately 3/4 in. between the external measurement and the actual epicondylar width.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Dimensional proportionality of widths at the femoral epicondyles related to the measurements between the tibial tubercle and the posterior border of the fibular head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of Knee Center</h3> <p>Based upon the dimensional relationships shown in <b>Table 1</b> and <b>Fig. 3</b>, a method (<b>Fig. 4</b>) is advanced for locating the approximate functional knee center, using the figures in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Steps in locating functional knee center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A. With the patient standing and leg extended, measure the knee width at the condyles.</p> <p>B. With the patient standing, knee flexed and relaxed, locate the posterior border of the fibular head.</p> <p>C. With the patient standing and the knee vertically extended, mark a reference line up the knee and lower thigh.</p> <p>D. With the patient standing, leg unweighted and knee slightly flexed, locate the lateral tibial plateau by pressing into the knee with the thumb.</p> <p>E. Keeping the thumb in position to maintain the exact location as the patient extends the knee, mark the tibial plateau level horizontally.</p> <p>F. Using the applicable figure from <b>Table 2</b>, mark the measurement at the plateau level and extend a line vertically from that point toward the thigh.</p> <p>G. Using the same measurement as in step F, mark the axis reference on the anterior vertical line horizontally.</p> <p>H. To mark the knee center references on the medial side, have the patient sit with the medial aspects of the knees 1/2 in. apart, flexed at 90 deg. Place a straight edge across the patellas. Measure the distance from the straight edge to the lateral reference (step G) and mark the measurement on the medial side (I). Measure the distance of the lateral reference from the floor and mark the measurement on the medial side.</p> <h3>Acknowledgments</h3> <p>Edward Peizer, Ph.D., Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, assisted the authors in the design and analysis of the knee data. Gabriel Rosenkranz, M.D., Medical Consultant, gave guidance and encouragement.</p> <p><b>References:</b></p> <ol> <li>Berndt, Albert L., and Michael Harty, <i>Trans-chondral fractures (osteochondritis dissecans) of the talus</i>, J. Bone Joint Surg. (Amer.), 41A:5:988-1020, September 1959.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., <i>Construction of the patellar-tendon-bearing below-knee prosthesis</i>, Artif. Limbs. 6:2:25-73, June 1962.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Slocum, Donald B., <i>An atlas of amputations</i>, C. V. Mosby Company, St. Louis, 1949.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body under normal and pathological conditions</i>, Charles C Thomas, Springfield, Ill., 1955.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank W. Clippinger, JR, M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Orthopedic Surgery, Duke University Medical Center, Durham, N. C; Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Hospital, Durham, N. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry F. Gardner </b></td></tr><tr><td class="clsTextSmall">Technical Assistant to the Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Method for Location of Prosthetic and Orthotic Knee Joints Creator An entity primarily responsible for making the resource Henry F. Gardner * Frank W. Clippinger, JR, M.D. * https://staging.drfop.org/files/original/d824e24cf044272c06c6c6eef12d0ea7.pdf c91b6f3dbdcb7034212884899f66193b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_00i.pdf Year 1968 Volume 12 Issue 2 Page Number(s) i - iii 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_02_00i.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_00i.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Problem of the Geriatric Amputee</h2> <h5>Herbert E. Pedersen, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It has been demonstrated that 70 to 90 per cent of all peacetime amputations result from gangrene in the lower extremities of elderly patients. Hansson<a></a> reported that in Sweden the amputation rate in males over 60 years of age rose from 34 per 100,000 population in 1947 to 129 per 100,000 in 1962. He predicted that those rates would continue to rise. Our experience in the United States seems to parallel that in Sweden, and therefore interest in the specific problems of the "geriatric" amputee is now high.</p> <p>During the period of increasing incidence, the mortality rate following amputation for gangrene has declined sharply, from 45 per cent to approximately 5 per cent for all amputations. Furthermore, studies show that, following amputation, patients live long enough to justify every effort at their rehabilitation, and that when they effectively use a prosthesis they live longer and the remaining extremity survives longer.</p> <p>For some time it has been recognized that the lower the level of a successful amputation the greater the chance that the patient will effectively use a suitable prosthesis. The most important factor in the ability of the geriatric amputee to use effectively a satisfactory prosthesis is the presence of the knee joint. In the absence of other complications, the patient who was able to walk before the onset of his disease should be able to walk with any type of satisfactory prosthesis after amputation below the knee once the stump is well healed.</p> <p>It is apparent that the current problem of the geriatric amputee is not primarily one of prosthetic components, prosthesis design, fitting and alignment, or gait training. The current problem of the geriatric amputee is preservation of the knee joint.</p> <p>For at least 20 years literature has been available which discusses the specific indications for amputation levels of the lower extremity and details the surgical techniques necessary to ensure successful amputations at low levels in the ischemic extremity. The principles set forth in that literature became very important to surgeons who were particularly interested in amputations. Recently, as the result of the work of Burgess et al. on immediate postsurgical fitting and the concomitant upsurge of interest in amputations, many more surgeons have come to recognize the importance of these principles. The research project headed by Burgess and sponsored by the Prosthetic and Sensory Aids Service of the Veterans Administration, aside from its other important contributions, has done more to stimulate interest in amputations than any other single peacetime venture.</p> <p>Despite the renewed interest in amputations, it is still true, unfortunately, that most amputations for gangrene are performed by surgeons who are much more interested in other problems. Far too many feel that the nature of the disease makes amputation above the knee inevitable, or that the mortality and morbidity associated with unsuccessful attempts at amputation at low levels preclude such efforts. The techniques for successful management of delayed healing are poorly understood. In many areas it is still not recognized that the problem in diabetes, leading to progressive lower-extremity tissue necrosis, is frequently uncontrolled infection, rather than ischemia.</p> <p>This all suggests that in terms of man-hours, dollars, and total available facilities, great improvement in the rehabilitation of the geriatric amputee can come from a more efficient educational program which will lead to a higher incidence of successful amputations at low levels.</p> <p>It has been suggested that to reach the surgeons who perform most of the amputations for gangrene there is need for a document which is generally accepted and widely distributed, and which will be read by those surgeons. In 1961 the Committee on Prosthetics Research and Development, recognizing the need for improvement in the rehabilitation of the geriatric amputee, sponsored a conference for the purpose of stimulating research in that area. The report of the conference, <i>The Geriatric Amputee </i>(NAS Publication 919), was well received, and, in addition to serving its original purpose as a reference for research personnel, has been used extensively in education and training of medical and paramedical personnel. New knowledge has made obsolete much that is contained in <i>The Geriatric Amputee</i>, and CPRD has recommended to the Committee on Prosthetic-Orthotic Education that the necessary steps be taken to provide an authoritative document that will be useful to all who are engaged or expect to be engaged in the rehabilitation of the geriatric amputee. To this end, CPOE is calling upon a number of individuals from various disciplines with vast experience to assist in the preparation of such a document.</p> <p>Surgeons need not wait, however, until publication of this volume to begin to take positive action to improve the lot of future geriatric amputees. They should review the literature and take every action possible to retain the knee joint in the geriatric case when amputation is indicated.</p> <p><b>References:</b></p> <ol> <li>Hansson, Jan, <i>The leg amputee</i>, Acta Orthop. Scand. (Suppl.), <b>69</b>:1-104, 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Hansson, Jan, The leg amputee, Acta Orthop. Scand. (Suppl.), 69:1-104, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert E. Pedersen, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetic-Orthotic Education, National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418; Chairman, Department of Orthopaedic Surgery, Wayne State University Medical School, Detroit, Mich. 48207</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Problem of the Geriatric Amputee Creator An entity primarily responsible for making the resource Herbert E. Pedersen, M.D. * https://staging.drfop.org/files/original/4ebe6c9358e369d2dfcc780525f71744.pdf 01ca7a3bb92c5f91b306060769848ed9 https://staging.drfop.org/files/original/fd2a976afd43f432a91856fbb3542adb.jpg 4cd388f1bb2e5bb5c7d6e8658721feb3 https://staging.drfop.org/files/original/5ea20b480864b5662268ba574fb4df90.jpg 404b82d99bc176c0c3b47905d236e7ef https://staging.drfop.org/files/original/2c56957b9735b01a9f5c9fe75689c927.jpg 57e264451217b8c83f7667a500f4caca https://staging.drfop.org/files/original/0939c6a9623e986d55b567dbe6f9704f.jpg 3da4ca037b4b925d204360e54d41830b https://staging.drfop.org/files/original/83f69a234f7756caf1d51f0b94e4ce93.jpg efc5c9cd7ee1708de022357d15829c4a https://staging.drfop.org/files/original/7b3ddab93a637e18d8e2ceb0c867ea1a.jpg d263fb414ce5d3e085085e28830834eb https://staging.drfop.org/files/original/135a37db3f3673e23afdb5ba5411f6b0.jpg 34b6fbf004c0a0ea762ecccc0a6e38fb https://staging.drfop.org/files/original/38ea4d432e4466c58292d70162ecd0a2.jpg 8150ce6a83ac114ca162be9ae6615263 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_049.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 49 - 58 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_049.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>Dynamic Structure of the Human Foot</h2> <h5>Herbert Elftman <a style="text-decoration:none;">*</a><br /></h5> <p>The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</p> <p>The human foot acts in concert with the rest of the body during standing and movement. It provides man with his most effective physical contact with the environment and is especially responsible for successful regulation of initial and final contact of the body with the ground. The foot must also provide adjustable support during the characteristic human occupations of manipulating the environment or of simply standing in line.</p> <p>Human bipedality was made possible by the redesign of an ancestral foot with five long toes used for the grasping of the limbs of trees. We still testify to our heritage by having a big toe larger than the rest but no longer opposable. The heel bone was brought down into contact with the ground to provide additional area of support. Each of these changes traded an old advantage for a new one and the barter is still going on.</p> <h3>The Foot in Motion</h3> <p>Walking is more characteristic of human movement than running, since man has substituted cunning in the management of external devices for fast movement of body parts when speed is desired. The foot must constantly adjust to the varying loads imposed upon it. Particularly important are the stresses it must withstand at the initiation of contact with the ground and again at its termination.</p> <h4>Initiation Of Contact</h4> <p>The heel is the first part of the foot to touch the ground in walking. It is consequently entrusted with the delicate mission of gradually bringing the foot to rest on the ground. In running this can be done without the help of the heel since the limb is already in the midst of its backward swing with respect to the body and the ball of the foot can touch the ground at zero velocity.</p> <p>In walking, the advanced leg has barely started its backward swing with respect to the body when the heel touches the ground. The initial velocity of the ankle after contact is only slightly less than that of the hip joint, making heel-roll imperative. As the ankle approaches zero velocity at ball contact, the forward velocity of the hip joint is preserved by ankle and knee flexion (<b>Fig. 1</b>). Failure to do this properly is one of the most common deficiencies of assistive devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Forces acting on the foot during two important phases of its activity: (1) completion of heel roll; (2) initiation of rolling off on the hall. From Elftman, 1967. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The normal human heel is specialized for the part it plays in walking. Resilience is supplied by the construction of the connective tissue under the heel. The collagenous fibers are arranged so as to produce cylindrical compartments filled by more fluid tissues. Since the fluid changes volume only slightly in compression, pressure is accommodated by elastic deformation of the surrounding connective tissue. While this elastic deformation is taking place the foot rolls forward on the heel. The character of this movement is determined by the contour of the calcaneous combined with the shape which the heel-pad assumes under pressure. Artificial heels can be of assistance if properly shaped, usually achieved when wear erases original design.</p> <h4>Termination Of Contact</h4> <p>Although the foot moves only slightly in the interval between ball contact and heel rise, it is subjected to constantly changing stresses. As the body moves forward over the ankle until the knee becomes almost straight, tension is built up in the calf muscles in preparation for the critical events which terminate ball and toe contact. In this phase of walking the transformation of the ape foot into a human foot shows its functional worth. With grasping no longer the chief function of the toes, they have been shortened and the connective tissue pad beneath the ball has become stronger. The great toe has lost its opposability and is permanently aligned parallel to the others. This relieves the peroneus longus muscle of its ancestral responsibility of adducting the hallux and enhances the aid which it gives to the tibialis posterior in resisting splaying of the foot. The first metatarsal and its attendant phalanges retain the size which they had attained in the ape. This led to the accentuated use of this toe during push-off and the important role which the flexor hallucis longus plays in terminal contact with the ground.</p> <p>Rolling over the ball of the foot has a function similar to that of the heel but acting in reverse. It must control the gradual acceleration of the ankle so that the lower limb as a whole is moving forward with body speed close to the time at which the advanced heel makes contact and double support begins. Here again knee flexion adjusts the relative velocities of the limb segments and allows the calf muscles to push off the limb as it begins its forward swing.</p> <h4>Control Of Foot Position By Hip And Knee</h4> <p>Primary control of foot position is exercised at the hip joint with assistance from the knee when it is flexed. After the primary position of the foot is determined by these distant factors, fine control is added by joints of ankle and foot. The forces and moments which act on the foot are largely determined by the disposition and accelerations of other parts of the body. The importance of knee and hip joints in controlling the spatial relationships of the foot is emphasized frequently by unwelcome responses in these joints to abnormal stresses in the foot.</p> <h3>Fundamental Architecture of the Foot</h3> <p>The foot consists of 26 bones controlled by 42 muscles and is held together by an almost unbelievable number of ligaments. Fortunately, in the normal performance of its major functions, many of these parts co-operate so closely that an initial workable concept of the foot can be based on very few units. The talus is the uppermost of these. When it is removed, the subtalar part of the foot reveals two major divisions: the calcaneus and, articulating with it by the calcaneocuboid joint, a semirigid constellation of bones terminating in the ball of the foot. This leaves the toes jutting out, to become of importance in activities which require forward extension of the base of support beyond the ball.</p> <h4>The Ankle-Joint Complex</h4> <p>The talus is a bony meniscus which allows the movements of the foot with respect to the shank to be divided between a pair of articulations: the subtalar below and the ankle joint above. Since the same external forces act on both joints, the normal body is interested in their combined movement but the clinician is frequently faced with the results of differential insult.</p> <p>In the ankle joint, normal pressure is transmitted from the tibia to the trochlear surface of the talus and lateral bending moments are resisted, within limits, by the malleoli and ligaments. When the joint is compressed, as in weight bearing, the instant axis is determined by the curvatures of the surfaces in contact at the moment. The classical concept of an invariant axis passing horizontally through the lateral malleolus to emerge just below the medial malleolus has been revised in recent years. Barnett and Napier (1952) have described the difference in curvature between the parts of the talus used as movement progresses. Close and Inman (1952) have emphasized a component of vertical rotation conforming to the curved lateral surface of the talus. Both of these factors are sufficiently variable to require assessment in each individual.</p> <p>Even more variable is the orientation of the axis of the ankle joint with respect to the foot and to the transverse axis of the knee. The situation in any individual can be estimated by observing the position of the malleoli; the results of such measurements recorded by Elftman (1945) are shown in <b>Fig. 2</b>. It is obvious that the orientation of the ankle joint determines the plane in which dorsi- and plantar flexion occur and this influences the amount of movement required in the subtalar joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Range of variation in the orientation of the axis of the ankle joint. Two-thirds of the individuals measured were within the limits shown here. From Elftman, 1945. ties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The subtalar joint is guided in its movement, when it is under compression, by the areas of contact between the calcaneus and the lower surface of the talus. These surfaces are beautifully sculptured to form parts of a helical or screw-shaped surface. The helix is right-handed in the right foot; the resulting advance of the talus during eversion is important for the control of the transverse tarsal joint, but may be neglected during consideration of the ankle. For this purpose the major axis of the helix, also called the compromise axis, suffices. Its position in one foot is shown in <b>Fig. 3</b>. This axis emerges from the talus so as to pierce the tendon of the tibialis anterior; its other end is variably located on the lateral surface of the calcaneus. The movements about this axis are called inversion and eversion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The instant axis for the combined movement in the upper ankle joint and the subtalar joint lies in the thin disc represented by the dashed circle. Attention is also called to another variable functional feature, the arc of the ball of the foot. From Elftman, 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obliquity of this axis confers on the subtalar joint its most significant properties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control.</p> <p>Since the ankle joint and the subtalar joint are not subject to independent regulation, the resultant movement when the two are combined is of greater practical value than the separate components. The location of this resultant axis is indicated in <b>Fig. 3</b>. If the two joint axes actually intersected, the resultant would lie in the plane determined by the two axes. Since they almost intersect, but not quite, the resultant is confined within a thin disc which may be treated as a plane for practical purposes. Once this plane is determined, the problem of substituting new artificial axes for the old ones is simplified.</p> <p>Movement in the ankle-joint complex is controlled by: (1) moments due to the ground reaction; (2) constraints due to joint surfaces and ligaments; and (3) moments produced by the leg muscles which pass over the ankle. The part played by the ankle muscles can be studied quantitatively from the data shown in <b>Fig. 4</b>. This is essentially an oblique section through the ankle oriented so as to include the axes of the ankle joint and the subtalar joint. The lever arms of the muscles with respect to these axes can be read from the diagram; the relative maximum strengths of the muscles are proportional to the areas of the circles which represent them. The resultant moment of various muscle combinations can then be found. Important points to note are: (1) the tibialis anterior is a dorsiflexor and not an in-vertor in this position; (2) the gastrocnemius and soleus are strong invertors as well as plantar flexors; (3) the peroneal muscles are stronger for eversion than for plantar flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Muscular control of the ankle. The figure is essentially a section through the right ankle in the plane of the disc shown in Figure 3 and includes the ankle-joint axis (TC) and subtalar axis (ST). The circles representing the muscles are proportional in area to the physiologic cross sections. The muscles may be identified by their initials, e.g., triceps surae (TS). From Elftman, 1960. The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in Fig. 5) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Transverse Tarsal Joint</h4> <p>The part of the foot which lies immediately in front of the talus and calcaneus forms a semirigid unit articulating with the rear part of the foot by means of two joints, the calcaneocuboid and the talonavicular. Since they act together much of the time, it is convenient to call the combination the transverse tarsal joint.</p> <p>The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in <b>Fig. 5</b>) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transverse tarsal joint, pronated at left, supinated at right. The joint axes are labeled as follows: AJ, ankle joint; ST, subtalar; CC, calcaneocuboid; TN, talonavicular. When the heel is placed on the ground in the supinated position, inversion in the subtalar joint restores the vertical orientation of the shank and rotates the head of the talus so as to lock the transverse tarsal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The talonavicular joint is the controlling element in the transverse tarsal joint complex. The head of the talus is a cam of ellipsoidal shape which is not concentric about the subtalar axis but makes a considerable angle with respect to it. As a consequence of this, rotation of the head of the talus during rotation about the subtalar axis changes its orientation, and movement in the transverse tarsal joint ensues to bring the navicular concavity to a conformable position. The important thing to remember is that inversion produces supination and eversion causes pronation. At the extremes of this range of association, the transverse tarsal joint becomes independent of the subtalar in extremely pronated (flat) feet and the subtalar motion can occur alone at extreme supination.</p> <h4>Ball Of The Foot</h4> <p>The structures which allow the heads of the metatarsals to transmit pressure to the ground consist of connective tissue and skin which have been modified in the human foot to spread the pressure in the hope of preventing painful concentrations. When weight is not borne by this region, a transverse metatarsal arch is visible. Even slight pressure is sufficient to bring the heads of the metatarsals in alignment with the ground and the arch disappears. The extreme variability in the lengths of the metatarsals has important consequences for foot action. The distribution of pressure as the heel is raised is very closely dependent on the contour of a line connecting the metatarsal heads, as shown in <b>Fig. 3</b>. Morton (1935) has stressed the difficulties resulting from first metatarsals which are short or have posteriorly located sesamoids. Equally disastrous effects can come from contours which are sharply curved or hairpin in shape.</p> <p>Among a number of variable features in this part of the foot is the extent to which the base of the fifth metatarsal transmits weight to the ground. Another condition, splaying of the foot, can result when the cooperative efforts of the tibialis posterior and the peroneus longus are insufficient to give transverse stability.</p> <h4>Toes</h4> <p>Although human toes can be used for grasping when occasion demands, their customary use is accessory to the ball of the foot which lies behind them. The toes are the anchors for the long flexors which play an important part in managing the ankle-joint complex. By differential contraction of the flexors of the toes it is possible to adjust the distribution of pressure between parts of the ball of the foot. Because of the strength of the big toe and the long flexor attached to it, this part of the foot is usually the last to leave the ground and contributes the final touch to the control of movement.</p> <h3>Control of the Foot by the Heel</h3> <p>When the body rolls forward on the heel until the foot rests on the ground, the position which the foot assumes is determined by the manner in which the calcaneous rolls forward. Proper contouring of the sole of the shoe where the heel nests in it will not only provide assistive forces but will also originate sensory feedback to stimulate better foot alignment.</p> <p>If the heel cup is so constructed that its anteromedial quadrant is elevated, the calcaneus will come to rest with a predetermined amount of inversion about the subtalar axis. This places the contact area of the calcaneus more nearly under the vertical thrust of the body, decreasing its rotational moment. Since the ankle-joint axis strives for a horizontal position, the talus is forced into inversion and this drives the transverse tarsal joint into supination. Sensory feedback, in the course of a few steps, will encourage the hip joint to bring the foot down in a slightly toed-in position, thus restoring the knee joint to its usual orientation.</p> <p>The details of the sculpturing of the heel cup need not be left to chance since the desired conformation of the internal architecture of the foot is almost identical with that which it assumes when the subject stands on an inclined plane. Instant orthotics can be achieved by placing the proper compound in the shoes and having the subject stand in them, with heels supported at a proper elevation, to impress the functional shape.</p> <h3>Measurement of Foot Function</h3> <p>The foot is sandwiched between the pressure of the ground below and the weight and inertia forces of the body above. Since these are the forces to which the foot must accommodate, their measurement assumes primary importance.</p> <p>The total pressure of the ground on the foot and the point at which its resultant is applied can be measured easily when the individual is standing. The only equipment needed consists of three reasonably accurate scales and a ruler. The usefulness of the information which can be obtained should not be underestimated; it is sufficient to tell whether many therapeutic devices achieve their objectives.</p> <p>When the body is in motion, measurement of the ground reaction is more important and becomes more difficult. This can be accomplished by means of force plates, the earliest results of which are shown in <b>Fig. 6</b> from Elftman (1939). From data such as this and photographic determination of the location of joint axes, muscle moments and joint forces can be obtained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Force plate record of the ground reaction acting on the foot of J. T. Manter during a step described by Elftman, 1939. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In foot problems the distribution of the ground reaction over the foot is frequently of greater interest than its total value. Many interesting methods of making such measurements have been recorded and some are still useful; they have been reviewed by Elftman (1934). Since the distribution of pressure changes in the course of movement, instantaneous recording is of value. This can be accomplished by means of the barograph, introduced by Elftman in 1934. The changes in area of a pressure transducer placed under the foot are recorded photographically. <b>Fig. 7</b> shows two phases of a step; when the pressure is on the ball of the foot the structural characteristics of this region reveal themselves. Calibration of the pressure transducer allows the derivation of quantitative data from the photographic record. In <b>Fig. 8</b> it is even possible to recognize the concentration of pressure under the sesamoid bones beneath the head of the first metatarsal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Barograph record of the distribution of pressure at two phases of the step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Load distribution on the human foot during one step of J. T. Manter. (Isobars at 4 lb. per sq. in.) The records made on the original barograph and published in Elftman, 1934, were measured after calibration of the pressure transducer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Abramson, E., <i>Zur Kenntnis der Mechanik des Mit-telfusses</i>, Skand. Arch. Physiol., 51:175-234, 1927.</li> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des amputes des membres in-ferieurs aux Etablissements Helio-Marins de Berck</i>, Ann. Med. Phys., Tome IV, No. 4, October-November-December 1961.</li> <li>Bamett, C. H., and J. R. Napier, <i>The axis of rotation at the ankle joint in man</i>, J. Anat., 86:1-9, 1952.</li> <li>Basler, A., <i>Bestimmung des auf die einzelnen Schlen-bezirke wirdenden Teilgewichtes des menschli-chen Korpers</i>, Alderhalden's Handbuch der biologischen Arbeitsmethoden-Abt 5 Teil 5A, Heft 3, 559-574, 1927.</li> <li>Basmajian, J. V., and J. W. Bentzon, <i>An electromyographic study of certain muscles of the leg and foot in the standing position</i>, Surg. Gynec. Obstet., 98:662-666, 1954.</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpol-sters</i>, Morph. Jahr., 73:1-68, 1934.</li> <li>Bohm, M., <i>Das mechschliche Bein; seine normale Entwicklung und die Entstehung der Wuchsfehler</i>, Enke, Stuttgart. 1935.</li> <li>Braus, H., <i>Anatomie des Menschen, I Band: Bewe-gungsapparat</i>. Springer, Berlin, 1921.</li> <li>Bressler, B., and F. R. Berry, <i>Energy characteristics of normal and prosthetic ankle joints</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series 3, Issue 12, 1950.</li> <li>Carlsoo, S., <i>Influence of frontal and dorsal loads on muscle activity and on the weight distribution in the feet</i>, Acta Orthop. Scand., 34:4:299-309, 1964.</li> <li>Close, J. R., <i>Some applications of the functional anatomy of the ankle joint</i>, J. Bone Joint Surg., 38A:761-781, July 1956.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the ankle joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 22, 1952.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the subtalar joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 24, 1953.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator</i>, WADC Tech. Rep. 55-159, pp. 83-84, 102-104, 173-178, 1955.</li> <li>Donitz, A., <i>Die Mechanik der Fuszwwzel</i>, Dissertation, Berlin, 1903.</li> <li>Du Vries, H. L., <i>Surgery of the foot</i>, Ed. 2, C. V. Mosby, St. Louis, 1965.</li> <li>Elftman, H., <i>A cinematic study of the distribution of pressure in the human foot</i>, Anat. Rec, 59:481-491, 1934.</li> <li>Elftman, H., and J. Manter, <i>The axis of the human foot</i>, Science, 80:484, 1934.</li> <li>Elftman, H., and J. Manter, <i>The chimpanzee and human feet in bipedal walking</i>, Amer. J. Phys. Anthrop., 20:69-79, 1935.</li> <li>Elftman, H., and J. Manter, <i>The evolution of the human foot with especial reference to the joints</i>, J. Anat., 70:56-67, 1935.</li> <li>Elftman, H., <i>Forces and energy changes in the leg during walking</i>, Amer. J. Physiol., 125:339-356, 1939.</li> <li>Elftman, H., <i>The orientation of the joints of the lower extremity</i>, Bull. Hosp. Joint Dis., 6:139-143, 1945.</li> <li>Elftman,.H., <i>Torsion of the lower extremity</i>, Amer. J. Phys. Anthrop., n. s. 3:255-265, 1945.</li> <li>Elftman, H., <i>The transverse tarsal joint and its control</i>, Clin. Orthop., 15:41-46, 1960.</li> <li>Fick, A., <i>Die Gelenke mit sattelformigen Flachen</i>, Z. rat. Med. V. 9, 1854 (also reprinted in A. Fick, Gesammelte Schriften. V. 1, Wiirzburg, 1903).</li> <li>Fick, R., <i>Uber die'Bewegungen und die Muskelarbeit an den Sprungelenken des Menschen</i>, Sitzungs-berichte der Preuss. Akad. der Wiss. Physik.-mathem., Kl., XXIII:458-495, 1931.</li> <li>Gardner, E., D. J. Gray, and R. O'Rahilly, <i>The prenatal development of the skeleton and joints of the human foot</i>, J. Bone Joint Surg., 41A:847-876, July 1959.</li> <li>Harris, R. I., and T. Beath, <i>Army foot survey</i>, National Research Council of Canada, Ottawa, 1947.</li> <li>Helfet, A. J., <i>A new way of treating flat feet in children</i>, Lancet, 1:262-264, Feb. 11, 1956. Henke, W., Die Bewegung des Fuszes am Sprung-bein, Z. rat. Med., 7:225-234, 1859.</li> <li>Hicks, J. H., <i>The mechanics of the foot, I. The joints</i>, J. Anat., 87:345-357, 1953.</li> <li>Hicks, J. H., <i>The mechanics of the foot, II. The plantar aponeurosis and the arch</i>, J. Anat., 88:25-30, 1954.</li> <li>Hicks, J. H., <i>The mechanics of the foot, III. The foot as a support</i>, Acta Anat., 25:34-45,1955.</li> <li>Hicks, J. H., <i>The mechanics of the foot, IV. The action of muscles on the foot in standing</i>, Acta Anat., 27:180-192, 1956.</li> <li>Hohmann, G., <i>Fuss und bein; ihre Erkrangungen und deren Behandlung</i>, Bergmann, Miinchen, 3 Aufl., 1939.</li> <li>Hutter, G. G., and W. Scott, <i>Tibial torsion</i>, J. Bone Joint Surg., 31A:511-518, July 1949.</li> <li>Jones, F. Wood, <i>Structure and function as seen in the foot</i>, Bailliere, Tindall and Cox, London, 1946.</li> <li>Jones, R. L., <i>The human foot, An experimental study of its mechanics, and the role of its muscles and ligaments in the support of the arch</i>, Amer. J. Anat., 68:1-39, 1941.</li> <li>Jones, R. L., <i>The functional significance of the declination of the axis of the subtalar joint</i>, Anat. Rec, 93:151-159, 1945.</li> <li>Karpovich, P. V., and L. B. Wilklow, <i>A goniometric study of the human foot in standing and walking</i>, U.S. Armed Forces Med. J., 10:885-903, 1959.</li> <li>Keith, A., <i>The history of the human foot and its bearing on orthopaedic practice</i>, J. Bone Joint Surg., HA:10-32, January 1929.</li> <li>Kolb, H.,<i> Morphologische und funktionelle Analyse des m. tibialis anterior</i>, Z. Anat. Entwicklungs-gesch., 106:770-781, 1937.</li> <li>Lanz, T., and W. Wachsmuth, <i>Praktische Anatomie, I Band, 4 Teil; Bein und Statik</i>, Springer, Berlin, 1935.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, <i>Transverse rotation of the segments of the lower extremity in locomotion</i>, J. Bone Joint Surg., 30A:859-872, October 1948.</li> <li>MacConaill, M. A., <i>The postural mechanism of the human foot</i>, Proc. Roy. Irish Acad., 50B:265-278, 1945.</li> <li>Mann, R., and V. T. Inman, <i>Phasic activity of intrinsic muscles of the foot</i>, J. Bone Joint Surg., 46A: 469-481, April 1964.</li> <li>Mann, R., and V. T. Inman, <i>Structure and function</i>, in Du Vries' <i>Surgery of the foot</i>, Ed. 2, C. V. Mosb'y, St. Louis, 1965, pp. 1-44.</li> <li>Manter, J. T., <i>Movements of the subtalar and transverse tarsal joints</i>, Anat. Rec, 80:397-410, 1941.</li> <li>Manter, J. T., <i>Distribution of compression forces in joints of the human foot</i>, Anat. Rec, 96:313-322, 1946.</li> <li>Marsk, A., <i>Studies on weight-distribution upon the lower extremities in individuals working on a standing position</i>, Acta Orthop. Scand., Suppl. 31, 1958.</li> <li>Meyer, H., <i>Statik und mechanik des menschlichen fusses</i>, Jena, 1886.</li> <li>Morton, D. J., <i>The human foot</i>, Columbia University Press, New York, 1935.</li> <li>Paul, J. P., <i>Forces transmitted by joints in the human body</i>, Paper No. 8, Proc Instr. Mech. Engrs., 181:3:8-15, 1966-67. (Joints of the foot are included in the discussion.)</li> <li>Pfitzner, W., <i>Beitrdge sur Kenntnis des menschlichen Extremitdtenskelettes, VII. Die variationen in Aufbau des Fuszskelettes</i>, Morph. Arb., 6:24-528, 1896.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 1, J. Bone Joint Surg.,. 40B:674-683, November 1958.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 2, J. Bone Joint Surg., 44B:642-647, August 1962.</li> <li>Rydell, N. W., <i>Forces acting on the femoral head prosthesis</i>, Acta Orthop. Scand., Suppl. 88, 1966. (Forces acting on feet during locomotion measured by means of an electronic walkway.)</li> <li>Scherb, R., <i>Kinetisch-diagnostische Analyse von Gehstorungen</i>, Technich und resultate der myo-kinesigraphie, Beilageheft Z. Orthop. Bd. 82, 1952.</li> <li>Schwartz, R. P., and A. L. Heath, <i>Foot function correlated with anatomic, clinical, and laboratory data</i>, New York J. Med., 41:447-451, 1941.</li> <li>Skinner, B. M., <i>Notes on the relative lengths of first and second toes of the human foot</i>, J. Anat., 66:123-4, 1932.</li> <li>Smith, J. W., <i>The act of standing</i>, Acta Orthop. Scand., 22:2:159-168, 1953.</li> <li>Smith, J. W., <i>Muscular control of the arches of the foot in standing: an electromyographic assessment</i>, J. Anat, 88:152-163, 1954.</li> <li>Smith, J. W., <i>The forces operating at the human ankle joint during standing</i>, J. Anat., 91:545-564, 1957.</li> <li>Smith, J. W., <i>The relationship of epiphyseal plates to stress in some bones of the lower limb</i>, J. Anat., 96:58-78, 1962.</li> <li>Strasser, H., <i>Lehrbuch der Muskel- and Gelenk-mechanik, III Band, Spezieller Teil Die untere Extremitat, II Fuss und Unterschenkel</i>, 1917, pp. 156-309.</li> <li>Straus, W. L., Jr., <i>The growth of the human foot and its evolutionary significance</i>, Contrib. Embryol. Camegie Inst., 19:93-134, 1927.</li> <li>Straus, W. L., Jr., <i>The foot musculature of the highland gorilla</i>, (Gorilla beringei), Quart. Rev. Biol., 5:261-317, 1930.</li> <li>Thomas, D. P., and R. J. Whitney, <i>Postural movements during normal standing in man</i>, J. Anat., 93:524-539, 1959.</li> <li>Thoren, O., <i>Os calcis fractures</i>, Acta Orthop. Scand., Suppl. 70, 1964.</li> <li>Volkov, T., <i>Les variations squeletique du pied chez les primates et dans les races humaines</i>, Bull. Mem. Soc Anthrop. Sci., 5T4-632, 1903; 5:1:201-331, 1904.</li> <li>Weidenreich, F., <i>Der Menschenfuss</i>, Z. Morph. Anthrop., 22:51-282, 1921.</li> <li>Weidenreich, F., <i>Evolution of the human foot</i>, Amer. J. Phys. Anthrop., 6:1-10, 1923.</li> <li>Wetzenstein, H. A., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, Acta Orthop. Scand., 30:2:91-100, 1960.</li> <li>Wetzenstein, H., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, 75, 1964.</li> <li>Whitney, R. J., <i>The stability provided by the feet during manoeuvers whilst standing</i>, J. Anat., 96:103, 1962.</li> <li>Wright, D. G., S. M. Desai, and W. H. Henderson, <i>Action of the subtalar and ankle-joint complex during the stance phase of walking</i>, J. Bone Joint Surg., 46A:361-382, March 1964.</li> <li>Wright, D. G., and D. C. Rennels, <i>A study of the elastic properties of plantar fascia</i>, J. Bone Joint Surg., 46A:482-492, April 1964.</li> <li>Wyller, T., <i>The axis of the ankle joint and its importance in subtalar arthrodesis</i>, Acta Orthop. Scand., 32:4:320-328, 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>Herbert Elftman </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy, Columbia University, New York, N.Y. 10016 The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_049/spring69-45.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_049/spring69-46.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_049/spring69-47.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_049/spring69-48.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_049/spring69-49.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_049/spring69-50.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_049/spring69-51.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_049/spring69-52.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 Dynamic Structure of the Human Foot Creator An entity primarily responsible for making the resource Herbert Elftman * https://staging.drfop.org/files/original/2004b9922067489189c4d3ae92485e41.pdf b5adf4cefb2c7793eaa0d0c236efe080 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_001.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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>Limbs in Limbo</h2> <h5>Herbert Elftman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>To stand on his feet and to walk with his legs wherever his heart desires are natural rights guaranteed to man by his own constitution. Heads may plan and hands may build, but only where legs and feet have brought them. Loss of the lower limb is therefore a major catastrophe.</p> <p>When loss of leg occurs, replacement becomes the primary hope. Ages past, an unknown man hobbled forth from his cave in search of a willow; with one of its limbs adopted as his own, he walked back with majesty. Since then the stage of history has resounded with the staccato echo of countless amputees marching with peg-leg, grit, and gumption.</p> <p>Rapid perfection of limb construction was to be anticipated after these early ventures had focused human ingenuity upon the problem. To the superlative talent which mankind has shown in the production of machinery both intricate and sturdy, the building of a mechanical leg would appear to offer little difficulty. Why is it, then, that artificial limbs have so generally belonged to the limbo of things undeserving either of unstinted praise or of utter condemnation? Failure of artificial legs to satisfy our hopes results less from the imperfection of their mechanisms than from the extravagance of our expectations. People who do not expect a glass eye to see or a prosthetic hand to play the piccolo are disappointed when an artificial leg squeaks while dancing the polka. Man has never commanded clear appreciation of his means of locomotion. From time to time he has been ecstatic about the eye and the liver, the heart, the brain, the hand. Legs have been referred to most frequently as symbols of neighboring functions, so lightly have their own merits been regarded.</p> <p>Why is the performance of the lower extremity so much less spectacular than that of the upper? Independence of the upper limb from obligation to the rest of the body allows it to indulge in ornamentation of movement, so impressive to the eye. The lower limb, sandwiched between the ground and the torso, must ever be responsive to the needs of the body as a whole. It cannot choose to support some parts of the body and not others or to walk with the body through only portions of each step. The intricacy of function of knee and ankle does not exhibit itself in capricious movements but excels when it modulates countless disturbing factors so that no tremor mars the stark simplicity of normal locomotion.</p> <p>No one can rightly expect an artificial limb to take over completely the functions of its predecessor unless it is endowed with an equivalent of muscular and nervous control. Difficult as it is to provide substitutes for bones and joints, such provision is simplicity itself compared with the incorporation within the prosthesis of its own control. Although considerable progress has been made in the field of decelerating mechanisms for lower-extremity prostheses, the leg amputee must still use his own resources when he needs to supply energy or to exercise discretion.</p> <p>The contribution which the amputee makes to the over-all prosthetic result far exceeds that of acting as a model for exhibiting the achievements of inventors. It is he who must finish creation of the new locomotor mechanism by reshaping the pattern of his muscular activity and establishing alertness to new sensory cues. The success of the artificial leg depends on how thoroughly it becomes a part of the form and the function of the amputee after he has blended its metal, wood, and plastic with his muscle and perception. It is only appropriate that the new mechanism, having superseded the natural limb, should contribute to amputee gait that special accent which identifies the supernatural walk.</p> <p>The complexity of human motion makes it inevitable that fundamental improvement in leg prostheses must come slowly, since it is based on factors so numerous that no one individual can comprehend them all. In addition to the profession of engineering, there is needed the cooperation of the physician, the physicist, the physiologist, the physiotherapist, the prosthetist, and the psychologist-to list them in alphabetical order—so that the patient may get the total care he deserves.</p> <p>The problems which need attention are of different degrees of complexity and must be approached by different methods. Choice of materials, details of construction, and provisions for repair require less consideration of the over-all characteristics expected in the rehabilitated amputee than do problems of fit and socket shape. More general considerations must be weighed in projects concerned with alignment, basic design of mechanisms, and evaluation of performance. For these there should be a conscious choice of a realizable objective, the attainment of which requires integration of man and machine into a functional unit.</p> <p>All of these are practical problems amenable to increasingly useful solutions year by year, provided we do not surrender to the impatience of those who must have the answer to the question of the century today and of the millennium tomorrow. It is necessary to preserve clear vision of long-term objectives, although some members of every team find the environment more familiar when details arise.</p> <p>Had trial-and-error and serendipity been able to produce truly satisfactory lower limbs, we would not still be waiting for such. It was left for the National Academy of Sciences-National Research Council to initiate the development of artificial limbs on a modern basis by creating the Committee on Prosthetic Devices and, later, its successor, the Advisory Committee on Artificial Limbs. By carefully balancing the fundamental and the practical in their program, these Committees have laid a firm basis for some progress today, much more tomorrow.</p> <p>This is the key to the future in lower-extremity prosthetics. Used wisely, it will allow us eventually to rescue the limb problem from limbo and to provide the amputee of the future with a fitting legacy.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert Elftman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Anatomy, College of Physicians and Surgeons, Columbia University; member, Lower-Extremity Technical Committee, ACAL, 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 Limbs in Limbo Creator An entity primarily responsible for making the resource Herbert Elftman, Ph.D. * https://staging.drfop.org/files/original/ffc8eca439bcae403581feacfc98144e.pdf 4193bb67ab6993250dcf123adae8278b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_001.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 1 - 2 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Measurement and Evaluation</h2> <h5>Herbert R. Lissner, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>"I often say that when you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it in numbers your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge but you have scarcely in your thoughts advanced to the stage of science, whatever the matter may be."</p> <p>-<i>Lord Kelvin</i></p> <p>Most of us devote appreciable time in the course of daily activity to making evaluations and forming value judgments. Every time we make a purchase, watch television, eat a meal-the list is endless-we make evaluations. Factors considered may involve monetary costs, saving of labor and time, ethical principles, aesthetic enjoyment, and many other matters.</p> <p>In order to reach a final decision, it is usually necessary to combine, or even to counterbalance, evaluations made in many subsidiary categories. Those subgroups to which numbers can be applied, such as initial monetary cost and maximum attainable speed, are the easiest to consider, while those to which numbers cannot be easily assigned are more difficult to evaluate.</p> <p>The establishment of standards is a recognized aid in the making of evaluations. Standards may consist simply of a set of lower limits; any product which fails to meet them is automatically eliminated from consideration. Examples of this hurdle or barrier type are some of the standards of the Underwriters' Laboratories for electrical appliances. A variant of this kind of standard may involve an upper as well as a lower limit, such as the "go-no-go" type. Conversely, a standard may involve the expression of a ratio of the specific item to the ultimate attainable, so each evaluation is a rating indicating how closely the limit is approached. A standard of this type is involved in the grading of examinations. (Even then the relationship between the score and the practical application is not always clear; the "A" student is not always successful in later life.) An intermediate form of standard is a rank ordering of individual items, along some defined scale, thus allowing comparison of each item with the average and its fellows.</p> <p>All these types of standards are clearly of value, so the establishment of standards, at least tentatively, should generally precede the process of evaluation. In the production of materials and the fabrication of products of all kinds, industry and Government depend on established standards in making purchases, compliance testing, and the design of more complex products. For many years the American Society for Testing and Materials, the American Standards Association, numerous trade associations, and various Government agencies have sponsored development of standards and specifications.</p> <p>Now what has all this to do with artificial limbs and braces? Evaluation serves one primary purpose in this case-the improvement of the product, a special type of man-machine combination. If the artificial limb could duplicate exactly all the functions of the natural limb in spite of the limited resources of power, sensibility, and control remaining available to the amputee, presumably we would have an ideal prosthesis. Minimal standards can rule out gross malfunctions, frequent and hazardous physical breakdowns, and obvious discomfort. Reasonably accurate lower and upper boundaries of physical dimensions to match specific categories of amputees can be established from anthropometric data illuminated by the best experience of the industry. In another sense, the physical strengths and practical minimal wall thicknesses set lower limits to weights, while maximal tolerable weights and inertias can also be estimated. By specifying the functional capabilities of the human limb we can establish the maximum standards we would like to achieve with our replacement. (The frequent recent suggestions of servo systems or "man amplifiers," though, imply that merely human performance may not be an upper bound.)</p> <p>These standards of several types should be specified in many categories. Any problem, no matter how complex, can be approached by breaking it down into small segments which can be analyzed. It is only as we define the significant categories, establish and progressively refine standards, and make objective evaluations that further appreciable advances in artificial limbs and braces will be made.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert R. Lissner, M.S. </b></td></tr><tr><td class="clsTextSmall"> Professor and Chairman of the Department of Engineering and Mechanics, and Coordinator, Biomechanics Research Center, Colleges of Engineering and Medicine, Wayne State University, Detroit, Mich. 48202; Chairman, Subcommittee on Evaluation, Committee on Prosthetics Research and Development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Measurement and Evaluation Creator An entity primarily responsible for making the resource Herbert R. Lissner, M.S. * https://staging.drfop.org/files/original/55a3a7b173a4ea49841968b5b80df860.pdf 30ec3d14f98a7ba60ecf7428947253e5 https://staging.drfop.org/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg 02bb4d6365ac241f87b6773edcb7e0c1 https://staging.drfop.org/files/original/8f618f54353873ee21984ffd68d8d05a.jpg c3e7d29a8e7b778ed3c74a7defb1e58b https://staging.drfop.org/files/original/44447ecd073a0cc7c351cea452163a32.jpg ee515bdf345c39774428067d5ecef159 https://staging.drfop.org/files/original/5b949cda2964dd9764e61908c066bc6f.jpg 760890658c08795998286568770b9a05 https://staging.drfop.org/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg 517767050abb9972fcd7bb791f3c924c https://staging.drfop.org/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png da19301ad0fdfca7f5f640abb9c3b40b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_009.pdf Text Any textual data included in the document <h2>A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket</h2> <h5>Howard Adelglass, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Don Sung Chu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />H.R. Lehneis, Ph.D., CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>R.W. is a 62 year old male with a 32 year history of insulin dependent diabetes mellitus. He was in a normal state of good health until August, 1982 when he developed gangrene of the first three toes of his left foot. A left femoral popliteal bypass was performed unsuccessfully. He then underwent a left below-knee amputation which also was unsuccessful and, in October, 1982, a left above-knee amputation was done. In December, 1982, he was admitted to the Institute of Rehabilitation Medicine, NYU Medical Center(IRM-NYU) for a prosthetics rehabilitation program. At that time, his stump became infected and dehisced, requiring stump revision.</p> <p>In July, 1983, he was readmitted to IRM-NYU and started on gait training with an AK prosthesis with a semi-suction socket, hip joint and pelvic belt, polycentric knee joint (Lang) and SACH foot (<a href="/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg"><b>Fig. 1</b></a>). During the course of his rehabilitation training, he began complaining of pain at the distal stump. The socket was adjusted numerous times by alternately relieving painful areas distally and placing padding above these areas, but with little success. Subsequently, x-rays taken of the stump revealed a small amount of soft tissue calcification distally with a small spur at the posterior lateral side of the femur (<a href="/files/original/8f618f54353873ee21984ffd68d8d05a.jpg"><b>Fig. 2</b></a>). The patient was started on anti-inflammatory agents which provided a moderate amount of pain relief. However, he still had difficulty ambulating secondary to stump pain.</p> <p>A lateral pad above the distal end was inserted into the prosthesis which relieved some of the pain. However, within a few days, the patient developed a skin breakdown in the left peroneal area, and an erythematous area on the distal stump. The patient was not allowed to wear his prosthesis for 2 1/2 weeks. During this time, a repeat stump x-ray showed a large spur in the posterior lateral side of the distal stump and more soft tissue calcifications on the anterior surface of the stump (<a href="/files/original/44447ecd073a0cc7c351cea452163a32.jpg"><b>Fig. 3</b></a>). Consequently, a new socket was designed to give relief over the distal anterior and posterior stump in order to decrease the pain and improve ambulation.</p> <p>This socket consisted of a vacuum-molded ionomer (Surlyn®) flexible socket contained in plastic laminated socket. There were fenestrations put into the anterior (<a href="/files/original/5b949cda2964dd9764e61908c066bc6f.jpg"><b>Fig. 4</b></a>) and posterior walls (<a href="/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg"><b>Fig. 5</b></a>) of the rigid outer socket, which afforded relief to the area of spur formation and soft tissue calcification. The flexible inner socket was chosen for several reasons :</p> <ol> <li> <p>Flexibility of the socket results in a more comfortable fit and reduces pressure concentration.</p> </li> <li> <p>Its transparency allows direct visualization of the stump, if skin breakdown is a problem, and to monitor pressure areas.</p> </li> <li> <p>It permits quicker heat dissipation because of reduction in socket wall thickness.</p> </li> <li> <p>The socket allows improved sensory feedback, especially while sitting, due to flexibility in fenestrated areas.</p> </li> </ol> <p>The patient tolerated the prosthesis well, however, he still had pain over the anterior distal stump. Thus, new x-rays of the patient were taken while he was wearing the prosthesis to determine if the fenestrations were, in fact, over the spur and the soft tissue calcifications. Because of the design of this socket, it was easy to determine that the fenestrations needed correction.</p> <p>The anterior cut out was then enlarged to better accommodate the soft tissue calcification (<a href="/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png"><b>Fig. 6</b></a>). This afforded the patient the relief needed. He is presently ambulating independently with a straight cane and the above-knee prosthesis without any pain.</p> <p>In summary, this flexible socket technique allows improved accuracy in fitting not only routine cases, but is especially suited for problem cases as illustrated here.</p> <em><b>*H.R. Lehneis, Ph.D., CPO </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Don Sung Chu, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Howard Adelglass, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-6.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-2.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket Creator An entity primarily responsible for making the resource Howard Adelglass, M.D. * Don Sung Chu, M.D. * H.R. Lehneis, Ph.D., CPO * https://staging.drfop.org/files/original/75dc06cd0cb2f16f20c55049bd0bdbc7.pdf f76171ab4432c6a50cf6f259be7af891 https://staging.drfop.org/files/original/d81d51673f68ef5fe93f7930d455e5f8.jpg 7008a305e99a0abc591c52fc2411bb17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_004.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 4 - 7 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Lower-Extremity Prosthetics Program</h2> <h5>Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>Man depends upon his legs to support the body and to move it from place to place as occasion warrants. Since mobility is nearly indispensable to most human activities, the loss of part or all of a leg—through accident, war, or disease—imposes serious limitations and has always made a replacement of some sort more or less of a necessity. Accordingly, artificial legs of one kind or another have been made and used since the most ancient times. As a result of the long-continued effort, leg prostheses have undergone progressive, if slow, development through the centuries, so that many lower-extremity amputees have in the past been successfully restored to something resembling a normal life. With the advent of industrial development, and of improved tools and materials with which to work, the nineteenth century marked the appearance of many new lower-extremity devices and of new techniques in the medical treatment of amputations.</p> <p>Impetus provided by World Wars I and II gave rise to rapid advancement in all branches of technology and thus made possible a concerted attack on the problem of supplying the best possible artificial limbs. The term "lower-extremity prosthetics" has now come to mean the practice of rehabilitation of the leg amputee by providing him with an artificial limb that will restore lost functions to the greatest possible degree. But more than just the artificial leg is involved. The amputee himself is a most important part of the end-product, and amputees, like other people, are individuals with widely differing characteristics and abilities. Of course surgical procedures should be designed to secure a painless stump and to retain maximum function, and it would seem that the artificial leg, when properly fitted, should duplicate as closely as possible the normal activity of the lost part. Moreover, physical conditioning and gait training are both important phases of the whole rehabilitation process.</p> <p>This concept of lower-extremity prosthetics has developed during the years since the start in 1945 of the program of the Advisory Committee on Artificial Limbs, National Research Council. Initially, the primary objective was to develop improved devices, it being considered as obvious that, if a better prosthetic knee or ankle or foot could be devised, the amputee would benefit. Attempts to produce such items, however, made necessary the determination of functional requirements and thus immediately revealed the lack of necessary fundamental information. Basic research into the complicated phenomenon we call "locomotion" was therefore carried on simultaneously with the development of devices.<a style="text-decoration:none;">*</a> These investigations indicated a need for the application of basic mechanical principles to fitting and alignment of artificial legs. A three-pronged approach, all parts of which are complex and interrelated in various ways, has thus evolved. Basically, the three objectives are:</p> <ol> <li>To extend knowledge of the amputee, of lost and remaining functions affecting locomotion, and to collect information on the best possible medical treatment.</li><li>To improve fitting techniques and practices, including training, so that existing devices might be used with greater comfort and function.</li><li>To develop improved lower-extremity devices.</li></ol> <p>Relative emphasis on these three phases is shown in <b>Fig. 1</b>. Implied in such a program is the dissemination of information and techniques to those who serve the amputee. Many of the accomplishments to date are recorded, and fully documented with the report literature, in Klopsteg and Wilson's <i>Human Limbs and Their Substitutes </i>(McGraw-Hill, in press). In addition, various seminars and short courses for surgeons and prosthetists have been conducted throughout the program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the lower-extremity prosthetics program, 1945-54, projected through 1956 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fundamental Studies</h3> <p>Detailed and comprehensive study of normal human locomotion is the basic key to improvement in all phases of the lower-extremity problem. Walking is to all appearances so natural and simple a process that it is difficult to conceive of its complexity. A knowledge of the behavior and the contribution of each anatomical part in providing the many services required of legs in normal use is essential to determine the functions that have been lost through amputation and the functions that still remain. The surgeon needs such information in order to provide the best amputation stump with maximum remaining function. The prosthetist must understand the limitations and potentialities of the amputee-prosthesis combination for optimum fitting, alignment, and adjustment. The designer needs detailed information on angles, displacements, velocities, accelerations, forces, energy requirements, and functions in order to improve existing devices and to develop new ones. And finally, the amputee himself has problems that require a fundamental approach. Causes and treatment of phantom or other pain, circulatory difficulties resulting from amputation, skin tolerance to pressure in areas never intended for such use, as well as the better understanding of the psychological problems of the amputee are examples of important areas of investigation.</p> <p>The objectives of the program of fundamental studies of the lower extremity may be summarized as:</p> <ol> <li>To study the phenomenon of locomotion in a sample of normal individuals and to analyze the results for use by the surgeon, the designer, and the prosthetist.</li><li>To develop design criteria for new or improved devices and as a basis for evaluating existing devices.</li><li>To develop an understanding of the compensatory mechanism of the human body and its ability to adapt itself to overcome functional deficiencies of its parts.</li><li>To provide a frame of reference for evaluating the degree of success obtained in replacing lost functions by means of an artificial leg.</li><li>To obtain information on the cause and possible treatment of phantom pain and other medical problems of the amputee.<a style="text-decoration:none;">*</a></li></ol> <h3>Development of Techniques of Fitting and Alignment</h3> <p>It appears obvious that, no matter to what degree an artificial leg is perfected mechanically, its effectiveness will depend upon the comfort afforded the wearer. Comfort is a function of the fit and alignment of the prosthesis.</p> <p>Although the artificial-limb industry has, through the years, developed reasonably successful techniques for fitting and aligning artificial legs, the results have been obtained mostly by trial-and-error methods; seldom have basic mechanical and anatomical principles been employed. It was found, for instance, that even among the most successful prosthetists there existed little agreement as to what constituted a satisfactory fit. For these reasons it appeared necessary to include in the lower-extremity program a project to develop fitting and alignment techniques based on sound scientific principles and to include, if necessary, the development of auxiliary tools and a study of materials and of methods of suspension.</p> <p>The study was launched with the following objectives in mind:</p> <ol> <li>To learn from the artificial-limb industry the procedures used in fitting and alignment of artificial legs.</li><li>To work with the industry in applying fundamental principles to the problem of fit and alignment and to formulate the guiding principles involved.</li><li>To develop mechanical aids to improve fit and alignment and to serve as tools to simplify shop operations.</li><li>To investigate and evaluate types of suspension as well as materials and methods used in socket fabrication.</li><li>To develop simplified methods of evaluating the amputee-limb combination-to be used as a check by the prosthetist, the surgeon, and the physiotherapist.</li><li>To improve methods of training the lower-extremity amputee in order to get better functional and more effective use of his prosthesis.</li></ol> <p>Out of this study have come such developments as the introduction of the above-knee suction socket and the University of California adjustable legs and alignment duplication jig. The study of fitting and alignment continues at the University of California, Berkeley Campus.</p> <h3>Development of Prosthetic Devices</h3> <p>New and improved devices have always been a major objective of the ACAL program. Great effort has been expended in this direction, often without the necessary or valid criteria. Although engineering designs can be made to accomplish nearly any specified function, the end result of any given design may be unsatisfactory if the specifications were unrealistic. The device may be too complicated, too heavy, uneconomical for the improvements obtained—or it may actually interfere with some service functions though improving others. Since the beginning of the ACAL research program, a number of outstanding industrial firms have engaged in development of devices. As a result of these activities, a great deal has been learned about what is possible—and about what <i>not </i>to do. Together with the fundamental studies, a body of knowledge has been developed to provide a realistic approach to design criteria. A number of devices based on this information are now in the development stage; they show promise for the future.</p> <p>Criteria for improved knee joints for above-knee amputees have undergone great changes as fundamental knowledge of locomotion has increased and as various knees, alleged to be improved ones, have been tested on amputees. Similarly, dependence of knee performance on ankle function, fit and alignment, training, and total coordination is becoming better understood. In the light of present knowledge, it seems clear that "super-devices" are not apt to be the solution to improved artificial legs and that considerations of natural appearance, minimum energy consumption, and simplicity of mechanism for maintenance and economy will in the end be the controlling factors. Of course no device should be made available for general distribution until it has been checked thoroughly for function, strength, maintenance requirements, life expectancy, and adaptability to different types of amputees. A complete testing program has there- fore been established under the direction of New York University to ensure the adequacy of each device approved under the program.</p> <p>Present objectives for the development of prosthetic devices may be stated as:</p> <ol> <li>To invent new mechanisms, improve and adapt existing mechanisms, and apply new materials so as to add functions, or to improve presently provided functions of prostheses, seeking in the end to provide better devices to meet the needs of every amputee type.</li><li>To perfect those functions involved in level walking, with the best possible solution for oilier services such as sitting down, walking on slopes and stairs, etc.</li><li>To adapt devices that take advantage of remaining functions in the amputee's stump.</li><li>To increase stability during the weight-bearing phase but to reduce the energy requirement during transition as well as during the entire cycle of walking.</li></ol> <h3>Clinical Study</h3> <p>Throughout the program, amputees have been fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. Techniques and practices involved in fitting amputees are so varied, however, that some orderly means of investigating these areas became necessary. Accordingly, in 1952 a program of clinical studies was established under the project at the University of California, Berkeley, in space at the Artificial Limb Shop of the U. S. Naval Hospital at Oakland, California. Here an orderly approach can be made to a review and formulation of best practice in lower-extremity prescription, fabrication, fitting and alignment, and training in the use of the prosthesis. Complete documentation of each step in the process, as applied to a variety of amputee types, under the supervision of an advisory panel and with the cooperation of members of the limb industry in the San Francisco Bay-Area, will serve to close the gap between fundamental work in the laboratory and practice in the field. Besides this, it will serve to supply source material for the information of the various professions involved in physical rehabilitation of the amputee as well as to define areas where more information or new devices are required.</p> <p>In addition to establishing what is the best prosthetic practice, the objective of the clinical study is to develop, for distribution to each member of the rehabilitation team, including the amputee, information such as:</p> <ol> <li>Medical data for use by the surgeon in connection with amputee problems.</li><li>Criteria for use in proper prescription of a prosthesis.</li><li>Principles and practices of fabrication, fitting, and alignment of a prosthesis.</li><li>Suggested means of evaluating prosthesis and amputee, Including gait analysis, performance checks, and achievement tests for use by the prosthetist, the surgeon, and the physical therapist.</li><li>Suggested curriculum for training the amputee in the use of his prosthesis.</li><li>A comprehensive list of specific prosthetic appliances and devices, with descriptions of their individual characteristics and functions, for use in preparing prescriptions.</li><li>Suggested curriculum for training the prosthetist, the surgeon, and other members of the clinic team in lower-extremity prosthetics.</li><li>Data useful to the research and development laboratories in continuing their studies.</li></ol> <h3>Future Program</h3> <p>The investigation and development involved in a lower-extremity prosthetics program are complicated and time-consuming. And since it appears impossible to reach the ultimate goal of replacement of all functions that have been lost, the task must be considered as never-ending. For the immediate future it is contemplated that development of devices, the clinical study, fitting and alignment studies, and fundamental research will continue. The relative emphasis on each phase is projected on <b>Fig. 1</b> through 1956.</p> <p>As progress is reflected in the results of the clinical study, some means must be developed for effectively transmitting this information to orthopedic clinic teams throughout the nation. Whether this is to be accomplished periodically at a central location, or whether through field teams on a continuing basis, will depend to a large extent upon the results obtained in the clinical study during the coming year. Whatever method evolves, every effort will be made to ensure that any useful information is disseminated to the field as quickly and efficiently as possible.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be noted that the work on phantom pain is applicable to both upper- and lower-extremity amputations.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A more logical and systematic approach, had there been sufficient time, might have been to postpone device development until the results of the basic work became available. But the urgency of amputee demands at the end of World War II made such an approach less desirable than the one adopted.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_004/May-1954OCRBatch1-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/6d1bdbfb3822612ccf70563fefbb4019.pdf 356c1ebffaaa95283031c39e033f657c https://staging.drfop.org/files/original/9b3dbfd47f4e205b3f3566f5c2598ac8.jpg 5a1fa0e5452223577fc6c6f63fe3d92d https://staging.drfop.org/files/original/98ee1f01a6ef29370ac9ad0bbfb94469.jpg d73980b5e63ccd830a91b081fe43edd0 https://staging.drfop.org/files/original/0fecb05ac19dc561124c48611c56a93a.jpg 623b7bf0044a88b7d34c77709fa54bb5 https://staging.drfop.org/files/original/95e006b3a425afa6d9f016bd69c3c4be.jpg 2e7e56d1bb7cdaf6bf13a8ff13e075d3 https://staging.drfop.org/files/original/1a32f54d3357fabb1ad9960c341aebf1.jpg d7abfc1d599e85de9900579f35a25034 https://staging.drfop.org/files/original/ef60e5343c1d3795a8af570b62a2645d.jpg 4fee5b46777df4d2048fd04943f125a5 https://staging.drfop.org/files/original/96be9b456a559b47dc97d6b1d8762776.jpg 6138c8980b24c30dd059ffc8d4a80251 https://staging.drfop.org/files/original/36c9b2abea8e6ce94e65566293c465a1.jpg c83e90321948696244f77976e48ff66a https://staging.drfop.org/files/original/6ae2fccc79bd5e8aa4f65fb1aaf2e51f.jpg 5159bf1873b503d8f3054c3182d51ff4 https://staging.drfop.org/files/original/9354bdc5ff2a0e6de61afdf78f664d83.jpg 8c50f7c6f65863d52a9dc7a767d3cd9d https://staging.drfop.org/files/original/852b96d874c1c25e67850af48b8d494d.jpg e0747089b4f52509b68a3e938ee55bd6 https://staging.drfop.org/files/original/a8a745290d743a87ddf6cd43e7f4d514.jpg d4510cc8170aed8908dbcbc660b26231 https://staging.drfop.org/files/original/854bb6844fef8050def39efea9a8447c.jpg 78018016d2195bca56aa7ca163f91998 https://staging.drfop.org/files/original/20bc29a508bf9a567e95fb90f7016bb0.jpg 4ee050bd695563984ed8ed14ca0ab801 https://staging.drfop.org/files/original/f92594d34b7d0d92262b30e6614a5fd5.jpg ed668351f5e0faad932ac687328a3385 https://staging.drfop.org/files/original/34ba0a161c273f2936d369676640a72f.jpg 61e794fe0c4f3caa10ce7fee4e05e438 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_009.pdf Text Any textual data included in the document <h2>Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis</h2> <h5>Ivan A. Long, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>On March 13, 1974, I saw the first x-ray of an amputee standing with his prosthesis, equal weight on both feet, heels 2" apart and toes 3" apart. (See <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg"><b>Fig. 1</b></a>. Notice the two zippers on the boots.) After seeing the amputated femur in such abduction, I realized that the quadrilateral socket and standard alignment procedures were not adequate for an above-knee limb. In December 1975, <i>Orthotics and Prosthetics</i>, the journal of the American Orthotic and Prosthetic Association, published my article, "Allowing Normal Adduction of Femur in Above-Knee Amputations."</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg"><strong>Figure 1. X-ray of standing patient showing relative abduction of amputated femur as compared to normal side.</strong></a><br /> <p>On February 2 and 3, 1981, I presented a demonstration and the booklet "Fabricating the 'Long's Line' Above-Knee Prosthesis" at Sabolich, Inc. in Oklahoma City. Shortly thereafter, news of a CAT-CAM socket available through Sabolich was announced.</p> <p>For the last 11 years, I have been fabricating only above-knee limbs and all have "Long's Line." The following article is presented so that prosthetists can provide the above-knee amputee with a limb that has a comfortable socket and alignment that allows him to walk in a normal fashion without drawing attention. Recently, it has been decided to call this work "Normal Shape-Normal Alignment" (NSNA) above knee prosthesis.</p> <h3>What Is Wrong With Our Present A/K Prostheses?</h3> <p>Most above-knee amputees walk with a wide base and a lurch to the amputated side. Only 100 percent concentration can change that pattern. We looked at 100 x-rays of above-knee amputees standing in their prostheses and found 92 out of 100 to have a difference in angle of the femur. In 91 to 92, the difference was towards abduction. (In this article, the angle of the sound femur is considered normal and movement away from the midline will be called abduction.) Most amputees would have to cross their legs to put the amputated femur in normal position while wearing the standard quadrilateral socket made all over the United States.</p> <p>Abduction was caused by the quadrilateral socket being entirely too large in the M-L dimension and too tight in the A-P. The ischium sits on top of the seat at best and a couple of inches above it in most fittings. The x-rays show the lateral wall to be several inches away from the femur except at the most distal point. When the femur exerts force against the lateral wall in weight bearing, the quadrilateral socket moves laterally immediately, because the ischium has no effect on stopping this shift. With the more narrow socket and increased A-P, the ischium is inside the socket, preventing lateral shifting of the socket during weight bearing.</p> <p>To insure proper angle of the femur, the distal femur is brought directly under the head of the femur. This allows hip musculature to work in a normal fashion. The narrow socket with a well shaped lateral wall will support this angle, and the ischium will secure the socket from shifting laterally, which destroys femoral support.</p> <p>Balance is dramatically improved when the foot is placed directly under the head of the femur rather than under the ischium. The amputee will immediately bring his feet closer together when he starts to walk, as opposed to a widened position when the foot is placed under the ischium.</p> <p>Long's Line is a straight line from the head of the femur (located approximately at the center of a narrow socket), through the distal femur, and down to the center of the heel. This line is not always vertical because it constantly shifts when changing from a standing position to a walking position.</p> <p>In order to support the femur, it is necessary to narrow the M-L dimension of the socket. The resulting greater A-P allows muscular function which is not possible with the crowded effect of a narrow A-P. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg"><b>Table I</b></a> is used as a guide in establishing the width of the finished positive model. The figures were taken from approximately 500 sockets made in this facility, and may of these sockets have now been worn eight years. Very few, if any, sockets have been replaced because of shrinkage. Many sockets have been replaced as muscles return to normal and the thigh takes on its original shape and size increases. Most of the increase in size will take place in the A-P dimension, with very little change in M-L. Increasing the M-L dimension by anything more than 1/4" will result in a lateral gap at the top of the socket.</p> <h3>Technique</h3> <p>Thigh is measured as to length and circumference as high as possible and every two inches.</p> <p>Taking a cast: Take two pieces of 6" wide cotton stockinette, 32" long. Cut 17" into each piece and sew together to make undergarment for casting (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg"><b>Fig. 2</b></a>). Measure length of thigh and sew one leg of garment to fit thigh. Cut small holes in front and back of top of garment and insert cord to tie up over amputee's shoulder to help hold garment securely in place. With a snug fitting undergarment on the patient, and with the seam as near center as possible, the prosthetist will work from the side and completely circle the pelvis above the trochanter with a single wrap of 4" non-elastic plaster bandage. Pull it snug, for this wrap is to prevent downward slippage of the cast as more wraps of plaster are applied around the thigh. Work quickly so your finger can be placed around the ischium to mark its location and proper depth of cast before the plaster sets. This spot will be used to measure length to floor, pelvis level. The hand should be held to indicate the medial and posterior surfaces of ischium. Do not push forward of ischium. Ask the amputee to bring his knees together as tightly as possible and to extend his thigh to tighten the hamstrings. Hold this position until the plaster sets. Now place a vertical mark on lateral surface, with muscles tightened in extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg"><strong>Figure 2. Casting garment.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg"><strong>Figure 3. Lateral view of cast ready to pour.</strong></a><br /> <p>Tear the single wrap of plaster than encircles the pelvis. The cast will drop away. Immediately check depth of cast and location of ischium.</p> <p>Prepare cast for filling by adding duct tape around top to make top level. Pipe must be parallel with lateral mark, and tipped to medial to approximate Long's Line angle (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg"><strong>Figure 4. Anterior view of cast.</strong></a><br /> <p>Now pour the cast full of plaster and let it set.</p> <p>When the plaster bandage and stockinette are peeled away, we now have a grossly oversided model (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg"><b>Fig. 5</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg"><b>Fig. 6</b></a>) that must be reduced in size. Practically all the reduction will take place on the lateral wall.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg"><strong>Figure 5. Posterior view of unaltered model.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg"><strong>Figure 6. Lateral view of unaltered model.</strong></a><br /> <p>Referring to <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg"><b>Table I</b></a>, the socket M-L will be 4.5" for a 19", 0 circumference level measurement of the amputee.</p> <h3>Socket Modification</h3> <ol> <li> <p>Lateral wall is to be shaped to give support over a wide area, and particularly the lateral posterior aspect of socket.</p> </li> <li> <p>The medial wall will be lower than seat level, and the cast will be the guide as to how low (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg"><strong>Figure 7. Medial view of modified model.</strong></a></li> <li> <p>Depth of the socket will be the same as measured length of the thigh.</p> </li> <li> <p>The seat will be at right angle to Long's Line.</p> </li> <li> <p>Long's Line is drawn from center of M-L (see chart) to center of distal femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg"><b>Fig. 8</b></a>). (Distal femur will be very close to lateral surface, probably covered only by skin.)</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg"><strong>Figure 8. Posterior view of modified model.</strong></a></li> <li> <p>Top 1" of medial wall will flare outward at 45° (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg"><b>Fig. 9</b></a>, point Y).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg"><strong>Figure 9. Anterior view showing relationship of medial brim (point X) to ischium and of lateral wall (point Y) to greater trochanter.</strong></a></li> <li> <p>Lateral wall is higher than usual. Do go above the trochanter (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg"><b>Fig. 9</b></a>, point Y).</p> </li> <li> <p>Seat need not be wide, but sharp edges must be avoided (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg"><b>Fig. 10</b></a>). The ischium will bear on flare of socket, both medial and posterior.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg"><strong>Figure 10. Lateral view.</strong></a></li> <li> <p>Do not worry about the socket touching the greater trochanter. Take the cast down as though the trochanter does not exist. Practically all sockets gap in this area. In order to achieve the desired M-L, many casts will be reduced 2" or more (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg"><b>Fig. 11</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg"><b>Table II</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg"><strong>Figure 11. Proximal view of socket and socket pattern for thigh measuring 19". Actual measurement of the pattern is 18".</strong></a></li> <li> <p>Many sockets require fill added distally on medial side, only because I failed to remove enough material in this area when modifying the model.</p> </li> <li> <p>Laminate socket using two layers of 1 oz. dacron felt plus extra felt around top.</p> </li> <li> <p>Remove socket from cast and trim excess plastic.</p> </li> <li> <p>Mark the center of the lateral wall at seat level for TKA. TKA should be parallel to lateral cast mark lines (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><strong>Figure 12. Lateral view of bench aligned prosthesis.</strong></a></li> <li> <p>Mark Long's Line on posterior of socket (Center of M-L through distal femur) (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><b>Fig. 13</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><strong>Figure 13. Posterior view of bench aligned prosthesis.</strong></a></li> <li> <p>When using a standard wood set-up, knee bolt should be 4° higher on lateral side when Long's Line is vertical. Long's Line will thus not be in center, but towards lateral side.</p> </li> <li> <p>Mount socket on set-up so that lines are straight (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><b>Fig. 12</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg"><b>Fig. 13</b></a>) and medial wall checks out for height.</p> </li> <li> <p>Install valve and walk amputee.</p> </li> </ol> <p><b>DO NOT</b> change the alignment. Allow the amputee to take a few steps and watch the foot come in to a narrow base normal gait pattern. Notice level knee bolt while walking.</p> <p><b>DO</b> expect the amputee to have much more difficulty in readjusting to his old prosthesis. He will need to widen his base and may experience vertigo at first due to lack of support and extreme inward location of the foot.</p> <p>To finish shaping of the thigh, material is added to the knee block to widen the knee block in front of medial joint. This must not limit full extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg"><b>Fig. 14</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg"><strong>Figure 14. Anterior view of prosthesis following completion of shaping.</strong></a><br /><br /><em><b>*Ivan A. Long, CP. </b> Ivan Long, CP., is President of Polycadence, 6080 West 55th Place, Arvada, California 80002.<br /><br /><br /></em> Page Number(s) 9 - 14 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg THIS IS TABLE I Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg<br />THIS IS FIGURE 2 Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg THIS IS FIGURE 3 Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg THIS IS FIGURE 4 Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg THIS IS FIGURE 5 Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg THIS IS FIGURE 6 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg THIS IS FIGURE 14 Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg THIS IS FIGURE 7 Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg THIS IS FIGURE 8 Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-10.jpg THIS IS FIGURE 9 Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg THIS IS FIGURE 10 Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg THIS IS FIGURE 11 Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg THIS IS TABLE II Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 12 Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 13 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 Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis Creator An entity primarily responsible for making the resource Ivan A. Long, CP. * https://staging.drfop.org/files/original/956af9917cfd9fb73b6117b9755a239b.pdf 28056c529a6ea46e1a814ecafe5a80c1 https://staging.drfop.org/files/original/1f49c6a6104459f23e9dfa8d412ffc20.jpg f3c1be296810afcc436d77a028f4096f https://staging.drfop.org/files/original/18c0fff3747573c51ca352089bae7d61.jpg 7e809e33d97818d7336120ed42eeea61 https://staging.drfop.org/files/original/85ee0c8d37dc935163afb0a9962cc2f9.jpg 6e15d3342841553335fed7733d7d17e5 https://staging.drfop.org/files/original/0cd11f516d0a8d898a1c077d7f69c1d6.jpg 76b674ec1dfcf7f7d9228fccbd189ac4 https://staging.drfop.org/files/original/0ad3855daa5c64e669f6370bf4205d4e.jpg abc0396ea518e5bbd060585896a1670c https://staging.drfop.org/files/original/7b1e0d9f3acae3755f18794c4f13b5a9.jpg 1d1373c5a7ecaa142510b3fd7af23352 https://staging.drfop.org/files/original/a3f371e62d05f358ab3cf22baa7a04e3.jpg fa7512603a3985b6d5dc6cd28e082c65 https://staging.drfop.org/files/original/2024c472036ebd49cd351ae5072ccc7b.jpg e9485f2fdf3d4b688a644d35ab9208ff https://staging.drfop.org/files/original/2dc0c7d069912311dcc03cf6a6e4edd0.jpg 44805da8539f659e38ba2b6923ae23a7 https://staging.drfop.org/files/original/a0111079818b806d3cab00d12fdcf44a.jpg 6bd9f29bc5719a3f614184f504eb757b https://staging.drfop.org/files/original/a5d1d87db952fade6693daab80374e3b.jpg d1a98712df54e4fad870a24509d8c845 https://staging.drfop.org/files/original/4514ab332afd9e2ed6ada5ddf5e492cf.jpg 614b532eff922c51d19dc05e84a0d77a https://staging.drfop.org/files/original/578d772bde6a5c2a41ca7d6c6d6a708f.jpg 81b48b5acfcce6adf954134ba1632329 https://staging.drfop.org/files/original/92434ac02ce39b964cf841a8c3029e32.jpg 8879f138a8690b98a030f427a690ee51 https://staging.drfop.org/files/original/7634a137bdb42ac7bc88e89c969baff2.jpg d6970f01166c5e4483c4d09c3e192bd2 https://staging.drfop.org/files/original/a4e96c00f56e7528a88f795778034019.jpg 26e361bd945b842e6234dab07062df02 https://staging.drfop.org/files/original/45866a1de62c43372d858339cb0da3b8.jpg 1d658e11e001f0feab567d69a8014abc https://staging.drfop.org/files/original/4c657635e36b1cefe1d39c19f4113f5d.jpg b2010734777bcb3871335633a345e369 https://staging.drfop.org/files/original/6a4f8fcc12e7f2468458df8c09de853b.jpg fa79703822387436f620508ee389b651 https://staging.drfop.org/files/original/fc32068d54284cb07ea26577879848fd.jpg 5c12ecf92371977a3d8ccbf60619c57d https://staging.drfop.org/files/original/4da1345a2d271e4dc861aec691c18790.jpg 10464557b1f2336fa5c8692e44f39e8d https://staging.drfop.org/files/original/678a25ec51a9a74d262f5b192ac6d455.jpg aa0e051b42977683bbe6fba20c999bad https://staging.drfop.org/files/original/3f7acdef049a4e860068b0ba70107199.jpg 813f193ce34ce2551d80fbb2de03bcf6 https://staging.drfop.org/files/original/884e577ac31b028021608f33fc19035d.jpg c4c3d97f45d64348ce25dd32021b9cd9 https://staging.drfop.org/files/original/c89a9b0bf901d5ead0d311f1d6594647.jpg deb348ac5024036fe39b11b71df865fd https://staging.drfop.org/files/original/7c089cb36dae52e33064e3aee182771d.jpg 30568fcf56955d1579ddeb52a586e9a4 https://staging.drfop.org/files/original/f096896c807afb36a307a0e411d0ed1d.jpg e5e6eb8ca8a16d7ad060234d4586a822 https://staging.drfop.org/files/original/df2bb6c8e62291390610da54233f07b4.jpg e2086606367ea634b8d76f839fd3a890 https://staging.drfop.org/files/original/e6f39ff4932c931b96962c20f53dd136.jpg 297c2bdf7a7130af48d737f98ee56be6 https://staging.drfop.org/files/original/16991f31b18a6af294f160286d006f48.jpg f77c226f1afd1a87eb1d2875c41402e0 https://staging.drfop.org/files/original/88c86eef7c137e26d99b1fa83179eb6b.jpg 940fcd55d76b5030bbafa3d11828a7cc https://staging.drfop.org/files/original/558a4264f026c229641591b232b8f5f3.jpg c20d1278438bae7072788e8ef808411a https://staging.drfop.org/files/original/69e28afdd6ed6bb9aa3a4cc7ff8d4bcc.jpg 946d63a2bd3e82c2d758a2b0e6dd4c10 https://staging.drfop.org/files/original/22cd6c0d4dea3a9cd00ed4a56ca6c7fc.jpg ae78f10177a3eada809893f54e6a493c https://staging.drfop.org/files/original/8c88c00f9a9da16d60b1f734dc8bafc5.jpg fb81e4666dab0b4f292a620106dad32f https://staging.drfop.org/files/original/923a5481243d688972cf556770c36a57.jpg 24ed8bc0e0820831ecb614f36196709b https://staging.drfop.org/files/original/c599282a2fc78c845b5ea8aa7131a727.jpg 31b347ffccbc9edae996d86890b9da0b https://staging.drfop.org/files/original/029b578bf376ed522eb4c2d61cf0c294.jpg fc7a8ae579056009c2a5d7a4ba31565d https://staging.drfop.org/files/original/1d68b4e019c469ee6451cc4198e3c440.jpg 24d57eb839c4d4390db7867c5cfd39ee https://staging.drfop.org/files/original/34f49d2626dbc6668bc1c80ee9b6ba0b.jpg 2bbe6f6750eaaf23a56b3a8d7682dfb4 https://staging.drfop.org/files/original/1711d925a52af68dee82c03968869a24.jpg b69868dbc60d0ed0fd2d5cf02c26f95b https://staging.drfop.org/files/original/53d9fb75ddf043805fe0975c2a67b3e0.jpg 09372d0e9d3b8df08bf515c5ee002e75 https://staging.drfop.org/files/original/b27035ad808ea6507aef71dd844510ab.jpg b40f2eb74bd1024fbb83de02826b6d04 https://staging.drfop.org/files/original/cd4bb2ae68b572c8ea97cacedbdc5ac8.jpg d4dc072e9fb4a64ff00707b0d2881306 https://staging.drfop.org/files/original/8b4ea6699b987d172a9622186bdb2184.jpg 4ddf912a8f315968b93c942cbe408722 https://staging.drfop.org/files/original/43e68efc76978d52a0fae3068d33314c.jpg 5c48d466aeea53a63f4feddca6643bae https://staging.drfop.org/files/original/91b0ef72cda9d858fe92cb61b0ccd5f1.jpg 370c3c9363c960523302e41bfa382199 https://staging.drfop.org/files/original/eed9d01f0ca86895932e527335c22e0f.jpg 3301b3bac2f637a1c7201485e524f707 https://staging.drfop.org/files/original/c3e16779d44ba8c1213419f5b6af944d.jpg 193abb8ce34e7ddd32a90f1b9dc67441 https://staging.drfop.org/files/original/a6a2e88e1625b6c1aa15a4892486a1c4.jpg b3cb5a6642c21726a462d145239c7e6f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_137.pdf Text Any textual data included in the document <h2>Seating for Children and Young Adults with Cerebral Palsy</h2> <h5>J. Martin Carlson, M.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />John Lonstein, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Karen O. Beck, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />David C. Wilkie, B.F.A.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>This paper will reflect the experience, perspective, and design rationale of one institution rather than attempt to give a comprehensive survey of the full spectrum of experience and designs.</p> <p>Several examples are given and references made to Duchenne muscular dystrophy (D.M.D). The D.M.D. examples are used when they are particularly good illustrations of a general principle which helps complete our understanding of seating for children with cerebral palsy. For more information on our experience and rationale relative to seating boys with Duchenne Muscular Dystrophy, refer to the reference section.<a></a></p> <p>The study of seating has many facets (cosmetic, functional, economic, etc.) and many professional perspectives (engineer, therapist, orthotist, physician, manufacturer, etc.). Engineers tend to relate to biomechanics and the economics of standard design. Therapists are concerned with function, development, inhibition of spasticity, etc. Each medical specialist has a different predominant focus. In different settings, it is inevitable that availability of professionals, availability of funds, age and severity of client population culture, etc., vary, and these factors will direct the seating program. Another important factor is that ortho-tists have not traditionally been trained in the provision of special seating, most are not active in special seating, and in most communities, there is a shortage of orthotists. These realities are a major reason why pre-manufactured, easy to assemble, and adjustable designs have predominated in many regions. The potential for commercial success and profit for the manufacturer, the ability to provide a system without the involvement of orthotic professionals (who are scarce and often inexperienced in seating), and the need to minimize costs, all seem to be best served by the wide distribution of pre-manufactured designs. In many communities, that is the best option available at this time. However, there are communities and settings wherein the circumstances make it possible to have a higher average of custom fabricated designs.</p> <p>To help you put this paper into perspective, we need to provide some information on the history of our seating program. The Orthotic/ Prosthetic Laboratory at Gillette Children's Hospital became involved with seating in 1974. Our seating program developed out of almost ideal circumstances. Orthotic services were strong and there was a close working relationship between our orthotists, therapists, and medical specialists. Weekly clinics brought a steady stream of clients through our outpatient clinic where the team members worked together to solve both general and individual problems. Also extremely important was our strong tradition and mechanisms for follow-up, which provided us with excellent feedback. Our early entry into seating, and the growth of the program, quickly gave us a significant volume so that specialists could be assigned and efficient procedures developed.</p> <p>Another factor bearing positively on our program is Gillette's extensive experience in spinal orthopedics. The volume of patients and specialization of our staff enabled us to offer quality care at economical costs.</p> <p>Although we have some experience with people of middle and advanced age, our experience at Gillette Children's Hospital is primarily with people from birth into young adulthood. This younger age group will be the focus of this paper. Our client population with cerebral palsy includes the full spectrum of severity, but the severe cases far out number the less severe.</p> <p>It is important that we all endeavor to recognize and respect the various aspects, perspectives, and variable circumstances mentioned earlier. Two very different seating programs may offer equally excellent care, but both can be even better if they "compare notes." This paper is a compilation of our "notes."</p> <h3>Fundamental Goals</h3> <p>The seating systems we provide must benefit the impaired person, those who care for that person, and society. Balanced against that, every piece of equipment inherently carries costs and disadvantages. Our systems cannot be all things to all people, but we will most nearly approach the ideal by keeping our sights aimed directly at the fundamental benefits and goals, while we endeaver to minimize the negatives.</p> <p>What are the fundamental goals? The main categories are outlined below.</p> <ol> <li> <p>Function</p> </li> <li> <p>Orthopedic/Neurologic</p> </li> <li> <p>Cosmesis</p> </li> <li> <p>Safety</p> </li> <li> <p>Economy</p> </li> </ol> <p>Function is primary. It affects a range of activities and benefits which can be best explained by examples: recreation for the child and family, making it easier for a care worker to feed a youngster, improving the child's field of vision, increasing his comfort, increasing the level of independence, etc. A functional seating system improves the childs development, decreases the amount of work required to take care of the child, and promotes a more enjoyable existence for the entire family.</p> <p>Federal laws passed in the U.S. in the early and mid 1970's mandated that children be transported from their living environments to educational settings. Safe transportation necessitates secure seating. Ultimately, society benefits, both tangibly and intangibly.</p> <p>From an orthopedic/neurologic standpoint, the ideal would be to prevent the progression of hip and spine deformities, and maintain body positions which reduce spastic reflex patterns. The benefits are better voluntary control, less severe deformity, less surgery, and a corresponding decrease in the work and cost of daily care. The advantages are perhaps most apparent to those of us who have visited state hospitals and have seen severely involved adult patients who were maintained only in recumbent positions during their earlier years. Positioning options for these adults are so severely limited that constant and expensive care is required to prevent ulcers and maceration. Also, hospitalization for those problems and pneumonia tend to be more frequent.</p> <p>Cosmetically the ideal is a well camouflaged, hidden, or attractive seating system which helps the youngster sit upright with the head in a position to see and be seen. The aesthetic and emotional benefits of a cosmetically appealing seating system accrue to the child and everyone in his environment.</p> <p>Comparing the costs of various seating approaches is difficult, because of the many costs which should be taken into account and the complexity of the various alternatives. We must take into account the cost of the seat, the cost of wheeled bases, repairs, frequency of replacement, and the cost of therapist involvement. The most important economic factor is the impact of a particular seating decision or system on the long range cost of daily care and health care. Long range costs must be considered, but they are very hard to estimate.</p> <h3>Biomechanics Of Seating</h3> <p>A normal head-trunk complex gets its stability from the spinal column, which acts as a controlled stack of compression elements, and partly from a multitude of muscles, which support it in different ways. The paraspinal muscles have a direct action on the configuration of the spine extention through lateral flexion and rotation. The abdominal (and to some extent, costal) muscles, in addition to being direct skeletal motors, affect the spine's stability and configuration indirectly, but importantly, through their action on the viscera. Muscle action to constrict and control the circumference of the abdomen and thorax allow compressive body weight loads to be taken partly down through the fluid filled abdominothoracic cylinder rather than all acting down through the spinal column. This adds significantly to the stability of the torso. We must note that recent research by Nachemson, et al.<a></a> (indicating that the Valsalva maneuver fails to lower pressure in the intervertebral disks) challenges this classical explanation of Morris,<a></a> but does not propose a new analysis of abdominal muscle function in trunk stabilization. Swedish data suggests that we don't fully understand what the Valsalva maneuver consists of and how it functions biomechanically. (The Valsalva maneuver is a general tensing of abdominal muscles.)</p> <p>The normal activity of sitting consists of a series of frequently changed postures. Each of those postures would be non-functional, uncomfortable, and even injurious if it were the only posture available to us and maintained for hours. It is the frequent voluntary change which makes those postures collectively safe, acceptable and tolerably comfortable for more than ten minutes. It is quite an undertaking to design a seating system in which our client can safely and comfortably sit, with little or no change, for a matter of hours. In the case of a person with cerebral palsy, the abnormally high muscle tone about the pelvis and thighs is the major reason this can be accomplished.</p> <p>It is important to note that when a child has some limited postural alignment capability, that capability is greatest at the head and neck. There is less ability to control the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg"><b>Fig. 1</b></a>). (This capability reflects the early developmental stages of an infant, but when we see it in the older child, it represents delayed or arrested development.) Arm-propping is typically used to stabilize the upper thorax for effective neck and head control. This illustrates two seating principles. The first is that the postural control and use of the superior body elements is dependent on the stability of body elements inferior to them. Second, the seat should bring the stability from the pelvis upward to meet the descending/decreasing voluntary stability of the client. Terminating stability too low will fail to maximize the child's function. Carrying stability too high will deprive the client of his full voluntary movement capability.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg"><strong>Figure 1. Alignment capability is greatest at the head and neck, less at the pelvis.</strong></a><br /> <p>Since "normal" sitting postures are so variable and changeable, we cannot relate supported sitting postures to a specific normal posture. We must reason and choose a sitting posture which has the most advantages, and propose it as a "standard."</p> <p>We choose the "sitting at attention" sagittal configuration (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg"><b>Fig. 2</b></a>), because it represents a mid-range spine configuration, it allows significant weight bearing on the proximal thighs as well as the bottom of the pelvis, it is a cosmetic posture (chest and head upright, facing outward), and it is a functional posture (head in a position to observe and thorax and shoulders forming a secure base for the neck and arms to move). In the sagittal plane, the sacrum is tilted anteriorly a moderate amount. There is moderate lumbar lordosis, thoracic kyphosis, and cervical lordosis. We would further propose that the "standard" posture consists of a pelvis level and the spine straight in the frontal plane. When the left side of the pelvis is elevated, the pelvis is said to be "tilted rightward," and when the right side is elevated, it is "tilted leftward" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg"><b>Fig. 3</b></a>). Likewise, in the sagittal view, the pelvis is "tilted posteriorly" or "tilted anteriorly" depending on which direction the upper parts of the pelvis are oriented relative to "standard" (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg"><b>Fig. 4</b></a>). In the transverse plane, if the right side of the pelvis is rotated forward relative to the shoulders, we would say the pelvis is "torqued leftward." We do not present this nomenclature as the most correct, but offer it for use in the absence of standard nomenclature.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg"><strong>Figure 2. Sitting at attention represents a mid-range spine configuration.</strong></a><br /> <p>Cerebral palsy is a disease that expresses itself in a wide variety of static and dynamic patterns, and we cannot go into the mechanics of all those variations. We will limit ourselves to a discussion of what, in our experience, is the most common combination.</p> <p>Fortunately, even some of the children with severe cerebral palsy do not have a significant deformity or collapse in the frontal plane. This is not to say, however, that scoliosis is rare in this group. Scoliosis is quite common, and we see very severe cases. When we examine a child with scoliosis, we should evaluate whether or not the scoliotic collapse is aggravated by asymetric trunk muscle spasticity. We can expect to be much more effective at controlling a scoliosis deformity when asymetric trunk muscle spasticity appears not to be a significant factor.</p> <p>One of the usual characteristics of scoliosis in neuro-muscularly impaired sitters is lateral tilting of the pelvis in the direction of the convexity of the major scoliosis curve (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg"><b>Fig. 5</b></a>). This is not surprising when we consider that pelvic orientation is usually not under voluntary control. This characteristic will become more interesting later as we discuss the various methods for generating spine stability.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.jpg"><strong>Figure 5. Lateral tilting of the pelvis in the direction of the convexity of the major scoliotic curve.</strong></a><br /> <p>There are several distinct biomechanical schemes for providing spine stability to resist scoliosis. These schemes do not, of course, operate exclusively in the frontal plane. Also, the employment of one scheme does not preclude the simultaneous employment of one or more other schemes. The first and most familiar of these is "three-point-force". We need not explain the principles of this scheme since they are so well known. However, it is appropriate to note that three-point-force schemes are much less effective at stabilizing a multi-joint, multi-axis system such as the spinal column, than stabilizing a single-joint system such as the elbow or knee. The application of the three-point scheme in a spinal support system, which includes a seat, has some advantage over a traditional spinal orthosis in that the most inferior force can be located at greater distance from the more superior forces to give a longer moment arm. However, the more the client functionally moves in his seated position, the less the seat is able to apply three-point support, because it doesn't move with the client. Furthermore, a spinal orthosis can be worn 23 hours per day, if necessary. These latter considerations make the spinal orthosis a stronger orthotic treatment of progressive spine deformity.</p> <p>The second scheme we will discuss has to do with the Valsalva maneuver, given earlier, in which the abdominal and costal muscles function to relieve the spinal column of compression and bending loads. No matter what exactly happens during the Valsalva maneuver, the Morris explanation is a valid biomechanical analysis of how a snug corset contributes to trunk/spine stability in the presence of flaccid paralysis of abdominal and costal muscles. Engineering analysis and empirical evidence indicate that when we passively apply circumferential abdominal constraint (ie. a snug corset), a hydraulic load bearing column is created and we reduce the magnitude of flexible collapse (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg"><b>Fig. 6</b></a>). In our experience, the corset is seldom used for children with cerebral palsy, but is virtually always useful for children with muscular dystrophy.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-06.jpg"><strong>Figure 6. Reducing the magnitude of flexible collapse.</strong></a><br /> <p>The third scheme for enhancing spine stability derives from the fact that the sacro-pelvic complex forms the foundation on which the flexible spinal column rests. Voluntary pelvic control is an important component of spine stability in the unimpaired trunk. If, by a conforming design about the pelvis and a proper donning procedure, we can increase the foundation (bottom end) constraint conditions, much is added to spinal stability. The pair of diagrams on the left side of <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><b>Fig. 7</b></a> illustrates the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin jointed (free to tilt) at its lower end. The two diagrams on the right in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><b>Fig. 7</b></a> illustrate the similarity between the controlled pelvic case and the built-in base end condition. Elastic column buckling equations for the two beams indicate that the built-in beam will withstand almost twice as much load as the other before buckling.<a></a> To achieve this end condition stability, we need a well made seat, as well as a procedure to level the pelvis each time the child is seated.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg"><strong>Figure 7. The diagrams on the left illustrate the similarity between the spinal column in the case of an uncontrolled pelvis and the slender column pin-jointed (free to tilt) at its lower end. The two diagrams on the right illustrate the similarity between the controlled pelvic case and the built-in base end condition.</strong></a><br /> <p>To fully appreciate the strength of this scheme in practice, compare the two x-rays in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><b>Fig. 8a</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><b>Fig. 8b</b>.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><b>Fig. 8a</b></a> is the x-ray taken just before the pelvic leveling procedure was performed and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><b>Fig. 8b</b></a> is the x-ray taken a few minutes later, after the pelvic leveling procedure was performed. The Cobb angle is reduced from 36 degrees to 20 degrees by this quick procedure, which is normally performed as a routine part of positioning the child in the sitting support orthosis. These x-rays are of a boy with Duchenne Muscular Dystrophy; he was not wearing a corset.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg"><strong>Figure 8a. An x-ray taken just before the pelvic leveling procedure was performed.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg"><strong>Figure 8b. The x-ray taken a few minutes later after the procedure.</strong></a><br /> <p>A second example is given in <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg"><b>Fig. 9</b>.</a> The left and center x-rays show the progression which occurred in the eight months following fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, with the only difference being the pelvic leveling procedure was performed before the last film. Note: once a spine deformity has become partially structural, the pelvis can be leveled only to the degree that the deformity is still flexible.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg"><strong>Figure 9. The left and center x-rays show the progression which occured in eight months following a fitting. During this period, the parents did not use the pelvic leveling procedure. The x-ray on the right was taken a short time after the center x-ray, and after the pelvic leveling procedure was performed.</strong></a><br /> <p>In summary, maintaining a level pelvis makes it easier to control the spine. Pelvic control and orientation in the frontal plane also relates strongly to the uniformity of pressures in weight bearing areas and minimizing the progressive deterioration of sitting comfort.</p> <p>Let us now look at two examples were these stabilizing schemes have been simultaneously applied. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg"><b>Fig. 10a</b> </a>is a photo of a 12 year old boy with muscular dystrophy, sitting as he was presented to us. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg"><b>Fig. 10b</b></a> shows the sitting support system properly applied. The corset is entirely independent; it is not attached to the seat. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg"><b>Fig. 10c</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg"><b>Fig. 10d</b> </a>compare his A-P spine x-rays without and with the orthotic system. The lateral tilt of his pelvis is reduced from 30 degrees to 14 degrees. The Cobb angle of his scoliosis was reduced from 65 degrees to 35 degrees. Curve control of this magnitude is not unusual as long as the deformity is still flexible. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg"><b>Fig. 11a</b></a> is the x-ray of J.S., a 14 year old girl with cerebral palsy. She presented a right thoraco-lumbar scoliosis of 38 degrees and a rightward pelvic tilt of 8 degrees. Her shoulders were tilted 13 degrees to the left partly because she used her right arm for propping to avoid falling to the right. We provided her with a soft corset and the Gillette Sitting Support Orthosis. The Sitting Support Orthosis was to provide pelvic control and bilateral "propping" support. It had no head rest or anterior support. The x-ray taken just after fitting shows pelvic tilt reduced to 2 degrees (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg"><b>Fig. 11b</b></a>), the Cobb angle of the scoliosis reduced to 22 degrees, and shoulders leveled. Both hands were free to function, and she said she could breathe deeper.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg"><strong>Figure 10a. A 12 year old boy with muscular dystrophy as presented.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg"><strong>Figure 10b. The Sitting Support System properly applied. Corset is independent.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg"><strong>Figure 10c. A-P spine x-rays without the orthotic system.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg"><strong>Figure 10d. A-P spine x-rays with the orthotic system.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg"><strong>Figure 11a. X-ray of J.S., a 14 year old girl with cerebral palsy.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg">Figure 11b. J.S. provided with a soft corset and the Gillette Sitting Support Orthosis</a>.</strong><br /> <p>In cerebral palsy, we occasionally see a case of lateral pelvic tilt and scoliotic posture secondary to a unilateral hip extension contracture. A right hip extension contracture, if not accommodated, will cause the right side of the pelvis to be elevated. The pelvis will be tilted leftward and a compensatory convex left scoliosis will be produced. When we see this problem, it is usually an older child or adult. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg"><b>Fig. 12</b></a> is an example of a rather extreme case of how the deformity was accommodated to minimize pelvic and spinal malalignment and stress.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg"><strong>Figure 12. An extreme case of how pelvic and spinal malalignment and stress is minimized in a cerebral palsy patient.</strong></a><br /> <p>In the sagittal view, we commonly see a posture dominated by the powerful, very active hamstring muscle group. The gluteals are often helping to resist adequate hip flexion for an ideal sitting alignment. To a greater or lesser degree, the pelvis is maintained in a posterior tilt position with weight bearing shifted posteriorly toward the sacrum. This pelvic alignment tends to reduce lumbar lordosis and convert it to a kyphosis (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg"><b>Fig. 13</b></a>). The loss of lumbar lordosis makes it more difficult for the thoracic extensors to maintain a vertical upper thorax. This explains why a flexible spine, maintained with a pelvic belt and lumbar bolster to restore lumbar lordosis, often produces better active alignment of the upper thorax and head. (We would caution you that different solutions are necessary for people with rigid hyperkyphosis.)</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg"><strong>Figure 13. A sagital view illustrating the pelvis in a posterior tilt position with weight bearing shifted posteriorly towards the sacrum, converting lumbar lordosis to a kyphosis.</strong></a><br /> <p>The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg"><b>Fig. 14</b></a>). Attention must be given to properly provide all three. The seat bottoms must be configured specifically to provide optimum thigh support. A flat horizontal seat bottom will never maintain hip flexion against active extension (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg"><b>Fig. 15</b></a>). The anatomy itself calls for a depression under the pelvis to bring the femurs to a horizontal position (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg"><b>Fig. 16</b></a>). More importantly, the hip flexion required to "break through" the extensor spasticity varies from child to child, but we usually find that some degree of seat bottom incline (pelvis to knees) is needed for the more severely involved children (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg"><b>Fig. 17</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg"><strong>Figure 14. The three forces needed to maintain the position of the pelvis and lumbar spine are the thigh support, lap belt constraint, and lumbar support.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg"><strong>Figure 15. A flat horizontal seat bottom will never maintain hip flexion against active extension.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg"><strong>Figure 16. The anatomy calls for a depression under the pelvis to bring the femurs to a horizontal position.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg"><strong>Figures 17a and 17b. We usually find that some degree of seat bottom incline (pelvis to knees) is needed for more severely involved children.</strong></a><br /> <p>The pelvic belt force is perhaps the most critical. The pelvic belt must be perfectly anchored: close to the body posterolaterally for good "wrap around" and at the correct level to achieve a good downward force component (<a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg"><b>Fig. 18</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg"><b>Fig. 19</b></a>). The most common mistake is to anchor the lap belt too high. We have never seen one anchored too low. (We must remember that none of the hip/lumbar support forces function properly in service unless the caretakers know why and how to put the pelvis in position and snug up the pelvic belt. Without education and training of the users, our designs are worthless. We must train and retrain on every return visit.)</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg"><strong>Figure 18. The pelvic belt force is perhaps the most critical.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg"><strong>Figure 19. The pelvic belt must be perfectly anchored: close to the body posterolaterals for "good wrap around" and at the correct level to achieve a good downward force component.</strong></a><br /> <p>A fourth support force is sometimes needed in the area of the upper thorax or shoulders to maintain adequate thoracic extension. This is accomplished with a vest or shoulder straps which must be adjustable for grading the amount of support to fit the need, which may vary through the daily routine of activities.</p> <p>Seating misalignment and deformity problems in the transverse plane are not uncommon among the severely involved cerebral palsy population. The problem consists of the pelvis being torqued right or left by deformities of one or both hips. A severe adduction confracture of the right hip will, for instance, cause a seated misalignment which includes leftward direction of the thighs (with respect to the pelvis), a rightwardly torqued pelvis, and an apparently (not actually) short right femur. This misalignment has been well diagrammed in an article by Mercer Rang, et al.<a></a> A severe abduction contracture of the left hip will cause a similar misalignment. These deformities are often referred to as "wind blown hips." We can see that when such a condition exists, forcing the thighs to be aligned straight forward will obligate the client to sit facing to one side, or the spine will be continuously twisted. In most cases, the direction of the thighs may be altered enough to avoid much of the spinal twist. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg"><b>Fig. 20a</b> </a>is a photo of a top view of a Sitting Support Orthosis we provided for such a client. <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg"><b>Fig. 20b</b></a> is the same view of the client in the orthosis.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg"><strong>Figure 20a. Top view of a Sitting Support Orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg"><strong>Figure 20b. A client seated in the S.S.O. The direction of the thighs is altered to avoid much of the spinal twist.</strong></a><br /> <p>It is of utmost importance, as we treat these clients, that we keep function and quality of life issues uppermost in our mind. Biomechanics and deformity prevention ideals often must be compromised to avoid undue impingement on any aspect of the child's development or function.</p> <h3>Client Evaluation</h3> <p>Seating evaluations at Gillette always include an orthotist, a therapist, and a physician in addition to the client, parents or caretakers, and, if available, a community therapist. The physical evaluation includes an assessment of orthopedic deformities, spastic reflex patterns, voluntary sitting capability, and other functional abilities. To assess sitting ability, two people manually control the child's thighs, pelvis and lower trunk. If, with this amount of stabilizing assistance, the child still cannot manage an upright sitting posture, we would grade voluntary sitting capability at non-existent to poor. If the child can, with that assistance, struggle to an upright sitting posture and maintain it for fifteen seconds, we would grade voluntary sitting capability at poor to fair. Better performance would be graded accordingly as better than fair.</p> <p>A thorough interview of parents and others with the child is immensely valuable. We want to find out about the child's daily routine, mode of family transportation, what they feel are positive and negative features about their present equipment and routine, and the child's usual status compared to what we are observing. We also seek all concerns and ideas they may have for optimum seating. The interview should gradually become more of an educational session and finally a discussion of options. The child and parents or caretakers should, as much as possible, feel they were heard, were educated, and have participated in the decisions made on the seat, mobility base, accessories, etc.</p> <h3>Seating Design</h3> <p>We currently solve the majority of the seating problems we encounter with variations on two basic designs. Both are custom made.</p> <p>Although there have been many very significant design changes along the way, the Gillette style Sitting Support Orthosis (S.S.O.) has continued, from 1974 to the present, as a portable system utilizing a custom molded unpadded plastic shell mounted in a plastic foam base (<b>Fig. 18</b> and <b>Fig. 24</b>). We have provided approximately 1100 of these Sitting Support Orthoses. Our present rate of S.S.O. production is about 140 per year.</p> <strong>Figure 24. Anterior upper thoracic support provided by shoulder straps.</strong><br /> <p>In the early years, we also constructed upholstery and plywood seats. In 1983, we converted that rectangular design to one that used upholstered removeable components attached to the inside surfaces of a plastic seat frame as shown in <b>Fig. 21</b>. (We first saw a design similar to <b>Fig. 21</b> at the Royal Ottawa Rehabilitation Center. In addition to our own changes, the present design incorporates features also learned from the Rehabilitation Engineering Center at Children's Hospital at Stanford.) To distinquish this design from the contoured plastic shell type S.S.O., we call it an Upholstered Sitting Support Orthosis (U.S.S.O.). We currently construct and fit about 200 of these units annually.</p> <strong>Figure 21. A plastic seat frame with upholstered removable components.</strong><br /> <p>A more specific discussion of the design of the S.S.O. must start with noting that the main structure is an unpadded, thin plastic shell. Because of the thinness of the supporting shell, the seat is less bulky, less visible, and lighter than other seats. It allows us to provide close thoracic support up to the axillary level and wrap around the thorax, between the arms and chest, and well past mid-line, without impinging on the arms (<b>Fig. 18</b> and <b>Fig. 19</b>). When properly contoured, the shell can be left almost totally unpadded. The unpadded shell is easier to clean and requires less maintenance. The pelvic portion is contoured and sized to fit the hip/pelvic area quite close, but not snug. At fitting time, we leave adequate space to push our fingers between the Glueteus Medius and the seat bilaterally. About 18 months ago, we began providing room in the shell to install bilateral pelvic growth pads (visable in <b>Fig. 22</b>), which are removed later as the pelvis grows wider.</p> <strong>Figure 22. An unpadded shell with room to install bilateral pelvic growth pads, which are removable as the pelvis grows wider.</strong><br /> <p>Anterior upper thoracic support is provided by either a special vest (<b>Fig. 23</b>) or shoulder straps (<b>Fig. 24</b>). The shoulder straps are more efficient at keeping the thorax in an extended, upright posture. However, when the child has some arm function, we prefer to use the vest because it can be configured to impinge less on the anterior deltoid muscles. Note that the lower attachment points for the vest or shoulder straps should be in the sub-axillary area to provide good wrap-around and a posteriorly directed holding vector. Some commercially available seats anchor the shoulder straps to the lap belt. That design is seriously flawed because the shoulder straps then pull the lap belt up out of proper position and pull down on the shoulders.</p> <strong>Figure 23. Anterior upper thoracic support is provided by a special vest or shoulder straps (see Figure 24).</strong><br /> <p>When the S.S.O. is used for people with severe scoliosis or hyperkyphosis, the polypropylene shell accomodates to the contours of the deformity. However, sometimes our best efforts fail to create sufficiently precise contouring to spread pressure evenly over the entire rib prominence. <b>Fig. 25</b> diagrams how we sometimes solve that problem: an adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour.</p> <strong>Figure 25. An adjustable denim cloth panel is installed through vertical slits in the shell. The panel wraps around the prominence, conforming to the contour.</strong><br /> <p>Head support varies from nothing to a simple occipital prop to a variety of designs, depending on the particular challenge presented. A few of the many designs we have contrived over the years are shown in <b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>. We do not have a good solution for the child who persists in actively bringing the head forward and down. In seating children with hydrocephalus, the sheer weight of the head presents special safety and weight bearing problems (<b>Fig. 29</b> and <b>Fig. 30</b>).</p> <p>We haven't the space to show and explain the wide variety of accoutrements which are variously added for shoulder protraction, arm positioning, etc. We work closely with the therapists so that they can help design the final configuration for best functional positioning.</p> <p>As emphasized earlier, a seating program must consider the sitting functional environment. The seating orthoses we produce are re-moveably mounted in wheelchairs, strollers, buggies, and other bases as the circumstances indicate. Being portable, they are also utilized as car seats, or to place the child very near the floor to facilitate peer interaction (<b>Fig. 31</b>). We have found that a seating program, to be effective, must address the full spectrum of life activities. It must also address related equipment in the sitting environment. Footrests, wheelchair upholstery, laptrays, and control boxes are some of the most common things which must be modified, moved, or completely replaced with special designs. It seems to us that the "standard" wheelchair was designed to be "slouched" into (<b>Fig. 32</b>) rather than to be sat erect in. Those chairs are not adequate, as manufactured, for extended use by anyone. In spite of the newer, more enlightened designs coming along, those "standard" wheelchairs are still part of the scene and must be dealt with. When we sit a client erect on a firm seat, and then place that seat in a wheelchair, the client's shoulders are far from the center of the drive wheels (<b>Fig. 33</b>). For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars. The standard upholstry must be removed and replaced with straps so that the seat can be recessed down and back between the bars (<b>Fig. 34</b> and <b>Fig. 35</b>).</p> <strong>Figure 31. The seating orthoses we produce are removable and made to mount in a variety of bases as the circumstances indicate.</strong><br /><strong><br />Figure 32. Lateral view of typical posture produced by hypotonic spine extensors and tight hamstrings.</strong><br /><strong><br />Figure 33. Lateral view of a patient positioned too high and forward.</strong><br /><strong><br />Figure 34. For clients who self-propel, the seat must be sized or shaped to sit between the upholstery mounting bars.</strong><br /><br /><strong>Figure 35. Standard upholstery is removed and replaced with straps so the seat can be recessed down and back between the bars.</strong><br /> <p>At semi-annual follow-up visits, we accommodate the child's growth by adjusting the size</p> <p>of the S.S.O. Thigh length is added as necessary. The bilateral pelvic growth pads are thinned or removed when appropriate. The back and sides of the shell can be heated to widen the shell width across the chest. Axillary extensions are welded on as necessary to accommodate increase in thoracic height. Head rests and the anchor points for vests and shoulder straps are also elevated as necessary. Presently, the basic S.S.O. shell is serving for an average of 37 months for children between 3 years and 14 years of age. We expect the use of the pelvic growth pads to push that service life even higher. For adults, the average useful life of S.S.O.'s is much greater.</p> <p>We recommend the S.S.O. for children who have non-existent to poor voluntary sitting capability. Other factors which would indicate a need for the S.S.O., in our program, would be significant orthopedic deformities (of the hips and spine) and moderate to severe spastic reflex patterns. Completed physical growth may also be an indication for the S.S.O., because the polypropylene shell is very durable. It requires less repair maintenance than the upholstered systems. There is complete freedom within the design to reduce the level and amount of support or match the client's need: it may not include a head support, vest, or shoulder straps, and bilateral thoracic support may be terminated at a lower level and leave more room for movement as appropriate.</p> <p>Provision of a good quality S.S.O. requires a relatively high level of specific orthotic skill and practice. This may be considered a disadvantage, but we feel the adaptability and quality which results more than justifies the necessary investment.</p> <p>The structural components of the Upholstered Sitting Support Orthosis are made of ABS plastic. The upholstered firm inserts are removable to facilitate cleaning and adjustments for growth. Thoracic supports are thin (of metal) and can be easily adjusted to change height and spacing. The pelvic belt is used on every U.S.S.O. Lumbar bolsters, vests or shoulder straps, and head rests are used when appropriate. <b>Fig. 31</b> shows some of these design features. During therapy sessions, and for certain daily time periods, therapists or parents may wish to work specifically on improving upper trunk or head control. For this reason, shoulder straps and vests are designed for partial or complete loosening. Head rests can be easily removed from the unit (true of the S.S.O. as well as the U.S.S.O.).</p> <p>The U.S.S.O. is most appropriate for children with poor-to-fair voluntary sitting capability, minimal orthopedic deformities, and less severe spastic reflex patterns. The easy size-adjustability of this design gives it some advantage over the S.S.O. for younger, rapidly growing children. For children under two years, we often utilize one of the commercial infant seat or car seat frames to which we can add support bolsters, lap belt, etc. (<b>Fig. 36</b>).</p> <strong>Figure 36. A commercial infant car seat can be supplemented with bolsters, lap belt, etc.<br /></strong><br /> <h3>Fabrication</h3> <p>Much about the fabrication of these orthoses can be inferred from the photos and design information given earlier. Some information on fabrication of the "Gillette" S.S.O. has been discussed in earlier articles on that orthosis.<a></a> However, there are some serious errors in the S.S.O. fabrication process we made in the very beginning. Other orthotic labs might repeat those errors unless we reiterate a couple of the procedural steps and more clearly explain the rationale for those steps.</p> <p>The polypropylene shell is obtained by covering a pattern developed from an impression of the child. To obtain the impression, we position the child, on a supporting fixture (<b>Fig. 37</b>) in a face-down, hips-flexed, knees-flexed configuration (<b>Fig. 38</b>). We use the weight relieving (horizontal) trunk alignment, support under the knees, and a waist belt for the precise purpose of achieving an impression which does not possess the poor alignment characteristics we are trying to avoid. The support under the knees allows us to locate the pelvis as directly as possible in alignment with the spine. For the child with tight hamstring muscles, a waist belt on the fixture helps reduce lumbar kyphosis and perhaps achieve a little lumbar lordosis, if possible. The contrasting diagrams in <b>Fig. 39a</b> and <b>Fig. 39b</b> illustrate the critical role of knee support. The hip flexion angle of the fixture can be varied and is adjusted according to the amount of hip flexion we want in the seat shell. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences (<b>Fig. 40</b>). Plaster is added across the back of the upper thorax to give room for extension. <b>Fig. 41a</b> and <b>Fig. 41b</b> are posterior and lateral views of a positive model fully modified and ready for covering. The resulting polypropylene seat shell is mounted in a polyethylene foam base (<b>Fig. 42</b>). Final trim lines, lap belt and vest attachment points, head-rest placement, etc. wait until the child comes for fitting.</p> <strong>Figure 37. A supporting fixture.</strong><br /><br /><strong>Figure 38. To obtain an impression for a polypropylene shell, the child is positioned facedown, hips-flexed, and knees flexed on a supporting fixture.</strong><br /><br /><strong>Figure 39a. Hip flexion angle of the fixture can be varied.</strong><br /><br /><strong>Figure 40. On the positive model, plaster is added to create the bulges and contours needed to avoid pressure on bony prominences.</strong><br /><br /><strong>Figure 41a. Posterior view of a positive model fully modified and ready for covering.</strong><br /><br /><strong>Figure 41b. Lateral view of a positive model fully modified and ready for covering.</strong><br /><br /><strong>Figure 42. The polypropylene seat shell.</strong><br /> <p>The molded "Chailey Heritage" supportive seat,<a></a> which also utilizes vacuum dilatancy to obtain an impression, creates a positive model, and vacuum forms the seat materials over that model. With the exception of those general similarities, the procedures, materials, and design of the Chailey Heritage seat is very different from the Sitting Support Othosis developed at Gillette Children's Hospital.</p> <p>Fabrication of the U.S.S.O. does not require a pattern and is therefore free of the potential problems inherent in obtaining and modifying a model.</p> <h3>Conclusions</h3> <p>This paper has dealt most heavily with biomechanics and design, but many other programmatic components have been mentioned. Devices do not solve seating problems. A program is required. A truly successful seating program, one that approaches the fundamental goals discussed at the beginning of this paper, must contain at least the following components:</p> <ol> <li> <p>Involvement of all appropiate and available professional disciplines.</p> </li> <li> <p>Comprehensive discussion with, and education of, the client (when possible), the parents and/or other caretakers, and other available community-based professionals.</p> </li> <li> <p>Attention to finding and solving the family-specific functional (including play, recreation, and transportation) problems and opportunities.</p> </li> <li> <p>Provision of effective equipment with thorough instructions on its use.</p> </li> <li> <p>Tenacious follow-up to uncover and solve the inevitable problems and opportunities brought on by growth and functional changes; to obtain feedback necessary to the efficient evolution of the program; and to reinforce, as necessary, the education of the users.</p> </li> </ol> <h3>Acknowledgments</h3> <p>The important roles of some individuals and institutions have been cited earlier and will not be repeated here. Our experience with Duchenne Muscular Dystrophy has come primarily through Dr. Lowell (Hap) Lutter, chief of the Growth and Development Clinic at Gillette, and orthopedic surgeon for the Muscular Dystrophy Clinic at Fairview Hospital. The seating systems were provided at Gillette by Team Leaders, Mark Payette and David Wilkie, and the people they supervise. Those people include (currently, and in the recent past) Tracy Lillehaug, Joe Bieganek, Dannel Friel, John Spielman, Katie Voss, Lee Hegfors, Bruce Tew, Wendy Schifsky, Rick Weber, Paul Swanlund, Paul Lemke, and Marcia Munson. Gene Berglund is orthotic group manager at Gillette. Former Therapy Superivsors, Diane Twedt and Jan Headley were very involved and important during the early years of the program. Gillette therapists significantly involved with the program currently (or in the recent past) include Rebecca Lucas, Lynn Bowman-Bathke, Cindy Theisen, Patricia Mathie, Gail Graff, Marilyn Kochsiek, and Ellen Kratz.</p> <p>Over the years, we have been privileged to work with many outstanding individuals and institutions in various communities in our referral area. Three institutions which have been especially cooperative and capable are the Cambridge Regional Human Services Center (formerly Cambridge State Hospital), People's Child Care Residence, Homeward Bound, Brainerd State Hospital, and Moose Lake State Hospital.</p> <p>We have significantly learned from (in addition to centers cited earlier) the professionals associated with seating programs at the Rehabilitation Engineering Center of the University of Tennessee, the Hugh MacMillan Center in Toronto, and the Winnipeg Rehabilitation Center for Children.</p> <p>Address inquires to: J. Martin Carlson, Director of Orthotics and Prostetics, Gillette Children's Hospital, 200 E. University Avenue, St. Paul, MN 55101.</p> <p><b>References:</b></p> <ol> <li><a href="http://www.acpoc.org/library/1973_10_007.asp">Bowker, John H. and Reed, "A Vacuum Formed Plastic Insert for Neurologically Handicapped Wheelchair Patients," <i>Inter-Clinic Information Bulletin</i>, 12:10, July, 1973, pp. 7-12.</a></li> <li>Carlson, J. Martin and Payette, Mark, "Seating and Spine Support for Boys with Duchenne Muscular Dystrophy," Program and Proceedings of the Rehabilitation Engineering Society of North America, Memphis, Tennessee, June, 1985.</li> <li>Carlson, J. Martin and Winter, Robert, "The Gillette Sitting Support Orthosis," <i>Orthotics and Prosthetics</i>, 32:4, December, 1978, pp. 35-45.</li> <li>Crandall, Stephen H. and Dahl, Norman C, "Stability of Equilibrium," <i>An Introduction to the Mechanics of Solids</i>, McGraw-Hill, 1959, Chapter 9, p. 420.</li> <li>Morris, J.M., Lucas, D.B., and Bresler, B., "Role of the Trunk in Stability of the Spine," <i>The Journal of Bone and Joint Surgery</i>, 43-A:3, April, 1961, pp. 327-351.</li> <li>Nachemson, Alf L., Andersson, Gunnar, B.J., and Schultz, Albert B., "Valsalva Maneuver Biomechanics: Effects on Lumbar Trunk Loads of Elevated Intra-abdominal Pressures," <i>Spine</i>, 11:5, June, 1986, pp. 476-479.</li> <li>Rang, M, Douglas, G., Bennet, G.C., and Koreska, J., "Seating for Children with Cerebral Palsy," <i>Journal of Pediatric Orthopedics</i>, 1:3, 1981.</li> <li><a href="poi/1978_01_030.asp">Ring, N.D., Nelham, R.L., and Pearson, F.A., "Moulded Supportive Seating for the Disabled," <i>Prosthetics and Orthotics International</i>, 2:1, April, 1978, pp. 30-34.</a></li> <li>Winter, Robert B., and Carlson, J. Martin, "Modern Orthotics for Spinal Deformities," <i>Clinical Orthopedics</i>, 126:5, July-August, 1977, pp. 74-86.</li> </ol> <em><b>*David C. Wilkie, B.F.A. </b> David C. Wilkie, B.F.A., is an Adaptive Equipment Team Leader at Gillette Children's Hospital.<br /></em><br /><em><b>*Karen O. Beck, R.P.T. </b> Karen O. Beck, R.P.T., is a Senior Physical Therapist at Gillette Children's Hospital.<br /></em><br /><em><b>*John Lonstein, M.D. </b> John Lonstein, M.D., is Chief of the Cerebral Palsy Spine Clinic at Gillette Children's Hospital and a Clinical Associate Professor with the Department of Orthopedic Surgery, School of Medicine at the University of Minnesota.<br /></em><br /><em><b>*J. Martin Carlson, M.S., C.P.O. </b> J. Martin Carlson, M.S., C.P.O., is Director of Orthotics and Prosthetics at Gillette Children's Hospital, 200 East University Avenue, St. Paul, MN 55101-2598, and Clinical Instructor for The Department of Orthopedic Surgery, School of Medicine at the University of Minnesota.<br /><br /><br /></em> Page Number(s) 137 - 158 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-05.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/1986_04_137/1986_04_137-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-07.jpg Figure 8 Figure 8a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-08.jpg Figure 8b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-10.jpg Figure 10 Figure 10a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-11.jpg Figure 10b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-12.jpg Figure 10c http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-13.jpg Figure 10d http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-14.jpg Figure 11 Figure 11a http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-15.jpg Figure 11b http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-16.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-17.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-18.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-19.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-20.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-21.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-22.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-23.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-24.jpg Figure 20 FIGURE 20A http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-25.jpg FIGURE 20B http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-26.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-27.jpg Figure 22 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-28.jpg Figure 23 http://www.oandplibrary.org/cpo/images/1986_04_137/1986_04_137-29.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 Seating for Children and Young Adults with Cerebral Palsy Creator An entity primarily responsible for making the resource J. Martin Carlson, M.S., C.P.O. * John Lonstein, M.D. * Karen O. Beck, R.P.T. * David C. Wilkie, B.F.A. * https://staging.drfop.org/files/original/bc9523cd81a3db7e15e5978454317e7d.pdf 57089e6c60b72cafca746442fcb5429d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_024.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 24 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_024.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_024.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Need for Research in Fundamental Biomechanical Studies</h2> <h5>J. Raymond Pearson, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The Subcommittee on Fundamental Studies of the Committee on Prosthetics Research and Development is interested in the promotion of scientific and technological investigations that are fundamental to applied research studies of prosthetic and orthotic devices. Hopefully, the results of the subcommittee's efforts will lead to the establishment and dissemination of knowledge that is of common interest to researchers and clinicians concerned with the design and development of assistive devices.</p> <p>Past experience with such research and its current state of development suggest that future studies should be made in the areas outlined in this article.</p> <h3>Concepts of Methodology</h3> <h4>Systems Analysis</h4> <p>It is believed that the application of modern techniques of systems analysis to discern and clearly define the needs of the disabled could lead to the establishment of appropriate specifications for use in the design of devices.</p> <h4>The Disabled Condition as it Affects Experimentation and Evaluation</h4> <p>Studies of the disabled condition should include investigation of psychological reactions to the use of prosthetic and orthotic devices. Thought should be given to the interplay of psychological and physiological reactions to the application of constraints and restraints. A study of the interactions of physiological systems might prove to be beneficial since it is apparent that there is an interplay of effects from one anatomical system to another.</p> <h4>Disability Evaluations</h4> <p>Corrective assistive devices alter the joint of the musculoskeletal system. Since positions, forces, kinematics, or stresses of the original condition may be changed by the therapeutic device, it is essential that the biomechanics of the normal, abnormal, and treated condition be well understood. This information is necessary for the proper use of such devices and the design of improved devices.</p> <p>The biomechanical analysis of any system must necessarily be preceded by an adequate, accurate description of the system. If forces are involved, it is essential to know the points of application of the forces and the direction of forces applied either by muscles or by constraining passive tissues such as ligaments.</p> <p>The addition of an assistive device to any part of the anatomy results in a hybrid mechanical-anatomical system. Complete understanding of the effect of such assistive devices rests upon the proper analysis of the hybrid system as a whole.</p> <p>Analysis rests upon quantitative data which can be secured only by measurement. Taking</p> <p>such measurements often involves the design and development of the experiment and instruments. This subject in itself is a worthwhile area of investigation.</p> <h3>Specific Research Areas</h3> <h4>Fundamental Physiology Of Muscle</h4> <p>Inconvenience, negative psychological reactions, and the complexity of design of exo-skeletal devices all lead to the hope that one day it may be possible in appropriate cases to stimulate muscles which have been denervated by trauma or disease. Some research in this area has been conducted, but very little is known about the optimum type of stimulation, the response characteristic of stimulated muscle in the disabled condition, and the ultimate possibility of using electromyographic signals of one muscle to control stimulation of another.</p> <p>Since muscles represent the actuators of the musculoskeletal system, it would be helpful to know more about the mechanical characteristics of muscle in terms of its strength, endurance, and efficiency. Hopefully, modern methods of measurements would permit the accumulation of quantitative data <i>in vivo </i>if research were pursued in this direction.</p> <p>While upper and lower motor neuron lesions usually lead to atrophy of associated muscles, it has been shown that exogenous stimulation of muscle counteracts atrophy to some degree. If research should lead to solutions of this type, it will be necessary to know more about stimulative hypertrophy of muscle.</p> <h4>Body and Device Mechanics</h4> <p>Data for proper design of orthotic and prosthetic devices require a knowledge of existing force capacity and range of motion for both normal and various selected abnormal conditions of frequent occurrence. It would be of much benefit to the designers to have such data assembled in a convenient reference volume.</p> <p>More knowledge of the kinematics and kinetics of the upper extremity, comparable to that of the ambulation cycle in the lower extremity, would also represent essential and valuable data for the design of devices. The existence of accelerometers and potentiometers for measurement of inertia forces and position facilitates the gathering of such information by experimental means.</p> <p>Recent advances in the art of simulation of linkages in engineering suggest that the musculoskeletal system of the upper extremity can be treated in a manner that will permit study of the effects of constraints or supplemental power to upper-extremity orthoses. It may prove to be possible to optimize designs with regard to various possible constraints to meet the needs of common motion patterns.</p> <h4>Comparison Of Mechanical Work and Physiological Energy Consumption of Natural As Well As Pathological Movements</h4> <p>Since one of the important criteria of evaluation of assistive and prosthetic devices is the conservation of the energy of the patient, it would be most helpful to devise ways and means of measurement of physiological energy consumption of discrete muscles or muscle systems for a determinable quantity of mechanical work output in the performance of needed tasks. While total oxygen-consumption measurements have been made for subjects with and without assistive devices in ambulation, very little has been done with regard to the upper extremity, particularly for discrete activities.</p> <h4>Control Modes and Locations on Patients</h4> <p>Underlying the problem of control of external power by electromyographic signals is the problem of proper association of biological signal and motion to be executed. In the case of amputation, the existence of the electromyographic signal of a remote muscle might be used as a control signal. However, this involves a retraining procedure for the subject. The improper or irrational selection of a control site may lead to an excessively complex learning procedure that would defeat the purpose of the design. The effects of paralysis may bring about a similar situation where the cause is a pathologic condition other than amputation. In any event, the success of any external power system controlled by electromyographic signals is highly dependent upon the rational selection of the site from which the biological signal is taken. The pursuit of such knowledge is highly important to the success of electromyographic control.</p> <p>Recent investigations of the feasibility of single motor units of muscles as a source of biological signal for controlled purposes indicate the value of pursuing this idea as an eventual method of associating thought processes with limb action. Such solutions should lead to utilizing a portion of the muscle signal without impairing the usefulness of the muscle for its original intended purpose. As this study is in its infancy, considerably more information is needed in order to evaluate its potential.</p> <h4>Rheology of Human Tissue</h4> <p>In the study of the biomechanics of joints, it becomes evident that the forces applied through bones find their reactions in the soft, passive tissues of constraint. Relative displacements of the bones of the joint are then a function of the mechanical characteristics of these tissues. The stress-strain ratio of the collagen tissue of tendon has been shown to be rate dependent for low and moderate rates of loading. Also, strain is a function of time; the tissue shows a recovery capacity when unloaded, demonstrating that viscosity plays a role in the mechanism of response. Investigations of some of the factors of some discrete tissues are examples of what can and should be done in the future by way of establishing factual knowledge of the response of component tissues and joints as a whole to the types of loading brought to bear by corrective devices.</p> <p>Past achievements have demonstrated that this kind of information is also useful in detecting the reasons for certain types of deformities. Such understanding leads to better therapy and to devices designed to counteract the system of forces causing the deformity.</p> <p>It is hoped that future research in this area will bring more knowledge of the factors involved. Investigation of more of the tissues involved is also essential.</p> <p>Further studies of the mechanical characteristics of bone, especially under loadings of the type encountered in orthoses and prostheses, are, of course, part of this picture.</p> <h4>Phyiological and Rheological Characteristics of the Stump</h4> <p>In addition to knowledge of the rheological characteristics of the tissues of the stump, which is needed for the determination of pressure and tension on skin and subcutaneous tissue, knowledge of tissue compartitions and the interplay of effects of forces thereon is also necessary. Interference with the flow of blood brings deleterious effects to the health of the tissue, and faulty distribution of pressure or skin tension can affect nerves and bring pain, Knowledge of the type proposed here would assist in avoiding these dangers.</p> <p>One of the problems encountered in the fitting of prostheses is that of edema. Measurement of the pressure encountered and the deformations involved should permit compensatory procedures providing better design.</p> <p>Since rheological experimentation has shown that the stress-strain ratios are rate dependent and load dependent, it seems that special studies of the properties of compressed and deformed tissues should prove to be beneficial.</p> <h4>Response of Bone and Connective Tissue to External Loads</h4> <p>Knowledge of the nature of the distribution of stress and strain in bone as a response to the implantation of pins in the marrow, such as those encountered in endoprosthetic joints and transcutaneous pylons, will be essential if these experimental methods are to develop into practical, clinical therapies.</p> <p>The tolerance of the tissues to implantation and to the magnitudes and types of loading will also be an important factor in this research.</p> <h4>Implantation of Artificial Organs of the Musculoskeletal System</h4> <p>Another aspect of the possibility of utilizing as much as possible of the natural anatomical system instead of exoskeletal devices is the use of implanted artificial muscles. It is envisioned that plastics capable of contraction excited by external signal will become available. Study of the materials and the tolerance of biological tissues for them will be required to realize this possibility.</p> <p>The effects of implantation on endoprostheses and endoorthoses need more comprehension if materials are to be developed to make approaches practicable. This will include the chemical and physiological reactions as well as the biomechanics of the arrangements.</p> <p>Of vital importance is knowledge of the tissue reactions to implants if methods of this type are to succeed.</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>J. Raymond Pearson, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Professor of Mechanical Engineering, University of Michigan, Ann Arbor, Mich. 48104; Chairman, Subcommittee on Fundamental Studies, Committee on Prosthetics Research and Development. Professor Pearson served as Chairman of the Panel on Fundamental Studies of the Conference on Prosthetics and Orthotics.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Need for Research in Fundamental Biomechanical Studies Creator An entity primarily responsible for making the resource J. Raymond Pearson, M.S.M.E. * https://staging.drfop.org/files/original/d473917f5c93279c86fec167ec3e6f8d.pdf 52522a97179122f2dab8aa3dded039d2 https://staging.drfop.org/files/original/cd42d129793a2e44547062aae35b954c.jpg 7fa5af2ce6f8ad613bc3161879335a63 https://staging.drfop.org/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg b4f8eac8a1df5167a5581f3d8051bb22 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_04_230.pdf Text Any textual data included in the document <h2>The Relationship Between Orthotics and Gainful Employment of the Disabled</h2> <h5>J.E. Yourist, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Z.A. Latif, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />S.T. Layton, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />J.H. Bowker, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Statement of Problem</h3> <p>Physical and sensory disabilities restrict individuals from functional access to the environment.<a></a> Since our environment is best suited to the average person, losses such as these represent formidable barriers to fruitful interactions with the environment and society.</p> <p>Of special significance in this regard is the ability to function productively in gainful employment. National statistics reveal that the unemployment rate among the disabled is tenfold that of the general population (70% versus 7%).<a></a> Barring all other variables, this statistic reflects that our environment is especially inaccessible to the disabled.</p> <p>There are several factors which contribute to this serious unemployment problem.<a></a> Notable among these is the fact that the disabled are unable to return to work due to "access" deficiencies caused by the nature of their disability. In this sense "access" means to bridge the barriers to the environment imposed by physical or sensory disability (<a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg"><b>Fig. 2</b></a>). This paper deals with the probable relationships between adaptive devices and employment/economic opportunities for the disabled.</p> <h3>Probable Solutions to Access Deficiencies</h3> <p>Appropriate solutions to these "access" problems can be complex, but all necessitate the use of orthotic or adaptive devices. Typically, these devices will aid the disabled to achieve a level of performance that, at best, approaches that of the able-bodied person.</p> <p>The primary device for the severely disabled remains the wheelchair which, when appropriately prescribed and adapted, provides mobility throughout the workplace and good sitting posture for proper interface with tools at the workstation. A stand-up chair allows the worker to utilize a standard file cabinet and reach objects on higher shelving. Quadriplegics can manipulate keyboard sticks either with wrist-driven flexor-hinge orthoses if C-6 function is present or with the use of a universal utensil holder for those with C-5 function.</p> <p>The advent of high-technology electronic devices such as computers and robots has greatly expanded the horizons of the severely disabled in the workplace. These devices, which are cost and energy efficient, can transform minimum physical energy into tangible and impressive work events. A simple example is that of a quadriplegic operating a microcomputer by activating a switch by a "sip and puff" device or speech-recognition software and hardware.</p> <p>For the purpose of this discussion, it is necessary to focus on the relevance of these devices to independent living and the achievement of gainful employment for the disabled. A behavioral model for task performance may be considered which allows the definition of the necessary device required to achieve a particular task.</p> <p><a href="/files/original/cd42d129793a2e44547062aae35b954c.jpg"><b>Fig. 1</b></a> is a schematic representation of the performance of a common task by an able-bodied individual. In this illustration, an intent or desire to perform a particular task is first identified.<a></a> After assessing the person's inherent capabilities and resources, the activity can then be performed. Consequently, the immediate environment is altered, a purposeful response is made, and the consequences are appreciated.</p> <p><a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg"><b>Fig. 2</b></a> depicts the same task presented to a disabled individual. This schematic is altered to demonstrate the physical and/or sensory barriers to completing a similar task.<a></a> A disabled person may have a desire to perform this task, but may not have the same inherent capabilities or the resources as the able-bodied counterpart. At this juncture, "access" deficits to the environment become obvious. An adaptive device is required to facilitate the fulfillment of this task. One might expect the appreciation factor to be much higher compared to the able-bodied person.</p> <h3>Improvement of Function</h3> <p>For many years orthoses have been successfully fitted to restore and sustain the ability to carry out common activities of daily living. These biomechanical devices have improved the ability of the disabled person to perform such physical tasks as sitting, walking reaching, and grasping.</p> <p>Functionally, many of these activities are no different than those found in the current workplace. Those disabled persons previously employed in manual labor or manufacturing jobs would probably be displaced from their previous employment. This is due, in part, to the fact that conventional orthoses have definite limitations in their ability to replace the physical potential of the able-bodied.</p> <p>Therefore, till now, the highly disproportionate number of unemployed disabled persons does not indicate a positive correlation between employment and the use of traditional orthoses or adaptive devices. However, the emergence of microcomputer technology during the last decade has provided new potential for more effective use of these devices. Furthermore, the microcomputer can be regarded as both a biomechanical accessibility device and an employment tool which can be utilized for physical and economic rehabilitation.</p> <h3>The Change in Definition of Work</h3> <p>Our global economy is rapidly evolving from an "industrial" to an "information" age.<a></a> Jobs are becoming more knowledge-based with increasing dependence on computer technology as the sole productivity tool.<a></a> Indeed, the management of information is being realized as a central resource or commodity for jobs. Consequently, demand for manual labor is being steadily replaced by a demand for workers who can effectively manage information. In the coming decade, more than 50 percent of all jobs in this country will be found in high technology based information management. The personal computer is the principal instrument used in these jobs.<a></a></p> <p>These events are quite beneficial to those who are physically disabled, because the labor market will depend in a large degree on mental rather than physical capabilities. Coinciden-tally, the tool used in these new jobs is the same tool that can be used to access the environment: the microcomputer.</p> <p><i>Economic Rehabilitation</i></p> <p>Even in view of recent economic and technological developments, the question of the high ratio of unemployment among the severely disabled remains a serious and complex problem. In most cases, the severely disabled are displaced from their previous careers and require intensive rehabilitation to re-enter the job market. This implies that rehabilitation is certainly not complete until educational/retraining and economic goals are met to achieve financial independence. Therefore, complete rehabilitation is defined here as the process by which a person who is disabled and unemployed, can be physically and, more importantly, functionally and economically rehabilitated. This can only be achieved through a comprehensive program which includes not only conventional strategies of physical and occupational therapy, but vocational diagnostics, vocational counselling and retraining, and lastly, job placement.</p> <p><i>MEED (Microcomputer Education for the Employment of the Disabled)</i></p> <p>Appropriate vocational diagnostics and job retraining are key elements in successful economic rehabilitation. In most instances, this training has been inadequate, frequently resulting in supported job placement. Such a disincentive is often compounded by the possible loss of government-subsidized unemployment benefits and health care coverages.</p> <p>Therefore, at the University of Miami, we have developed an economic rehabilitation program based on high-technology called MEED, or Microcomputer Education for Employment of the Disabled. MEED was conceived from the federal Projects With Industry (PWI) model to pilot a high-technology approach to rehabilitative training. It is a microcomputer-based training and placement program for the severely disabled, teaching information management skills which are necessary for competitive employment in business. This training is comprehensive, job-targeted, and cost-effective.</p> <h3>Other Causes of High Unemployment</h3> <p>Although access barriers are keeping many disabled persons from the workplace, their high rates of unemployment certainly reflect a minimal relationship between employment and adaptive devices. These devices may promote job function, but may not significantly increase the chance of that person acquiring a job. Many other factors come into play, especially the social issues facing disabled individuals and the marketability of their job skills. Other factors also contribute, including: first, unavailability of suitable retraining programs; second, chronic health problems; and third, government-established major work disincentives, such as disability payments.</p> <h3>Conclusions</h3> <p>In our judgement, feasible vocational retraining approaches are needed. They must be designed to equip disabled individuals with marketable skills which are necessary for competitive employment. Partnerships among several sectors of the community are essential to make these efforts a success. These include academia, government, business and industry, and the rehabilitation and health-care communities.</p> <p>Conventional orthoses will play a significant role in complementing the function of high technology devices. For example, various splints and universal utensils will improve computer keyboard access and function.</p> <p>However, technology holds the key to the future of economic rehabilitation. We believe that the computer, particularly the microcomputer, is central to achieving this goal. The microcomputer is not only a valuable business productivity tool, but is also a vehicle through which a severely disabled individual can "access" his environment. In a sense, the microcomputer itself can be viewed as an orthotic or adaptive device. It is an extension of not only the body, but also the mind. So, in the "information age," the microcomputer is assuming a pivotal role in improving the quality of life for the able-bodied as well as, and even more importantly, for the physically disabled.</p> <p><b>References:</b></p> <ol> <li>DeJong, Gerben, and Lifchez, Raymond, "Physical Disability and Public Policy," <i>Scientific American</i>, June, 1983, vol. 248, no. 6, pp. 40-49.</li> <li>Bowe, Frank, Ph.D., "Making Computers Accessible to Disabled People," <i>Technology Review</i>, January, 1987, pp. 54-59.</li> <li>Jaffee, David, "High Technology and New 'Access Devices'" from lecture and written material at High Technology Education for Employment of Disabled Conference, Miami, Florida, March, 1987.</li> <li>Harris and Associates, Inc., <i>The ICD Survey of Disabled Americans Bringing Disabled Americans into the Mainstream</i>, March, 1986.</li> <li>Spencer, William, M.D., "Technology and Rehabilitation," lecture at Symposium on Computers in Medical Care and Education, Washington, D.C, October, 1986.</li> <li>Cornish, Edward, "The New Industrial Revolution: How Microelectronics May Change the Workplace," <i>Careers Tomorrow</i>, C. Norman, 1983, pp. 26-35.</li> <li>Cornish, Edward, "Careers with a Future: Where the Jobs Will Be in the 1990s," <i>Careers Tomorrow</i>, M. Cetron andT. O'Toole, 1983, pp. 10-19.</li> </ol> <em><b>*J.H. Bowker, M.D. </b> John H. Bowker, M.D., is a professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami Schools of Medicine. He is also the Medical Director of the University of Miami/ Jackson Memorial Rehabilitation Center in Miami, Florida.</em><br /><br /><em><b>*S.T. Layton, Ph.D. </b> S.T. Layton, Ph.D., is Associate Director of the MEED Program at the University of Miami School of Continuing Studies.</em><br /><br /><em><b>*Z.A. Latif, Ph.D. </b> Z.A. Latif, Ph.D., is Assistant Professor in the Department of Medicine and Consultant to the MEED Program at the University of Miami School of Medicine.</em><br /><br /><em><b>*J.E. Yourist, Ph.D. </b> Jay E. Yourist, Ph.D., is Assistant Professor in the Department of Medicine and the Director of the MEED Program at the University of Miami Schools of Medicine and Continuing Studies, P.O. Box 016960, Miami, Florida 33101.<br /><br /><br /></em> Page Number(s) 230 - 234 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-1.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/1987_04_230/1987_04_230-2.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 The Relationship Between Orthotics and Gainful Employment of the Disabled Creator An entity primarily responsible for making the resource J.E. Yourist, Ph.D. * Z.A. Latif, Ph.D. * S.T. Layton, Ph.D. * J.H. Bowker, M.D. * 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/c056d5b5a2d5292f7ea7a2216c435354.pdf 14428dbbc64bb672eab6dba111374692 https://staging.drfop.org/files/original/039849a9bbceb9fb919ccc08ac599212.jpg 23bca0088192426d9167c9c7d9e9d44c https://staging.drfop.org/files/original/f197722dfcff2c0aac358b6fcc12d2eb.jpg 161a1c77318b8073974e27d61d273bc9 https://staging.drfop.org/files/original/1749053d5b5f32553d0c1fe1f894c64e.jpg 3380cde244b9b2f336392b04665d1732 https://staging.drfop.org/files/original/e0887c118d00cc471ff8de5bf88811f3.jpg d25c837f996f02af2fc5e6e1f15a76c5 https://staging.drfop.org/files/original/fb3a271a31f4d3f1d7d07493673581d3.jpg cc66ef1f8e51ec73b5b2f73b2cfb26a5 https://staging.drfop.org/files/original/a0cdfd4316a17eb6233a90ae1f54727d.jpg df6536c12852883e6140ab2bd6a2eb74 https://staging.drfop.org/files/original/37a2a6c5c5b3fa090ca1aa5f15a1c855.jpg e2c8a5972b78da0ae35e57c29ead0c0a https://staging.drfop.org/files/original/2d1dd36d6e47d7c89ef2024f8633baa2.jpg 5ff571b0dd18d2ce9ae71785e9716822 https://staging.drfop.org/files/original/d5ce24b019b33092116f6dab2dcb1ad8.jpg fa9b285cc6d96d43260008b1e6983207 https://staging.drfop.org/files/original/c4ef31384fca87b5d234cd3857247810.jpg 8f8fe63d422f492829cf8f7221eac5c9 https://staging.drfop.org/files/original/a16361aca619486a85231e5bf4f67da1.jpg bddcc94158c1706f18aaa77bf8cb0a7a 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_019.pdf Text Any textual data included in the document <h2>A Partial Foot Prosthesis for the Transmetatarsal Level</h2> <h5>Jack N. Collins, C.P.O.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Traditionally prosthetists and orthotists have faced the problem of partial foot amputations with the skills, materials, and observations gained from past experiences or from others in the field. The author is not aware of any extensive research in prosthetics for partial foot amputations. Attempts to provide a suitable prosthesis have ranged from a simple toe filler with arch support, to an ankle immobilizer at P.T.B, level, and lace-on fillers of many descriptions. In the author's observation, any prosthesis that goes above the ankle results in the buildup of unwanted forces.</p> <p>The late Charles Childs, C.P.O.,<a></a> made the greatest breakthrough in partial foot prostheses. I attended his seminar in late 1978 and was very impressed with the entire approach demonstrated, especially the cosmesis and fit at shoe level height. Unfortunately, after a few weeks wear, the rubber material used in the fabrication of the prosthesis did not retain its shape and support against the extreme forces exerted in walking. The forces developed on the short lever arm, the foot, in walking are greater than at any other level of amputation. These forces applied in walking and running are not confined to the plantar surface of the residual foot, but are transmitted in part to the entire surface of the prosthesis. In turn, some of these forces are applied to whatever footwear is worn. Thus, the footwear applies a resistant force to the prosthetic appliance, quite often to the detriment of the appliance and the residual foot.</p> <p>It must be stated at this point that the prosthesis about to be described has not been evaluated with foot amputations at the Lisfranc or Chopart level, but only on transmetatarsal level. And from our limited experience, developed over the past 7 to 8 years, a mid-trans-metatarsal amputation presents fewer problems in toe-off than amputations at a greater or lesser length. With this in mind, the evaluation, casting, and fabrication techniques used will be described.</p> <h3>Evaluation, Casting and Fabrication</h3> <p>Evaluation is made in routine manner, for amputation level, range of motion at ankle, contractures, cut bone covering, abrasions, callosities and sensitive areas.</p> <p>With patient seated in a chair, invaginate a casting balloon over the residual foot with a short piece of plastic tubing on the dorsum of the foot. Mark with indelible pencil all boney prominences, callosities and sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg"><b>Fig. 1</b></a>). Very carefully roll on a 4" roll of plaster in a manner to cover the entire foot to the inferior edge of the lateral malleoli and with a thickness sufficient to retain its shape on removal. While the plaster is still soft, have the patient place his foot on the floor, with the knee at 90°, foot in neutral position (not in valgus), and with the weight of the leg on the plaster. Make marks with indelible pencil on the cast at 90° across the plastic tube. With a cast saw cut down the tube to remove the cast. If care is taken in applying the plaster, you will have a very smooth and detailed cast on removal (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg"><strong>Figure 1. Foot ready for casting with casting balloon and plastic tubing in place.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg"><strong>Figure 2. Cast removed</strong></a><br /> <p>Close the cast carefully with plaster wrap, apply the release agent, and pour the cast with mandrel in place about 45° to vertical. This makes it easier to apply P.V.A. and stockinette. Remove the plaster wrap from the model.</p> <p>Very little modification should be necessary. Add about 1/8" plaster buildup over the boney prominence at the distal end and over any callosities or other sensitive areas. It is not necessary to modify as in the U.C.B.L. Shoe Insert casting method. Using a Scarpas knife, remove about 3/16" to 1/4" plaster from the plantar surface 1/2" proximal to the metatarsal ends, the width of the metatarsals, and taper in the direction of the heel about 1" to 1 1/2" depending on the size of the foot. The anterior edge of cut should have a 5/16" radius (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg"><b>Fig. 3</b></a>). Dry or seal the model.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg"><strong>Figure 3. Modified positive model</strong></a><br /> <p>Pull on one layer of nylon stockinette to allow for the patient's sock. Pull the P.V.A. over cast for vacuum. Tailor a piece of 1 oz. Dacron felt to cover the plantar surface. The felt should extend over the anterior distal end, laterally to cover the base of the 5th metatarsal, and medially to cover the scaphoid prominences. Sew one end each of four lengths of nylon stockinette and pull on the model with the Dacron felt in place. On heavier more active patients, one layer of woven glass reinforcement is added between the felt and stockinette. When pulling on the stockinette, take care not to pull out the stretch of the stockinette. The stretch needs to be retained in the silicone laminated areas to allow donning. Take two 4" P.V.A. sleeves and cut 12" long pieces from the small end of each to make feeder tubes. Apply a 6" moist P.V.A. sleeve to the model so as to give a smooth surface all over. Do not tie off the ends, but do dry with a heat gun. Use a tongue depressor to push the small end of one of the feeder tubes under the P.V.A sleeve at the heel of the model. The tube should be about 3/8" from the plantar surface of the heel. In the same manner, position the remaining feeder tube under the P.V.A. sleeve over the dorsum of the model. The tube should be about 3/8" from the proximal edge.</p> <p>Roll a 1" wide by 6" long piece of 1/16" thick polyethylene into a funnel and place in the open end of one of the tubes (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg"><b>Fig. 4</b></a>). Mix 80 grams of Dow Corning 382 silicone with 2 or 3 drops of appropriate color and catalyze as directed by Dow Corning, pour into the funnel and very carefully squeeze into the stockinette. On the dorsum of the foot, laminate the section the shoe lace will cover, or a little more area. Squeeze with your finger tips to get a thorough and even penetration working the Silastic, laterally, and distally down to, but not onto the plantar surface. Working with the fingers gives better penetration without spreading the resin to unwanted areas. After this has cured, repeat in the same manner posteriorally. The posterior portion should extend distally down the back of the heel to the sole and anteriorally along the proximal trimline for a width of 1" distal of the trimline so that it meets the posterior border of the anterior lamination medially and laterally (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg"><b>Fig. 5</b></a>). When the posterior portion has cured and both feeder tubes have been removed, tie off the pipe end of the 6" P.V.A. sleeve and pour in 150 grams of 4110 Laminae that has been catalyzed and pigmented. Saturate the remaining lamination and maintain it under a vacuum until cured. While the polyester is still warm, trim to the shoe top level and remove the prosthesis from model (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg"><b>Fig. 6A</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg"><b>Fig. 6B</b></a>). The prosthesis is now ready for fitting.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg"><strong>Figure 4. Completed layup with P.V.A. sleeve and feeder tubes in place</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg"><strong>Figure 5. Initial phase of lamination. Dorsum and proximal border of socket have been laminated with Dow Corning 382 Silastic.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg"><strong>Figure 6A. Socket completed and removed from model, medial view</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg"><strong>Figure 6B. Lateral view</strong></a><br /> <p>In weight bearing, check for comfort, undue pressure, and position of the foot. More than likely it is in some valgus, as any foot amputated proximal to the head of the first metatarsal loses its medial support. With small wooden wedges, you can determine the amount of posting needed under the distal end of the first metatarsal to hold the foot in a neutral position. When this has been done, mix a small amount of thickened polyester and add it to the distal plantar surface of the first metatarsal area to establish the desired position. When comfort and fit have been achieved, the prosthesis is ready to be completed.</p> <p>Obtain a shoe from the patient for foot sizing. Take a plaster wrap of the distal portion of an appropriately sized S.A.C.H. foot. When the plaster on the S.A.C.H. foot has cured, remove it from the foot, and inspect the inside for smoothness. Fill any voids and smooth nicely. Dry the plaster and paint the inside with ambroid or celluloid. Spray the inside of the toe cast with silicone release agent.</p> <p>Rivet with two #12 copper rivets, all" long by 1 1/2" wide .0035 thick blued steel spring, that has been shaped to the contour of the inside surface of the shoe sole, to the plantar surface of the socket. Shear off the distal portion of the spring so it ends about 1" from the toe. Drill a hole for a #12 copper rivet and rivet on a small "U" shaped piece of leather to act as an anchor for the silicone toe piece (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg"><b>Fig. 7</b></a>). Drill 1/2" hole in the distal plantar surface of the toe cast. Wipe the anterior surface of the prosthesis with acetone. It must be clean. Fit the plaster shell over the spring and anterior portion of the prosthesis as far proximal as necessary to obtain proper foot length. Be sure the spring or leather anchor does not come in contact with the inside of the plaster mold. When properly positioned, solidly tape the plaster wrap to the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg"><b>Fig. 8</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg"><strong>Figure 7. Socket with toe spring and leather anchor rivetted in place</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg"><strong>Figure 8. Socket and plaster toe mold</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg"><strong>Figure 9. Toe mold taped in place</strong></a><br /> <p>Mix 65 grams of Dow Corning #382, 5 grams Dow Corning Q74290 Prosthetic Foam, and 2 or 3 drops of appropriate pigment. Catalyze and pour slowly into the 1/2" hole in the toe. Stand the assembly on the back of the heel, toe up, and support it in this position until foamed and cured. When the foam has cured, carefully use a thin instrument to pry the silicone toe gently loose from the plaster. It should come off with little effort. Depending on the smoothness of your plaster toe mold, the release agent used, and the foam mixture, the prosthesis should be very presentable (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg"><b>Fig. 10</b></a>). If it is rough and has air holes, sand it smooth and paint on a coat of Pigmented Dow Corning #382.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg"><strong>Figure 10. The completed prosthesis</strong></a><br /> <h3>Summary</h3> <p>The rigid control of the residual foot, yet flexible entry and toe off, together with good patient acceptance, cosmesis, and wearibility makes this type prosthesis our choice in the prosthetic management of transmetatarsal amputations. We call this the C.O.S.I. Partial Foot Prosthesis (Collins Orthopedic Service, Inc.).</p> <h3>Addendum</h3> <p>It is the author's opinion that Lisfranc and Chopart level amputations could be approached in a similar manner by extending the distal support and point of toe off to a more normal position. However, this opinion is not based on personal experience with using the C.O.S.I. Partial Foot Prosthesis to fit these level amputations. This would require some thought and quite a bit more effort in the lamination procedure.</p> <p><b>References:</b></p> <ol> <li>Childs, Charles, Pacific Orthotic and Prosthetic Services, 111 East First Street, Medford, Oregon 97535.</li> </ol> <em><b>*Jack N. Collins, C.P.O. </b> Jack N. Collins, C.P.O., is with Collins Orthopedic Service, Inc. 2875 Joyce Street, Fayetteville, Arkansas 72703.<br /><br /><br /></em> Page Number(s) 19 - 23 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 6A http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg FIGURE 6B http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.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 A Partial Foot Prosthesis for the Transmetatarsal Level Creator An entity primarily responsible for making the resource Jack N. Collins, C.P.O. *