9 20 371 https://staging.drfop.org/files/original/694c8659897265452c14e9ca3192624d.pdf 58cc45863e2c275da7497de4ff593ec2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_013.pdf Text Any textual data included in the document <h2>Innovation and Improivement of Body-Powered Arm Prostheses: A First Step</h2> <h5>Maurice A. LeBlanc, M.S.M.E., CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Standard body-powered upper-limb prostheses have not changed significantly since developments in the 1950's which were spurred by World War II. They still employ aircraft technology using shoulder harnesses and steel cables for operation. If one looks at the Manual of Upper Extremity Prosthetics first edition (1952)<a></a> and the Orthopaedic Appliance Atlas—Artificial Limbs first edition (1960)<a></a> compared with 1985 state of the art, one will not find a great deal of change. It is the consensus of several leading prosthetists in the U.S. that many arm amputees are being led into purchasing externally powered arm prostheses because they look more modern and "hi-tech." Present body-powered arm prostheses simply do not offer a good alternative. They look more archaic, and the shoulder harnesses are uncomfortable and restrictive. Body-powered systems have more sensory feedback and generally are more functional (for unilaterals) than externally powered systems.<a></a> However, little or no research is being conducted to improve body-powered arms. More and more amputees are opting for externally powered prostheses,<a></a> and the gap is getting larger between the two types. Estimates of population in the U.S. place the number of upper-limb amputees at about 100,000.<a></a> Of the 50,000 arm amputees estimated to be wearing prostheses, surveys of prosthetic facilities suggest the following levels of amputation: 58% below-elbow, 27% above-elbow, and 15% at the hand/wrist and shoulder.<a></a> Of prostheses being worn, educated guesses suggest that the percentage of externally powered prostheses has increased from five to 10% in the past five years.<a></a> It is the desire of the author to undertake work to effect innovation in body-powered arm prostheses toward the ultimate goal of increasing the acceptance and use of "conventional" upper-limb prostheses for arm amputees in the U.S. Other people have stated this need.<a></a> The author has received support to conduct a one-year study of feasibility for accomplishing the above goal. As a first step, the author has conducted a survey to verify needs and priorities of arm amputees in order to give guidelines for future work. <h3>Conduct Of Survey</h3> Arm amputees and professionals were contacted to assess what wearers like most and like least about their prostheses. Also, ideas for change were solicited. A questionnaire was prepared to provide a standard format, and 30 people were contacted in person or by phone to complete the questionnaire. The people were: <blockquote> 17 amputees 8 prosthetists 3 occupational therapists 2 VA prosthetic reps (also arm amputees) 30 total </blockquote> Of the 17 arm amputees, there were: <blockquote>10 adults and 7 children 13 males and 4 females 14 unilaterals and 3 bilaterals</blockquote> <h3>Results Of Survey</h3> The survey included 11 questions. Results are reported below with the numbers of responses shown. (Some totals exceed 30 because respondents gave two or three answers per question.) <ol> <li> What do you like most about your prosthesis? Most frequent answers: <ul> <li> Function: 17 </li> <li> Reliability: 9 </li> <li> Symmetry/body image: 6 </li> </ul> </li> <li> What do you like least about your prosthesis? Most frequent answers: <ul> <li> Axilla/harness uncomfortable: 10 </li> <li> Appearance poor: 9 </li> <li> Socket hot: 5 </li> </ul> </li> <li> <ol> <li> Is the harness/cable control system satisfactory? 13—Yes, 16—No </li> <li> Does this type of control system need improvement? 25—Yes, 4—No </li> </ol> </li> <li> <ol> <li> Are the harness and socket comfortable? 12—Yes, 17—No </li> <li> Does the general comfort need improvement? 25—Yes, 4—No </li> </ol> </li> <li> <ol> <li> Do the motions and terminal device give you enough function? 11—Yes, 18—No </li> <li> Does the function of the prosthesis need improvement? 29—Yes, 0—No </li> </ol> </li> <li> <ol> <li> Are you pleased with the appearance? 11—Yes, 19—No </li> <li> Does the general appearance need improvement? 25—Yes, 5—No </li> </ol> </li> <li> Rate the following four aspects of your prosthesis in importance to you (1 = most important and 4 = least important) <blockquote> Average Scores: Function: 1.53 Comfort: 1.85 Appearance: 2.79 Control system: 3.53 </blockquote> </li> <li> Any other general complaints of this type of prosthesis?—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later. </li> <li> Any other ideas for improvement you would like to see worked on?—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later. </li> <li> If you could dream and create your own perfect prosthesis, what would it look like? Most frequent answers: <blockquote> Natural/normal: 12 Soft/smooth endoskeletal: 11 More function in fingers and wrist: 9 </blockquote> </li> <li> Do you want your prosthesis to look as normal as possible or would you prefer to have some fun with the appearance in colors and designs? Most frequent answers: <blockquote> Want it to look normal: 21 Want to have some fun with it: 4 </blockquote> </li> </ol> <h3>Miscellaneous Considerations</h3> In talking with each of the 30 people surveyed, a number of interesting comments were made which deserve consideration. <ul> <li> The prosthesis is not a second best arm but something different to itself and should have form and beauty for its own sake. </li> <li> While most people stated the goal of having a prosthesis which looks natural, they asked for one which is smooth, inconspicuous, natural in motion, fast, quiet, and streamline rather than asking for a prosthesis which looks human. </li> <li> Several people visualized having an arm transplant or regeneration. </li> <li> A couple of people talked about "functional appearance" or having a prosthesis which is dynamically alive and not dead looking. </li> <li> Many people expressed a desire for a prosthesis which is soft inside, adjusts to the body, feels like part of the body, and feels flexible. </li> <li> Cleanliness is a big issue with a harness, sockets, and prosthesis exterior. Some expressed the desire for throw-away parts and coverings. Also, it is difficult for bilaterals to clean their prostheses when doffed. </li> <li> Bilateral amputees stressed the importance of using their feet as well as the prostheses. There is more dexterity and sensory feedback for function and a preference for using feet except where social situations dictate using the prostheses. </li> <li> Several amputees stressed the importance of the sensory feedback/proprioception inherent in body-powered arm prosthesis. A few voiced the opinion that increased sensory feedback would provide increased function even with present components. </li> <li> A few parents confirmed the desire for very early fitting of infants for various reasons: body image, balance, symmetry, acceptance and function. One parent felt strongly that an infant should have an arm prosthesis because "the brain is looking for a hand" and it affects the growth/development of the child. </li> <li> While the author was conducting interviews with amputees, many of them asked the author for current information about arm prostheses and components. It was clear that some prosthetists are not fully informing amputees of their options and including them in the decision-making process. </li> <li> A few prominent professionals stated very strongly the importance of the prosthetist conducting a very thorough evaluation with the amputee prior to any prosthetic prescription and fitting. It provides the opportunity for the prosthetist to use his/her ingenuity to truly meet the needs of the amputee. </li> <li> Clinic teams sometimes make decisions on prosthetic fitting in five minutes, which is insufficient time to conduct a thorough evaluation. </li> <li> Central fabrication also can be a detriment to successful prosthetic fitting because standard components are applied by a third party without direct amputee contact, thereby reducing the incentive and likelihood for creative and individual solutions to amputees' needs. </li> <li> Education of prosthetists focuses mainly on the mechanics of fabricating prostheses with available components rather than looking comprehensively at the amputee as an individual with special needs. They "follow the book" too much and are "too rigid in prescribing." </li> <li> The success of upper-limb prostheses depends heavily on the skills of the prosthetist. It is too dependent on individuals. It would be beneficial if systems were more modular whereby they would be easier to fit, and performance could be predicted better. </li> <li> Two trends which seem to be gathering professional concurrence are (1) to fit an arm amputee within the "Golden Period" of 30 days after amputation and (2) to fit all arm amputees with a conventional, body-powered prosthesis first.<a></a> </li> </ul> <h3>Conclusions</h3> Function is clearly the most important feature which amputees want and expect from upper-limb prostheses. While the results may be biased because the survey was of body-powered wearers versus myoelectric wearers with hands, the numbers and opinions overwhelmingly emphasize function first. Uncomfortable harness and poor appearance were a close first and second for the most negative feature of arm prostheses. Body-powered arm prostheses need improvement across the board. When making changes, the upper-limb prosthesis should be viewed as a whole system rather than just looking at components. Amputees want a natural moving, pleasant appearing, inconspicuous prosthesis which does not necessarily have to look human. The questionnaire demonstrated a good cross check in validating what amputees and professionals said with how they rated the various aspects of upper-limb prostheses. There has been a great deal of encouragement from amputees and professionals to work on the improvement of body-powered systems. All are anxious to see some innovation and positive change. <h3>Acknowledgment</h3> This work is being supported by Research Fellowship #133FH40021 from the National Institute of Handicapped Research, US Department of Education. References: <ol> <li><a href="poi/1981_02_092.asp">Agnew, P.J., "Functional Effectiveness of a Myoelectric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," Prosthetics Orthotics International, Vol. 5, No. 2, August 1981.</a></li> <li>Aylesworth, R. Deane, Editor, Manual of Upper Extremity Prosthetics, Artificial Limbs Project, University of California at Los Angeles, 1952.</li> <li>Childress, Dudley S., Ph.D., Director, Rehabilitation Engineering Center, Northwestern University, Chicago, Illinois, personal communication, April 1984.</li> <li>Cottenden, A.M.; B. Stocking; N.B. Jones; S.L. Morrison and R. Rothwell, "Biomedical Engineering-Priorities for Research in External Aids," Journal of Biomedical Engineering, Vol. 3, October 1981.</li> <li>Epps, Charles H., Jr., M.D., "Prosthetic-Orthotic Research-A New Thrust Is Needed: A Clinician's Perspective," Clinical Prosthetics and Orthotics, Vol. 8, No. 1, Winter, 1984.</li> <li>LeBlanc, Maurice A., M.S., CP, Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," Orthotics and Prosthetics, Vol. 27, No. 3, September, 1973.</li> <li>Malone, J.M., M.D.; L.L. Fleming, M.D.; J. Rober-son, M.D.; T.E. Whitesides, Jr., M.D.; J.M. Leal, CP; J.V. Poole, O.T.R. and R. Sternstein Grodin, O.T.R., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," Journal of Rehabilitation Research and Development, Veterans Administration, May, 1984.</li> <li>National Center for Health Statistics, US Department of Health and Human Services, "Prevalence of Selected Impairments-United States-1977," Series 10, No. 134, February, 1981.</li> <li>Orthopaedic Appliance Atlas-Volume 2-Artificial Limbs, American Academy of Orthopaedic Surgeons, J.W. Edwards-Publisher, 1960.</li> <li>Stein, R.B. and M. Walley, "Functional Comparison of Upper Extremity Amputees Using Myoelectric and Conventional Prostheses," Archives of Physical Medicine, Vol. 64, No. 6, June, 1983.</li> <li><a href="http://www.acpoc.org/library/1983_04_009.asp">Trost, Francis J., M.D., "A Comparison of Conventional and Myoelectric Below-Elbow Prosthetic Use," Inter-Clinic Information Bulletin, Vol. 18, No. 4, Fall, 1983.</a></li> <li>Veterans Administration, Rehabilitation Research and Development Service, National Workshop on Prosthetics and Orthotics, Washington, D.C, April 27-28, 1983.</li> </ol> <div style="width: 400px;">*Maurice A. LeBlanc, M.S.M.E., CP. Maurice A. LeBlanc, M.S.M.E., CP. is with the Rehabilitation Engineering Center at Children's Hospital at Stanford, Palo Alto, California 94304. </div> Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Innovation and Improvement of Body-Powered Arm Prostheses: A First Step Creator An entity primarily responsible for making the resource Maurice A. LeBlanc, M.S.M.E., CP. * https://staging.drfop.org/files/original/aafea6cea49faeadc6dba48217d2ee06.pdf 1144c6f189f7e6d76ebed402cfb5d44c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_017.pdf Text Any textual data included in the document <h2>Externally Powered Prostheses for Children: 1984</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration: none;">*</a></h5> Not so many years ago children with upper limb deficiencies who appeared in our clinic with body powered prostheses asked for an arm like the one used by the six million dollar man. The television character routinely performed miraculous feats of strength and prehension that made the body powered prostheses look primitive by comparison. I was unable to satisfy such requests at that time. Now, at least for some patients, the long sought externally powered fitting is possible. The available arms do not approach that of the six million dollar man, but we have the means of fitting the below-elbow patient with a myoelectric prosthesis that is gratifying to patient and parents. In our own setting, two factors have converged to make this possible. First, the most important development in our clinic has been the affiliation of the local Variety Club, which established a Limb Bank. The concept is simple, the Variety Tent raises funds for myoelectric limbs, component parts and services. In some cases, the cost of the entire prosthesis is underwritten; in other situations Variety pays the balance not covered by insurance depending upon family finances. There are also components and spare parts available for repairs, courtesy of Variety. Such components keep the down time to a minimum and eliminate the need for two myoelectric prostheses. This arrangement developed between the Juvenile Amputee Clinic (Maternal and Child Health and Crippled Children's Services) at D.C. General Hospital and Washington, D.C.'s Variety Tent Number 11 is an example of how a public-private relationship can benefit the patient. Variety Tents are operational in Grand Rapids, Michigan; Memphis, Tennessee; Detroit, Michigan; Los Angeles, California; Toronto, Canada and other cities. Secondly, the technology has been available for a number of years, but we delayed because of the cost of myoelectric fittings and because the policies of many insurance carriers did not include such devices. It seemed undesirable to fit a child if one could not reasonably expect to continue with subsequent fittings and provide timely repairs. Sörbye in 1971 was among the first to apply myoelectrics to the young preschool amputee. His group operating in the government support health system in Sweden overcame these same problems by providing each patient with two prostheses. The second remained on the shelf as a back-up limb when the first needed repairs. In this manner, down time was eliminated and the child was not without the prosthesis. In the United States there has been a recent change in the policies of many third-party insurance carriers. Today, most will provide funds not only for the initial prosthesis but for replacements and necessary repairs, a not inconsequential cost. Some insurance companies pay total cost while others pay a fixed percentage. <h3>External Power</h3> Over the years, a number of battery powered switch operated devices have become available. The Michigan Feeding Arm was specifically designed to assistance in eating activities and was the first externally powered device developed in the United States for the pediatric age patient. In the early 1970's the Ontario Crippled Children's Center developed the OCCC Coordinated Arm. This was followed by the OCCC Elbow. Both were operated by switches and were designed for the 4-10 year age group. The Michigan Electric Hook (10x size) appeared in 1973 and was appropriate for the child approximately 2-10 years. Its successor, the Michigan Area Child Amputee Clinic Hook (MACAC) (10x size) was an improved version of the earlier hook designed for the same age group. In 1977 we saw the advent of a second elbow, the NYU Motor Lock Elbow, sized for a child six to a small teenager. This item remains experimental. To overcome the objectionable operational noise of the previous powered elbows, the NYU "Hush" Electric Elbow was developed in 1982. A versatile unit, it can be operated by push button or harness pull. Complimenting this armamentarium is the switch operated NYU Prehension Actuator (1982) which is applicable to any cable voluntary opening terminal device. More recently, the Utah Elbow was developed for the adult population but may be used with a child about age 12 years; it can be used with any terminal device and utilizes a dual site myoelectric system. <h3>Myoelectric</h3> The available myoelectric devices also offer a spectrum of choices. There is the University of New Brunswick System which is appropriate for ages 12 and up. This unit uses a surface electrode over one muscle. A small contraction is for closing and a strong contraction for opening. Relaxation of muscle contraction stops the hand at the current position. Sweden contributed the Systemteknik hand in two sizes; 2-6 years for the small child and 5-9 years for the larger child. The unit utilizes a single or double myoelectric electrode. The Steeper hand produced in England has the same size and age indication and similar choice of myoelectric controls. The German contribution is the Otto Bock System covering ages nine to adult with a dual myoelectric site system. These units are expensive but commercially available. The absence of a myoelectric unit developed in the United States is conspicuous. This array of devices presents a challenge to the physician prescribing external power for his patient. There are wide differences in the weight which may be crucial in the young patient with a short stump. However, all are heavy when compared to the body powered prostheses. The battery systems vary from 5 volt to 12 volt with varying useful life after charging. The prescription, therefore, is best written as a collaborative effort by the physician, the prosthetist, and the occupational therapist who has evaluated the patient and will provide the training. <h3>Patient Benefit</h3> After witnessing the satisfaction of the patient and parents after a successful fitting has been accomplished, there is no doubt that external power is preferred over body power in most instances. Function seems more natural when hand opening and closing are controlled by forearm extensor and flexor muscle activity. It is obvious that the psychological benefit of the cosmetic effect is profound on patient and parents alike. The dramatic change can be seen even with the initial application of the arm. External power and myoelectric applications are now state-of-the-art in below elbow cases and should be made available to all who have the interest and proper indications. <h3>The Challenge</h3> There is still much to be done for the amelia and the high above elbow amputee. Efforts must continue to bring the maximum degree of function to patients who are less well served at present. The numbers of patients in this category are small and there are not the normal incentives to manufacturers to expend funds for research and development in this area. The Federal Government may have to support the requisite research to accomplish the necessary break-through. It is ironic that the below elbow patient who enjoys reasonably good function with conventional prostheses would benefit most from the new technology. This is explicable when we realize that this level of limb deficiency makes the task easier. Although the numbers of high level deficiency patients by contrast is small, the need is great. We must continue to work for solutions for these patients who remain underserved at this time. *Charles H. Epps, Jr., M.D. Charles H. Epp, Jr., M.D. is Professor and Chief at the Division of Orthopedic Surgery at Howard University Hospital, 2041 Georgia Avenue, N.W., Washington, D.C. 20060. Page Number(s) 17 - 18 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally Powered Prostheses for Children: 1984 Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/3eac73a4c08366301177654204d8badb.pdf 6c0ab74d419d52358a0371839fc85799 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_023.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Management Hybrid Design Approaches</h2> <h5>John N. Billock, C.P.O. <a style="text-decoration: none;">*</a></h5> With the advent of electric powered components and control systems in the past 20 to 25 years, there has been considerable transition in the prosthetic management and rehabilitation of individuals with traumatic and congenital upper limb deficiencies. Furthermore, it has only been within the past 5 years that electrically powered upper limb prostheses have gained clinical acceptance in the U.S. There now exists a complex variety of approaches from which the prosthetics practitioner must choose, in order to provide appropriate prosthetic restoration services. Along with the traditional variety of bowden cable control systems for actuating mechanical components, there now exists a number of myoelectric and switch control systems for use with electrically powered hands, wrists, and elbows. The introduction of these new components and control techniques has greatly increased the complexity of designing an appropriate upper limb prosthesis. As a result, some researchers and manufacturers have worked to develop total systems for the various levels of upper limb deficiencies. These systems generally are designed around a modular concept, where the batteries, electronics, electrodes, etc., are packaged as individual modules for easier handling and assembly. They also utilize a common electrical connection system, which may or may not be compatible with other components and control systems. The modular systems approach reduces the overall complexity in designing prostheses. However, it does not always provide the patient with the most appropriate prosthesis when his individual physiological and psychological needs are considered. It is in such a situation that thought must be given to the possibility of developing a hybrid prosthesis. A hybrid designed prosthesis utilizing components and control methods from various "systems" can, in many cases, enable the prosthetist to design and develop a prosthesis which is more functional and acceptable. The hybrid design approach becomes even more important when managing individuals with upper limb deficiencies above the elbow and higher. Many cases require a combination of electrically powered components that are switch and/or myoelectrically controlled and mechanical body powered bowden cable controlled components. A classical example of this situation occurs in the design of an above elbow prosthesis for an individual with a distal humeral deficiency. A limb deficiency at this level generally does not require the use of an electrically powered elbow since the individual should have sufficient range of motion at the shoulder joint and adequate muscle strength to control a mechanical elbow. A myoelectrically controlled hand introduced into the design of the prosthesis, for this level, can significantly improve it's functional capabilities and aesthetics. This particular hybrid design allows the individual to simultaneously control the elbow and hand rather than sequentially. It has been the author's experience that individuals with this particular design infrequently utilize the mechanical elbow lock to maintain the hand and forearm in a fixed locked position for functional activities. Rather, the elbow is allowed to flex freely and is held momentarily stable with cable tension. The overall control of the prosthesis is more natural since use of the elbow lock is not necessary the majority of the time. Unfortunately, many of the electric powered components and control systems are not designed for hybrid use even though they may have application. In many cases, they are not compatible and require electronic and/or mechanical changes before they can be incorporated into an appropriately designed prosthesis which best meets an individual's needs. Prosthetists of today must expand their technical expertise and knowledge in the areas of electronics and engineering to meet this challenge. With all the complexities surrounding the design and development to today's upper limb prostheses, this additional technical expertise and knowledge becomes even more essential when assessing and evaluating the particular needs of a patient. The clinical assessment and evaluation of individuals with upper limb deficiencies should involve a careful study of their psychological, as well as their psychological needs. All too often, this is an area of overall prosthetics management that receives too little attention. In the author's opinion, it is an essential foundation for successful prosthetic management and rehabilitation. The psychological aspects of an upper limb amputation and its resulting disabilities are too often considered secondarily when determining what will be the most appropriate prosthesis for an individual patient. As professionals, we tend to stress function over aesthetics, when in fact, a primary concern of the majority of patients is the appearance of the prosthesis. These psychological aspects are the greatest barriers an individual patient must overcome if successful prosthetic management and rehabilitation is to be achieved. Their personal acceptance of their disability and motivation to return to society is essential for successful rehabilitation. Their reaction to the prosthesis plays a major role in this acceptance and motivation. The reaction of their immediate family and friends also plays an important role in their acceptance of the prosthesis. Many patients have rejected a prosthesis not because of their own personal feelings, but because of the reaction of others. This is most apparent in the management of children with congenital upper limb deficiencies, since in most situations when the child is under the age of 5, you are managing the parent's desires and not the child's. If the parents have difficulty accepting the child's disability or the prosthesis, they will not encourage normal development and use of the prosthesis. Unfortunately, because many profesisonals are not responding to the psychological needs of the parents, many children are going with a prosthesis today. With adequate information gathered in the initial prosthetic evaluation, further clinical assessment and evaluation procedures should be carried out to determine the most appropriate interface design, control source, and components to be used in the fabrication of the prosthesis. These procedures initially involve the development of a test interface (check socket) for determining the best fitting and suspension techniques to be utilized in the prosthesis. A variety of interface designs and suspension techniques exists for both adults and juveniles at all levels of upper limb deficiencies. All require the development of an appropriate test interface. The development of a test interface is also necessary for use in establishing definitive E.M.G. potential sites when myoelectric control is being considered. When the E.M.G. potential are not adequate or when the patient requires further E.M.G. training, the test interface becomes essential for maintaining consistent placement of the electrodes relative to muscle stress. Further, the test interface allows the practitioner to evaluate a variety of optional control sources and components by developing a test prosthesis around it. This allows pre-prosthetic training and evaluation of the prosthesis in a variety of configurations before the development of a definitive prosthesis. The use of a test prosthesis is essential in evaluating "hybrid" and "system" design approaches for the definitive prosthesis. Myoelectric control systems vary considerably depending on the desired function and availability of adequate muscle sites. In some cases, it is necessary to utilize more than one type of myoelectric control system to achieve the desired functions in a prosthesis. Some systems utilize a single E.M.G. potential from a single site to control a single function, such as in the traditional Otto Bock or Veterans Administration/Northwestern University (VANU) myoelectric control systems. This type of control system would, therefore, require two E.M.G. potential sites to control two functions, such as, hand opening and hand closing. It is suggested that this type of system should commonly be referred to as a "2-site/2-function myoelecric control system." Another system may utilize a single E.M.G. potential from a single site to control two functions, such as in the University of New Brunswick system. This system utilizes one E.M.G. potential site to control two functions. In this type of system a light or low level contraction produces one function and a strong or high level contraction produces another function. It is suggested that this type of system be referred to as a "l-site/ 2-function myoelectric control system." Yet another system may utilize two E.M.G. potentials from two sites to control multiple functions, such as in the Utah Artificial Arm elbow-hand system. This system utilizes two E.M.G. potential sites to control five functions. In this system a single E.M.G. potential from each site (biceps and triceps) controls one function in each electric powered component (hand and elbow), while a co-contraction of both muscles together unlocks the elbow, switching from hand control mode to elbow control mode. It is suggested that this myoelectric control technique be referred to as a "2-site/5-function myoelectric control system." Switch control systems also vary depending upon the desired function and availability of body motions to actuate them. In many cases, in order to provide the desired functions in a switch controlled prosthesis, various types of switch control systems must be incorporated, achieving a hybrid design approach. The most commonly used switch control systems utilize a pull type switch which is actuated by a single body motion to actuate two functions, such as hand opening and hand closing. It is suggested that this switch control technique be referred to as a "1-motion/2-function pull switch control system." Another type of system utilizes a push button type switch, to operate the opposing function. It is suggested that this switch control technique be referred to as a " 1 -motion/1-function push button switch control system." Yet another type of system utilizes a rocker type switch which is actuated by two body motions to actuate two functions in the prosthesis, which in most cases oppose each other. It is suggested that this control technique be referred to as a "2-motion/2-function rocker switch control system." When body motion is being used to actuate a bowden cable control system in a hybrid manner along with switch and/or myoelectric control, it should always be remembered to activate the mechanical component with the primary body motion available. The theory behind this approach is that a bowden cable control system requires significant muscle activity and body motion to produce the force and excursion necessary to actuate a mechanical component. Myoelectric and switch control systems require less muscle activity to produce the force and excursion necessary for actuation of an electric component. The choice of controls utilized in the design and development of an upper limb prosthesis should involve a careful study of an individual's particular needs. Since the terminal device is the most important component of the prosthesis, it is necessary to choose a control technique which will provide the most appropriate actuation of that device. It is felt that myoelectric control provides the most physiological and natural source of control and that whenever possible, it should be given primary consideration. Furthermore, the majority of individuals with upper limb deficiencies generally prefer a hand as a terminal device. In many cases, this desire may be purely psychological, and as professionals we should respect that need. The majority of individuals with upper limb deficiencies are unilateral with the prosthesis obviously becoming the nondominant side. Therefore, it is important that the prosthesis first meet the individual's psychological needs, and secondarily, that it be easily controlled and provide adequate prehension for stabilizing objects, which is the primary function of the non-dominant side during bilateral hand activities. This would obviously seem to indicate that myoelectric control, which best utilizes the residual neuro-muscular system, and an electric powered hand, which provides forceful prehension, should be the first choices in developing a functional prosthesis. Electric powered components have been felt by many not to be sufficiently reliable and durable. This, however, has not proven to be the case when they are appropriately incorporated into a prosthesis and the patient is properly orientated to their care and use. There are those individuals and situations who are abusive to an electric powered prosthesis as well as a mechanical prosthesis. However, they are not the majority and require appropriate consideration prior to design and development of a prosthesis. Hybrid design concepts can also be utilized to enhance the reliability and durability of a prosthesis by allowing the encapsulation of components within the prosthesis that would otherwise be external. This is a concept known as self-containment. Hybrid prostheses can significantly improve the functional restoration and rehabilitation of an individual with an upper limb deficiency. They are an important consideration in the prosthetic management of such individuals and can be the difference between total rejection or functional use of a prosthesis. Unfortunately, upper limb prostheses of this type will most likely continue to be provided in specialized centers and not find their place in common practice unless developers and manufacturers work towards making their components more compatible and interchangeable with those of other systems. *John N. Billock, C.P.O. John N. Billock, C.P.O. is with the Orthotic and Prosthetic Centre of Warren, 145 Shaffer Drive, N.E., Warren, Ohio 44484. Page Number(s) 23 - 25 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper Limb Prosthetic Management Hybrid Design Approaches Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * https://staging.drfop.org/files/original/ab7543cd7a89fbb0411d1f34a0263db8.pdf c5354e4247d698b974287ba4eb8c3224 https://staging.drfop.org/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg 35a7c0b562014d4fb50dec04e1a2648b https://staging.drfop.org/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg ff2b1aea5b56e7f14acf06a7b8d20da9 https://staging.drfop.org/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg 9f95d03a610ddbb83b1ad23e3450dfd0 https://staging.drfop.org/files/original/963256fd362491bd682b123274398c06.jpg 6418500d7da7c502d4faec1731934241 https://staging.drfop.org/files/original/011d4c628e420168bd0745099f67527b.jpg f292217f59299efecabdeccec457d0ab https://staging.drfop.org/files/original/0d2ed862497f922a0790d0b16cef7986.jpg 2ab9a719c52fc5660d4b56961d2e5209 https://staging.drfop.org/files/original/354d1f58233229ce31c57886ff84b30f.jpg b44e5eff696f208e7c962ed258e16579 https://staging.drfop.org/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg e1c1fb775ede1e64579fb7405aa8a5d9 https://staging.drfop.org/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg b482408d3255d9e24ad276d2e4ba913a https://staging.drfop.org/files/original/0265d09264022def5d0709d4d7100463.jpg 769232d27df084123462e0300b6af339 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_026.pdf Text Any textual data included in the document <h2>Conventional Fitting of an Unconventional Orthosis</h2> <h5>Donald L. Fornuff, C.P. <a style="text-decoration: none;">*</a></h5> Amyoplasia Congenita (Arthrogryposis Multiplex Congenita) is a congenital abnormality of muscle development which is characterized by marked stiffness and severe deformity in many joints of the limbs—hence, the term arthrogryposis, which means "bent joints." (<a href="/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg">Fig. 1</a> and <a href="/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg">Fig. 2</a>). <a href="/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg">Fig. 3</a> shows one of our recent patients, a young woman from South America with arthrogryposis, who was seeking greater range of motion with her present left exoskeletal arm orthosis, combined with easier operation and better cosmesis. Her previous orthosis consisted of a left modified laminated shoulder cap with a large cut out for both the left arm and left breast. The shoulder cap extended from the left clavicle over the shoulder to the soft tissue area between the rib cage and the crest of the ilium on the left side. Set on the superior border of the shoulder cap was a nudge control unit which was used to lock and unlock the elbow and was operated by her chin (<a href="/files/original/963256fd362491bd682b123274398c06.jpg">Fig. 4</a>). A flexion-abduction joint was used at the shoulder. The elbow joint was an outside locking type. A custom made wrist unit served to receive a terminal device. Quarter inch (1/4")—7 cm diameter adjustable rods were the connecting members from the acromion to the elbow and from the elbow to the wrist unit. Operation of the terminal device was accomplished by means of a perineal strap on the left side. A chest strap was used as a means of suspension. Some major considerations for change were: type of socket, improved harness and a more efficient cable system. <h3>Socket</h3> We felt a more comfortable, cosmetically acceptable, and efficient working, above-elbow type socket would be a large improvement over the heavy, bulky, and ill-fitting shoulder socket she was now wearing. Consequently, the patient was casted as if for an above-elbow type prosthesis, with anterior and posterior wings at the proximal end of the socket and an open end distally (<a href="/files/original/011d4c628e420168bd0745099f67527b.jpg">Fig. 5</a>). <h3>Harness</h3> Without a doubt, the two most uncomfortable and least cosmetic harnesses a woman could wear would be a perineal strap and a chest strap. This patient was unfortunately burdened with both. Our solution was to use a conventional A/E harness in conjunction with the A/E type socket with modification of the control attachment strap, which ran from the harness ring through a 1 inch hanger of the control cable, across the back and attaching to the axilla (<a href="/files/original/0d2ed862497f922a0790d0b16cef7986.jpg">Fig. 6</a>). This modification serves two purposes: (1) it prevents the harness from rising on the back, which would be uncomfortable, and (2) it promotes cable operation efficiency by maintaining the cable flow through the lower third of the scapula, where maximum excursion occurs as a result of scapular abduction (which is the motion being used for the function of this orthosis). <h3>Cable Control System</h3> A conventional A/E dual control system was used (<a href="/files/original/354d1f58233229ce31c57886ff84b30f.jpg">Fig. 7</a> and <a href="/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg">Fig. 8</a>). <h3>Elbow Lock Control</h3> Operation of the elbow lock (E-500 outside locking joints) was facilitated by slight modification of the locking mechanism. Instead of using an elbow lock strap, the cable from the elbow lock was attached proximally to a nudge control unit similar to what was used on her previous orthosis (<a href="/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg">Fig. 9</a>). <h3>Forearm</h3> The forearm consisted of a threaded aluminum rod held onto the lower locking strap of an outside locking joint by means of an adjustable bracket which allows for shortening or lengthening of the forearm as necessary. At the distal end of the forearm, an adapter was placed to receive a wrist flexion unit, into which a hook was placed (<a href="/files/original/0265d09264022def5d0709d4d7100463.jpg">Fig. 10</a>). The forearm set-up was not an original idea, but was modified slightly to provide more range of motion. <h3>Summary</h3> Again, the overall idea was not an original one, but we feel the modifications which were improved upon and a good idea are worth sharing. With this device, combining both the working knowledge and components of prosthetics and orthotics, we made the life of this patient easier and more functional. We felt we met our original goals, which were to improve her range of motion, give her easier operation, improve cosmesis, and provide a more comfortable fitting orthosis. <h3>Acknowledgment</h3> Thanks to Mr. G. Robinson of Robins Aid, who had the original ideas for this orthosis. *Donald L. Fornuff, C.P. Donald L. Fornuff, CP. is with the Prosthetics and Orthotics Department at the Institute of Rehabilitation Medicine of the New York University Medical Center, 400 East 34th Street, New York, New York 10016. Page Number(s) 26 - 29 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Conventional Fitting of an Unconventional Orthosis Creator An entity primarily responsible for making the resource Donald L. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_030.pdf Text Any textual data included in the document <h2>Two-Stage Cast-taking Procedure for PTS Prosthesis</h2> <h5>Kurt Marschall, CP <a style="text-decoration: none;">*</a></h5> Proper cast-taking and accurate measurements of a patient's remaining extremity, combined with careful evaluation and modification of the positive mold, are the most important steps in the fabrication and fitting of any prosthetic-orthotic device. Success or failure in prosthetic-orthotic fitting is directly related to the cast taken and the modifications incorporated in the positive mold. It is my firm belief that the person taking the cast should also be the one to modify it. Ideally, the modification of any master mold should be accomplished as soon after cast-taking as possible. The reasons are obvious. It makes it possible to recall the characteristics of the patient's extremity and to pay special attention to particular landmarks and problem spots that have been identified. Long delays will only serve to wipe out the memory of these characteristics. Granted, the caseload in some facilities does not permit this ideal situation of an immediate cast-modification procedure. Therefore, it should be the aim that the cast-taker produce a cast that can be easily understood and interpreted by the person modifying it. In the case of the PTS cast, landmarks should be well identified, circumference and length measurements should be accurate and special consideration or conditions should be carefully recorded. These are preconditions for proper cast modification and subsequent fabrication of a superior fitting socket, and form the foundation of any successful below knee fitting procedure. It is now well over twenty years since I first introduced, together with my colleague and partner, Robert Nitschke, CP, the American concept of the PTS prosthesis in Palm Springs, California. It now enjoys a widespread acceptance in the field of prosthetics and has become an integral part of the prosthetic armamentarium. Since then, deviations from the original PTS concept, dictated by physiological reasons, geographic location or climactic conditions have been introduced. The Fillauer removable medial wedge,<a></a> as well as the removable medial brim version,<a></a> are such a case in point. The supracondylar fitting with the anterior portion of the socket cut distal to the midpatella level, which thus sacrifices intimate contact with the quadriceps, should also be mentioned. All of these different techniques have their place. They work well, if, as a prerequisite to socket fabrication, a cast of superior quality and accurate cast modification can be supplied. Twenty years ago, we advocated a one step cast-taking technique, necessitating the use of a cast cutter in the posterior portion of the medial and lateral hamstrings for cast removal. The noise of the cast cutter, accompanied by some heat development when the blade oscillates through the cast, proved to be quite troublesome and sometimes frightening, especially to children and geriatrics. For these reasons we have employed for many years now a two-stage casting procedure in our facilities that produces a cast of superior quality with built-in characteristics that are easily identifiable in our positive molds prior to modification. <h3>MEASURING AND CASTING PROCEDURE</h3> <ol> <li> Materials and tools necessary for cast-taking procedure (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg">Fig. 1</a>): <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg">Figure 1. Materials and tools necessary for PTS prosthesis cast-taking procedure.</a> <blockquote> 2 light cast socks 1" elastic belt and 2 holding clamps PTS caliper A-P tension clamp Bandage scissor Goniometer Modified Ritz stick Orthoflex plaster bandage, 4" Regular plaster of Paris bandages, 4", extra fast setting Revere rubber bands, size 33 or equivalent Otto Bock separation gel (Gipsisoliercreme) or vaseline </blockquote> </li> <li> After positioning patient properly and comfortably on table, examine and palpate extremity carefully. Record findings on measurement sheet. Apply two light cast socks over patient's extremity and identify with indelible pencil all pertinent landmarks and bony protuberances (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg">Figure 2. Identify all landmarks and bony protuberances.</a> <ol> <li> Record circumference at three levels: mid-patellar tendon, mid-portion and around distal end of extremity. </li> <li> Record length of amputated extremity with modified Ritz stick (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg">Figure 3. Record length of extremity with modified Rita stick.</a> </li> <li> Record M-L dimension with PTS caliper at widest margin of knee (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg">Figure 4. M-L dimension at the widest margin</a></li> <li> Record M-L dimension above the medial and lateral femoral condyles (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg">Figure 5. M-L dimension above medial and lateral femoral condyles.</a> </li> <li> Record A-P dimension with knee relaxed and slightly flexed. The amount of flexion depends on the length of the remaining extremity. Seven-10 degrees is usually sufficient for medium sized amputations. Shorter ones may require more flextion (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg">Figure 6. A-P dimension with knee relaxed and slightly flexed.</a> </li> </ol> </li> <li> Wrap the amputated extremity with Ortho-flex bandage starting at distal end and terminating at the mid-patella level. Reinforce with regular, extra fast setting plaster of Paris bandage, and identify with thuimbs the patellar-tendon bridge (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg">Fig. 7 </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg">Fig. 8</a>). </li> <li> With plaster of Paris cast still soft and moldable, apply A-P tension clamp (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg">Fig. 9</a>). This makes it possible to shape the cast with both hands while it hardens, thus keeping later cast modifications to a minimum (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg">Fig. 10</a>). Please note clamp and hand-induced characteristics of hardened first stage of mold (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg">Figure 9. Apply A-P tension clamp.</a> </li> <li> Use Otto Bock separating gel or vaseline and apply a thin layer to the proximal 1 1/2" of the superior portion of the cast (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg">Fig. 12</a>). Measure out six layers of 4" regular, extra fast setting plaster of Paris bandage or splints, sufficient in length to reach slightly past medial and lateral hamstrings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg">Fig. 13</a>). Apply to patient's extremity, overlapping first stage cast by at least one inch and extending over the patella and covering quadriceps tendon by one inch. Use six inch wide splints if necessary. Apply two thin rubber bands to superior edge of wings (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg">Figure 14. Apply two rubberbands to superior edge of wings. </a></li> <li> Place thumbs in the indentations of the mid-patellar tendon bridge and use the index and middle fingers of both hands to apply sufficient pressure to reach the depth of the recorded narrow M-L dimension just superior to the femoral condyles. The fingers should always straddle the ilio-tibial band on the lateral side (Fig. 15). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg">Figure 15. Apply sufficient pressure to reach the depth of the recorded narrow M-L dimension. </a></li> <li> After the second stage of the cast has set enough to hold finger impressions in place, remove the rubber bands and mark juncture between first and second stage with indelible pencil (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg">Fig. 16</a>). Remove second stage by carefully lossening and lifting medial and lateral wings free (Fig. 17). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg">Figure 16. Mark juncture between first and second stage.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg">Figure 17. Carefully loosen and lift medial and lateral wings free</a> </li> <li> Reflect the top cast sock distally. Let patient's musculature relax completely. While pulling the bottom cast sock proximal, slowly remove first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg">Fig. 18</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg">Figure 18. Slowly remove first stage while pulling the bottom cast sock proximal.</a> Cut off excess cast sock adhering to first stage (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg">Fig. 19</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg">Figure 19. Cut off excess cast sock adhering to first stage.</a></li> <li> Join both stages together again by matching the separation marks exactly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg">Fig. 20</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg">Figure 20. Join both stages together, matching the separate marks exactly.</a> While holding both stages securely together with the left hand, place plaster of Paris bandage about the juncture and wrap all the way to the top of cast. </li> <li> The negative wrap should display all landmarks clearly (<a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg">Fig. 21</a>). Check for correct flexion angle. Negative cast can now be filled. <a href="http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.jpg">Figure 21. The negative wrap should display all landmarks clearly</a></li> </ol> During the cast-taking procedure, I make it a point to involve the patient by explaining each and every step. I use proper nomenclature and anatomical description of the remaining extremity. We should remember that each patient has gone through a very traumatic, cosmetically and functionally destructive surgical procedure. His or her spirits need to be lifted and encouraged. Most patients appreciate an intimate involvement in their prosthetic rehabilitation. Some of them even retain the knowledge gained during their cast and fitting procedures and answer subsequent questions on a sophisticated level. Treatment of your patient as a human being, rather than as a number among many makes being in this profession such an outstanding experience. <h3>Conclusion</h3> The importance of a good cast-taking technique has been stressed. Ideally, the positive mold should be modified by the cast-taker. In the absence of such a luxury, the cast modifier, with the aid of the measurements and the recording of special considerations, should be able to readily understand the characteristics that have been built into the cast. Proper cast modification will contribute immeasurably to good socket fit and superior function and performance by the amputee. Where the above guidelines have not been followed, an inferior socket fit will result. In such a case, the cast-taking procedure should be repeated and a new socket should be fabricated. Successfully fitting 10 to 20 patients in a row does not make any of us an infallible super-prosthetist. Every once in a while we all have to admit defeat due to oversight of basic principles or failure to adhere to prescribed guidelines and procedures. These infrequent failures will keep us on our toes and make us humble again. But, admitting defeat or failure and correcting it without a moment's hesitation, will make you, in the eyes of your peers, in the eyes of your physician, but foremost, in the eyes of your patient, the better practitioner. References: <ol> <li>Marschael, K. and Nitschke, R., "Principles of the Patellar Tendon Supracondylar Prostheses," Orthopedic Appliance Journal, Vol. 21, No. 1, March, 1967, pp. 33-38.</li> <li>Fillauer, C., "Supracondylar Wedge Suspension of the PTB Prostheses," Orthotics and Prosthetics, Vol. 22, No. 2, June, 1968, pp. 39-44.</li> <li>Fillauer, C., "A Patellar-Tendon-Bearing Socket with a Detachable Medial Brim," Orthotics and Prosthetics, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> </ol> <div style="width: 400px;">*Kurt Marschall, CP Kurt Marschall, CPO is President of Empire Orthopedic Laboratories, a division of Rochester Orthopedic Laboratories, Inc., 249 East Adams Street, Syracuse, New York 13202. </div> Page Number(s) 30 - 34 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1985_01_030/1985_01_030-21.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 Two-Stage Cast-taking Procedure for PTS Prosthesis Creator An entity primarily responsible for making the resource Kurt Marschall, CP * https://staging.drfop.org/files/original/a9f10fd556c1a92dcd99130f4c4c7fb4.pdf 471c56da3d5a2d6cbb3f53fef609568e 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_02_002.pdf Text Any textual data included in the document <h2>The Nature of Contractures</h2> <h5>Justin Alexander, Ph.D. <a style="text-decoration: none;">*</a></h5> When orthotic devices are supplied to a patient, it is generally in the hope that function can be enhanced. If this expectation is to be realized, joint mobility or range of motion should be within normal limits. Unfortunately, there are many patients where a significant deficit in freedom of movement occurs. It is essential to realize that the causative factor for such limitation is varied, so that one may develop a reasonable treatment approach. Impedence to free motion can result from injury or malfunction of the skin overlying a joint, muscles or tendons surrounding or crossing joints, the joint capsule, or the joint surfaces. In many instances joint disturbances can be avoided by timely intervention such as correct positioning; active, assistive or passive exercises; or stretching and joint mobilization. Unfortunately, even when meticulous care is provided, limitations of movement can occur. Once tightness has been allowed to develop, it becomes more difficult and painful to restore normal function. A variety of mechanical devices designed to minimize the danger of developing contractures, or to overcome them, have been described in the literature. Surgical intervention may be attempted in carefully selected instances as well. A common sequela to prolonged inactivity is loss of flexibility due to shortening of muscle fibers and connective tissue. In an otherwise healthy individual this does not cause a serious problem and one can expect that with resumption of normal activity, muscles will regain length and flexibility. If, however, a limb is immobilized because of injury or disease, tissue repair involves replacement of muscle fibers with scar tissue which consist of collagen. Early, persistent, and careful physical therapy usually produces satisfactory restoration of movement. Delay in starting therapy or placing the responsibility for performing a prescribed regimen completely on the patient or family member, without assurance that the program is understood and that it will be performed, is prone to produce serious impedance to normal mobility. It is important to note that when a distal joint is immobilized, the more proximal joints are not utilized as much as under ordinary conditions and secondary joint limitation may develop. Some common examples are the concommitant tightness of hip flexors and knee flexors, or the limitation seen in the shoulder and elbow of the patient who has sustained a Colles fracture of the wrist. Immobilizing a part in a resting position does not necessarily produce limitation of movement, provided there is physiological rest.<a></a> On the other hand, if a part is immobilized and there is active muscle contraction to prevent the muscle from being elongated or the joint moved, muscle tightness can be invariably expected. When a person expects that motion might be painful, such as during the acute phase of Rheumatoid Arthritis or during severe and prolonged periods of ischemia, a "protective spasm" can be anticipated and frequently results in "irreversible contracture." The term "irreversible" must be used tentatively, since, if given enough time, the contracture may be relieved through ordinary activity.<a></a> In most instances, therapy cannot be provided or justified for the long period required to ameliorate the situation. In several instances, we have observed changes occuring over two years or longer following initial insult. Extravasation of fluid into tissue surrounding the joint, which may be observed following repeated trauma. This could be a result of stretching which is performed too enthusiastically, or after episodes of bleeding in an individual with hemophilia. It will invariably result in deposition of collagen and may continue to permit calcification of the capsule. This could end in heterotopic bone formation. Heterotopic ossification presents a difficult problem to manage. While there have been some reports of spontaneous remission over time, others have reported recurrence after surgical excision. Repeated insults to the integrity of the joint itself can lead to complete blockage of the joint, either as ankylosis of the capsule or due to fusion of the joint surfaces. Depending on which joint is involved, total or partial joint replacements have been very successful in restoring function and almost completely eliminating pain. The management of the patient with contractures is complicated and if it is to be successful, close collaboration between physician, therapist, orthotist, and the patient and family is imperative. In the presence of contracture, the application of an orthotic device can be wrought with danger. If too much tension is applied in order to gain motion when the patient is walking, protective spasms may counteract any stretching effect. It is also possible that excessive pressure can result in a fracture, especially if the patient has ben inactive for some time and if osteoporosis is present. The chances of successfully reducing joint limitations are increased when physical therapy and orthotic devices are combined in a comprehensive treatment program. References: <ol> <li>Harris, R. and Copp, E.P., "Immobilization of the Knee Joint in Rheumatoid Arthritis," Ann. Rheum. Dis., 21:353, 1962.</li> <li>Partridge, R.E.H. and Duthie, J. Jr., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis," Ann. Rheum. Dis., 22:91, 1963.</li> <li>Alexander, J., "Irreversible Contractures: An Impediment to Prosthetic Rehabilitation" Newsletter Prosthetics and Orthotics Clinic, 4:3, 1, 1980.</li> </ol> <div style="width: 400px;">*Justin Alexander, Ph.D. Justin Alexander, Ph.D., is with the Albert Einstein College of Medicine, Yeshiva University, 1300 Morris Park Avenue, Bldg. 'J,' Room 2N4, Bronx, New York 10461. </div> Page Number(s) 2 - 3 Year 1985 Volume 9 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Nature of Contractures Creator An entity primarily responsible for making the resource Justin Alexander, Ph.D. * https://staging.drfop.org/files/original/8a9d698b5aa9a88b1d78cca1010c8eea.pdf 19dc4e493a77c65d2001e424e6222098 https://staging.drfop.org/files/original/99962c094bd59683119343ed583b5ef4.jpg 39cc66fe8bd0fa42c218e04d12f792fa https://staging.drfop.org/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg 342634e484594f8c0b6ec6fe1e681ed9 https://staging.drfop.org/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg a24f4347ad26657b24aa89700949a9fc https://staging.drfop.org/files/original/8722aae75627f1d176b8d9a189158028.jpg e972a1cac03927a2aafa9101a7ca1f5c https://staging.drfop.org/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg bdd02cd537217663f89754a8cbf9e89e https://staging.drfop.org/files/original/bdccea442ad3ab930b10461937bd5371.jpg be9a619d33b72a6e85e028985e907098 https://staging.drfop.org/files/original/e625aaa21e9345136d836397f35f4a25.jpg a7924af794fc40802662208fcc8abc16 https://staging.drfop.org/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg f673166d26b71b65d9dc04bd19d51530 https://staging.drfop.org/files/original/35e4a19292bc235080a381e346afc9df.jpg 2d9d56f7b3531d006b2ab2c40616d544 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_02_003.pdf Text Any textual data included in the document <h2>Orthotic Correction of Blount's Disease</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a> John M. Mazur, M.D. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Infantile tibia vara is the result of abnormal growth in the proximal tibial epiphyseal late of the tibial plate. Blount<a></a> first identified the condition as osteochondrosis deformans tibialis in 1937. Clinically, tibia vara presents itself as a severe bowing of the proximal tibia, without the associated bowing of the tibial shaft or the femur, which is evident in physiological bowleg. On radiological examination of the child with tibia vara, a beaking of the medial aspect of the tibia metaphysis is noted. In 1964, Langenskiold and Riska<a></a> developed a grading system for chronologically staging the development of Blount's disease. Mitchell, et al.<a></a> advocated the use of the epiphyseal metaphyseal angle (E-M angle) as a simple quantitative measurement for Blount's disease in 1980. This method is useful to determine the severity of the disease and monitor treatment. Historically, the use of orthotic management in the correction of Blount's disease has not proven to be as successful as hoped. The lack of correction and increased laxity of the joint capsule of the knee have been the main reasons for not continuing with orthotic management. To this point, the treatment of choice for individuals with Stage IV or an E-M angle of greater than 30° has mandated that the child undergo one of several types of tibial osteotomies. Because of the high incidence of complications<a></a> and the recurrence of the condition, the authors felt that a new orthotic approach should be investigated. The result of that investigation has been the development of a knee-ankle-foot orthosis. This orthosis has successfully been used in seven cases of Blount's disease. <h3>Orthotic Design</h3> Previous orthoses used in the treatment of Blount's disease have been either a KAFO with a medial side bar only, or a KAFO with bilateral side bars. The medial side bar KAFO incorporated a varus corrective knee pad. The bilateral side bar orthosis is essentially a passive device to maintain the existing condition and to prevent it from getting worse. Neither system has proven to be completely successful in the treatment of Blount's disease. The design criteria established for the development of the knee-ankle-foot orthosis consists of the following: <ul> <li> The design must correct the varus deformity of the tibia. </li> <li> The medial joint capsule should not be distributed by the orthosis. </li> <li> Forces should be applied directly to the tibia and not the full length of the limb. </li> </ul> Because the patient is a growing child, it must be adjustable for growth as well as easily cleaned by the parents. The knee-ankle-foot orthosis which the authors have developed has met all of these criteria. Stress to the medial joint capsule was prevented by using an inversion of the supracondylar suspension technique used for below knee prostheses.<a></a> By having a medial thigh section extend beyond the joint space to the area of the medial tibial condyle, we were able to reduce the possibilities of applying stress to the joint space itself (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). <a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Figure 1</a>. Bilateral KAFO's for Blounts with stainless steel medial side bar, thermoplastic femural section, and elastic tibial strap. Femural section protects the knee joint while the elastic applies maximum force to the apex of the tibial curve. A dynamic system was used to apply corrective forces to the tibia. The use of an elastic material to provide dynamic forces has been well documented.<a></a> A six-inch wide elastic gusset material with velcro closures provided an adjustable and continuously applied force to the tibia (<a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Fig. 2</a>). The maximum force applied to the limb with the elastic material is at the apex of the curve (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). This allows the maximum amount of correction with minimum amount of force. The velcro allows easy removal for laundering. All orthoses are provided with two sets of elastic straps. <a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Figure 2</a>. Cross section of leg and orthosis at mid-tibial level. The relationship of the sidebar, elastic, velcro, and limb are shown. The orthosis needed to be strong and adjustable because these children are growing and extremely active. The side bars are made of stainless steel which overlap for growth adjustment only between the knee and ankle (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). The knee-ankle-foot orthosis was not made adjustable proximal to this area in order to maintain the tibial extension of the thigh piece in its proper relationship to the tibial condyle. The patient's foot is maintained in a high top shoe which is attached to the medial side bar by means of a free ankle stirrup. <h3>Prescription Criteria</h3> The E-M angle is used to determine whether the patient meets the criteria for orthotic management of the Blount's disease. The E-M angle is measured on an anterior/posterior x-ray of the knee. To construct this angle, a line is first drawn through two points on the base of the proximal tibial epiphysis, selecting the first point at the base of the normal lateral side of the epiphysis and the second medial point as far away from the lateral side as possible, but at the base of the normal non-depressed epiphysis. Next, determine the midpoint at the base of the epiphyseal center, then draw a second or metaphyseal line from the medial tip of the metaphyseal peak to the midpoint of the epiphyseal center (<a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Fig. 3</a>). If this E-M angle is equal to or greater than 20°, then orthotic intervention is recommended. Mitchell et al. determined that the mean E-M angle for normal children was 3°-11°. Orthotic management is maintained for a minimum of nine months and at such time as the E-M angle is less than 15°. If the child is over eight years of age, orthotic correction will not be achieved. Based on our experience, orthotic management in stages I through III tibia vara can be effectively corrected with orthotic management. Aggressive treatment is necessary to achieve these results. Stages IV and V Blount's Disease and children over eight years of age need surgical treatment. <a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Figure 3</a>. Method of measuring the E-M angle. <h3>Case Study</h3> A white male, age 3, was presented at the orthotic clinic by his parents because of bowing of his right lower extremity (<a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Fig. 4</a>). Clinical examination showed bilateral tibia vara. Bilateral standing AP radiograms were obtained. The E-M angle determined on these radiograms was 20° bilaterally (<a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Fig. 5</a>). The child was fitted with the bilateral KAFO's (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6A</a>) and a new set of standing AP radiograms was obtained which showed no difference in the E-M angle at that time (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6B</a>). <a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Figure 4.</a> Clincal appearance of B.D. at age 3 with bilateral Blounts Disease. <a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Figure 5</a>. Standing A/P radiograms show E-M angles of 20° bilaterally. <a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Figures 6A (top) and 6B (bottom).</a> B.D. fitted with bilateral KAFO's. X-rays show no change at time of fitting. For the next six months, B.D. wore his bilateral KAFO's 23 hours a day with the knee joints in the locked position during weight bearing. After one week's wearing time, the patient no longer objected to wearing the devices and adapted his lifestyle accordingly. No restrictions were placed on the child concerning his daily activities. At his six-month checkup, new radiograms, both in and out of the KAFO's, were obtained. The E-M angle at that time was determined to be 15° bilaterally. Clinically, the child appears to have less bowing of his tibia as well. It was determined at that time that the side bars needed to be lengthened, which was done. It was decided that the parents could then allow the child to use the orthoses in the unlocked position during the daytime, but to return to the locked position at night. Because of growth of the child's feet, a shoe change was necessary. At nine months, the patient was again presented to the clinic. Once again the orthoses were lengthened (<a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Fig. 7</a>). New standing AP radiograms were also obtained, showing no significant alterations from the previous exam at six months (<a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Fig. 8</a>). Day use of the KAFO was discontinued. <a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Figure 7.</a> Sidebars were lengthened twice during the treatment period. One shoe transfer was also completed. <a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Figure 8.</a> Radiogram taken after 9 months of treatment show an E/M angle of less than 15° as well as less bowing of the tibial shaft. The patient returned for a twelve-month evaluation. No significant changes had occurred clinically in the patient's extremities (<a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Fig. 9</a>), thus use of the orthoses was discontinued. <a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Figure 9</a>. Orthotic treatment discontinued after 12 months. Clinical examination shows normal lower limbs. <h3>Summary</h3> This successful use of orthotic management in the early stages of Blount's disease has been proven at Southern Illinois University School of Medicine. An orthosis was designed to specifically meet the established criteria of correcting the tibial deformity, reducing the stress on the medial joint capsule, and allowing adjustability for growth. The device has been used in seven cases of tibia vara with excellent results in all cases. The E-M angle of the affected tibias have been reduced to less than 15°. Aggressive treatment in the early stages of Blount's disease will reduce the necessity of tibial osteotomies with their significant level of complications. References: <ol> <li>Blount, W.P., "Tibia vara osteochondrosis deformans tibia," J. Bone Joint Surg., 19, 1-29, 1937.</li> <li>Langenskiold, A.N., Riska, E.B., "Tibia vara osteochondrosis deformans tibia: a survey of seventy-one cases," J. Bone Joint Surg., 46-A, 1405-1420, 1964.</li> <li>Mitchell, E.I., Chung, S.M.K., Dask, M.M., Greg, J.R., "A new radiographic grading system for Blount s disease," Orthopaedic Review, Vol. 9, No. 9, 27-33, 1980.</li> <li>Steel, H.H., Sandral, R.E., Sullivan, P.D., "Applications of tibial osteotomy in children for genu varum or val gum," J. Bone Joint Surg., 53-A, 1629-1635, 1971.</li> <li>Marschael, K., Nitschke, R., "Principles of the patellar tendon supracondylar prostheses," Orthopaedic Appl. Journal, Vol. 21, No. 1, 33-38.</li> <li>Clancy, J., Landseth. R.E., "A dynamic orthotic system to assist pelvic extension: A preliminary report," Orthotics and Prosthetics, Vol. 29, No. 1, 3-9, March, 1975.</li> </ol> *John M. Mazur, M.D. John M. Mazur, M.D., Associate Professor, Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine. *Terry J. Supan, C.P.O. Terry Supan, C.P.O., Instructor, Department of Surgery; Director, Orthotic/Prosthetic Service, Southern Illinois University School of Medicine, Room 102, 707 North Rutledge Street, Springfield, Illinois 62702. <div style="width: 400px;"></div> Page Number(s) 3 - 7 Year 1985 Volume 9 Issue 2 Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-09.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-02.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-07.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 Orthotic Correction of Blount's Disease Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * John M. Mazur, M.D. * https://staging.drfop.org/files/original/ae236bfbb39982337feabb0733c52902.pdf e72d5cf575ee14ceefaff511308e621b https://staging.drfop.org/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg ef072ec1bc27f9dcd672375601a67a9e https://staging.drfop.org/files/original/da001445312603a0ab4a223ff85c38d1.jpg 4f8a28f1624ff2e04786d747684a2057 https://staging.drfop.org/files/original/a32c142193dc07186843945607ee7c09.jpg 79706ff74b7376718ec3c1c01ef15ca3 https://staging.drfop.org/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg f251a6a6b93993eeba8075a00dd5ac91 https://staging.drfop.org/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg 9d90b7c57aaad093cb21238b39211ddc https://staging.drfop.org/files/original/c70f240f5eef716b30961b9ae75c899e.jpg 1e4183be00d6bedb3cc92fad6389248d https://staging.drfop.org/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg f7682f94bed1b0ccc9e390612c5dafdf https://staging.drfop.org/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg 35b4aa1ad815d9578b088cbbfd993f91 https://staging.drfop.org/files/original/dd41c84673e88dc6270e962c77261651.jpg 117eda80e9303ed50d584b0ee204d8f9 https://staging.drfop.org/files/original/4575504d9fda222439f290f7163145af.jpg 423c40aa07471e5f2cf3e718ae770e6b https://staging.drfop.org/files/original/91b675186e820e21469468d77ca70551.jpg 5afe9e85b461d2b3d97106de870921a2 https://staging.drfop.org/files/original/ac9d622bf611e960cead91b85bba30b1.jpg d785d4c25a39f7ab31ae8d5fc4053ed2 https://staging.drfop.org/files/original/554280c049e6a114db8463eaeefec20f.jpg e79e156f8cb8fe7c9dd123eec6027222 https://staging.drfop.org/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg eaa08643ef0c977a0f9e9974a26262f3 https://staging.drfop.org/files/original/9696814c90d3a127b31bdde25d16906a.jpg 1d2ed620db67e11602f865d0cbca66a1 https://staging.drfop.org/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg 7979974fd7a2d61065ebd35791b01993 https://staging.drfop.org/files/original/0be90617be2197739e9b7215c50adcc4.jpg 761099b39d2853060144d43fd50bce9e https://staging.drfop.org/files/original/cdf2e11044f459004d4cc3bea3571520.jpg b18f89555cc3b064d9679377782bc8d8 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_02_007.pdf Text Any textual data included in the document <h2>Passive Mobilization: An Orthotist's Overview</h2> <h5>Dwain R. Faso, C.O. <a style="text-decoration: none;">*</a> Mel Stills, C.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> The application of passive motion in orthopedics has brought a new dimension to an old concept for the treatment of musculoskeletal problems. It is now recognized that the adverse effects of immobilization such as joint stiffness, poor articular cartilage nourishment, and collagen loss can be reversed by prolonged passive mobilization. R.B. Salter demonstrated significant results with his experimental work in the healing of osteochondral defects in rabbits subjected to continuous passive motion. R.D. Courts followed with clinical experiences of improved range of motion after total knee replacements. The indications for passive motion have since broadened to include knee ligament reconstructions,  joint injuires, fractures, dislocations, joint sepsis, and many others. The orthotist is often consulted for the evaluation of passive motion devices, their set up, adaptation, and implementation with fracture orthotics, external fixation, and traction. This article will provide an overview of passive mobilization as a supplement to the practitioner's database and present a variety of clinical situations encountered in the Dallas area at a large trauma and reconstruction center. <h3>Background</h3> For centuries, the clinician has vacillated between the uses and benefits of rest versus motion in the management of various disorders and injuries involving body joints. Rest or motion have been the most prescribed forms of non-operative treatment, yet the controversy of indication, duration, and value of each is far from being resolved. In the teaching of Hippocrates, the injured body was to be at 'rest and lie up.' His use of splints in musculoskeletal injuries assured rest. With the impregnation of bandages with plaster of Paris in 1852 by Flemish surgeon Antonius Mathijsen, immobilization took on a new form. The use of plaster casts in treating trauma and injury unquestionably assured the concept of immobilization by orthopedic surgeons for the next 130 years with little examination of the potential damage to articular tissue. Additional support of the rest concept was led by the British surgeon Hugh Owen Thomas. His doctrine of rest was to be complete, prolonged, uninterrupted, and enforced. This was accomplished through the use of splints of his own design, many of which are still in use today with minor modifications. Thomas' immobilization techniques routinely included uninjured joints above and below the fracture site. The mobilization concept found its roots in the Aristotelian teaching that movement is life. In the late 1900's, a school of mobilization took on a significant form through its advocate, Dr. Lucas-Champonniere. This French surgeon supported the use of massage and motion as a means of preventing muscle atrophy and joint contracture during the management of fractures and joint injuries. He believed that motion helped to relieve pain rather than to aggravate it. The use of balanced skeletal traction for fractures involving joint surfaces, initiated by Professor George Perkins, emphasized active motion in the realignment of fragments and prevention of stiffness. In the 1950's, the 'movement is life' principle found a resurgence under the guidance of the Association for Osteosynthesis (AO). They coined the term "fracture disease" for the chronic edema, joint stiffness, muscle atrophy, and disuse osteoporosis found in the treatment of fractures with immobilization. The AO group's technique of open reduction, rigid internal fixation with compression, and no casting encouraged early mobilization and provided a significant aggressive treatment. Apley, Dehane, and more recently Mooney and Sarmiento advocated the closed functional treatment of fractures through the use of cast bracing. Although these two methods vary, both preserve joint motion and encourage early function. <h3>Continuous Passive Motion</h3> The human body has evolved and developed into an organism that needs to move in order to maintain optimum efficiency. When the body is immobilized, the overall physical fitness declines rapidly: the heart rate decreases, and cardiac output no longer rises sufficiently during even mild activity; the upright position is poorly tolerated; the nervous system response slows; calcium is released by the immobilized skeleton and is excreted in urine, reflecting the extent of bone loss; muscle atrophy occurs with the reduction of fiber size, thereby resulting in the decline of tensile strength and energy absorption capacity; and the immobile body loses three percent of its original strength per day in a linear fashion for the first seven days, after which little strength is lost. The joints of the body are especially susceptible to immobilization. The articular cartilage layers depend on synovial fluid for nutrition. Motion makes for constant interchange of fluid between the layers of articular cartilage and synovial fluid. Joint motion causes alternating cartilage compression and distension. The absence of these pressure fluctuations causes a stagnation of intercellular fluid and a decrease in nutrition. Surprisingly, the adverse effects of immobilization on the human body generated little interest for evaluation. In the 1960's, Salter began investigation on the effects of immobilization versus mobilization on articular tissue in rabbits. His studies produced significant laboratory evidence that continuous passive motion offered startling benefits in the articular repair process in knee joint injuries compared to the routine care of immobilization. Salter's conclusions for his first 12 years of experimentation are: <ul> <li> Continuous passive motion (CPM) is well tolerated and seems to be relatively painless. </li> <li> CPM has a significant stimulation effect on the healing of articular tissue, including cartilage, tendons, and ligaments. </li> <li> CPM prevents adhesions and joint stiffness. </li> <li> CPM does not interfere with the healing of incisions over the moving joint. </li> <li> The principle of rest for healing tissue is incorrect. </li> </ul> Evidence for the clinical effectiveness of continuous passive motion on the process of healing is both subjective and objective. In various studies, Dr. Richard Courts demonstrated that there is a reduction in postoperative pain and an increase in post total knee joint range following the use of continuous passive motion for several weeks. The decrease in pain experienced may be caused from the rhythmic joint movement providing competitive interference to retard the pain-spasm reflex and alleviate pain at the source. The increase in range of joint motion reported may be due to the improved orientation and strength of collagen fibers formed, preventing adhesions which would limit range without disturbing or causing damage to adjacent uninvolved normal structures. Clinically, Salter has indicated CPM use immediately postoperatively for the management of open reduction internal fixation (ORIF) of the ankle, knee, hip, and elbow with usage ranging from one to three weeks. Decreases in wound edema, joint effusions, pain medications, and an increase in patient comfort and shorter hospital stays are documented as compared to non-CPM patients. Schnebel and Evans found that while active flexion is acquired earlier in CPM patients, there was no statistical difference in active flexion in late motion studies between CPM and non-CPM total knee arthroplasty patients. <h3>Design</h3> Continuous passive motion machines can be categorized into three groups by design: mattress-mounted, bed frame mounted, and single joint units. Clinical use of continuous passive motion has primarily been utilized for mobilization about the knee and hip joint due to the mechanical design of the majority of motion devices, i.e. the mattress-mounted units. These machines are similar in that the patient lies supine with thigh and calf held in the unit, and the knee and hip are mobilized simultaneously. (In these units the patient is unable to move about in the bed or make significant posture changes.) Ankle movement may also be provided. Some mattress-mounted machines and their suppliers are: <blockquote> Autoflex, Chattanooga Corp. CAPE System, Zimmer CK-7 Passive Motion Knee Exerciser, OEC Danni-Flex, Danniger Medical Technology Kinetec Passive Leg Exerciser, Richards Powerflex 3000, Biodynamic Technologies of Florida Stryker Leg Exerciser, Stryker Sutter CPM 2000, Sutter Biomedical </blockquote> The bed frame mounted units attach to standard overhead Bulkin frames and provide the versatility for mobilizing multiple joints. These systems are: <blockquote> CPM K-10, Sutter Biomedical Passive Mobilizer, 3D Orthopedic Inc. </blockquote> Single joint units address specific joints of the body only. These are: <blockquote> Miami Ankle Motion Machine, Zoya Orthopaedic Kinetec Elbow Exerciser, Richards CPM-5000, Sutter Biomedical CPM Mobilimbs L1-A, Toronto Medical Corp. </blockquote> Functional features of all systems vary from: microswitching to torque sensing, mechanical range setting to computer programmed, 110 volt to battery operated, patient-controlled cycles to programmed cycles, and one speed to variable speeds. Yet all systems have been developed more from subjective than objective data. The questions of how much force, optimum speeds, duration of cycle, direction of pull/push/lift to the joint, control of joint motion, or should the joint be loaded or unloaded need to be addressed in order to quantify CPM and avoid the potential dangers of this modality. Dangers exist when these systems are utilized by those unfamiliar with mechanical systems and/or the expectant results they are trying to obtain. The level of knowledge required varies, i.e. the mattress-mounted units are limited in application and therefore are relatively simple. The multiple joint systems would require more expertise because of the increased options of use, the mechanical advantages gained with the use of pulleys and springs, and the variations of movements occurring about the anatomic joints. These systems tend to be more cost-effective since their various uses can be applied to a greater patient population. <h3>Two Year Experience</h3> In our experience at a major trauma hospital, the need for versatility, ease of use, and reliability were of utmost importance. We utilized five machine designs over a two year period: Sutter K-10, CPM Mobilimb L1-A, Richards Passive Leg Exerciser, 3D Passive Mobilizer, and a home-grown unit. All systems functioned very reliably. The Mobilimb unit had a rechargeable battery powered system which, for our use, proved to be the least practical. The mattress mounted units were limited to mobilizing knees and hips, especially in cases of joint replacement. The trays to these units were cumbersome to housekeeping. The staff would take the tray off the bed to change linens, causing frequent malalignments when setting it back on the bed, usually due to fear of reapplying and/or the lack of understanding how the system functioned. Patient comfort was a major concern. If the patient was not comfortable in the system due to the physical design of the system or improper positioning in the unit, the staff would turn off the machine, thereby reaping no benefits. The tray would not fit properly if the patient was above or below the average height of five foot ten inches. These systems did not provide a recorder to document how long the patient had the system on or how many cycles the limb experienced. Lack of full extension and flexion became another concern in our use of any of the units utilizing the tray that the leg simply laid in. Although the tray would indicate full extension, the leg would still be flexed, and usually abducted and externally rotated (<a href="/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg">Fig. 1</a>). Because of these reasons and the need to be able to utilize traction, cast braces, and rehabilitative orthotics with passive motion, we began using a homegrown version utilizing the Sutter K-10 without the mattress mounted tray. Through the use of dynamic suspension, we could achieve full extension with the assistance of gravity, mobilize a patient in traction, maintain abduction and adduction, and set up bilateral limbs with only one machine. This variation enabled the patient to move about in bed and provided easier bed pan use and overall more comfort. It won favor with our ancillary staff because there was nothing in their way to be moved or replaced (<a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Fig. 2</a>). In March 1984, we began using the Passive Mobilizer by 3 D Orthopedic Inc. This system had incorporated many of the features of our homegrown unit with some significant improvements. The system provides a linear pull rather than the rotating arc of the Sutter K-10 so that flexion and extension limits are more easily controlled and eliminates the potential hazard of the rotating arm (<a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Fig. 3</a>). Also, the unit includes a cycle counter to document how many cycles the patient has experienced. These two additional features were found to be very useful in our practice. <a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Figure 2.</a> Home grown unit using Sutter K-10 motor and control system. <a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Figure 3.</a> Patient with a right acetabular fracture with 30 lbs. of tibial traction in continuous passive motion (3D Passive Mobilizer). Hip flexed 0-90° and kept abducted. The use of passive mobilization should begin as soon as possible. The earlier the application, the better the results that can be anticipated. In the case of elective procedures, such as total joint replacements, the passive mobilization system should be set-up before surgery to familiarize the patient with the machine and its operation. At our center, the majority of the cases are trauma related and of a fracture variety. Patients are placed in passive motion postoperatively in the O.R., recovery room, or when transferred to the orthopedic floor. The unit is set to allow 30-40° of motion initially post-op with the rapid increase of range of motion to tolerance. In this two year experience, we have had 168 cases involving the use of continuous passive motion. These are broken down into three major categories: <dl> <dt></dt> </dl> Articular Fractures Knee—79 Hip—17 Elbow—4 Ankle—3 Joint Replacement Knee—14 Hip (Cup)—8 Other Knee Problems Sepsis—20 Lig. Repair—12 Edema Control 6 Continuous passive motion was also applied to mobilize the cervical spine (in halter traction post soft tissue trauma), the shoulder (post manipulation or rotator cuff repair), and the lumbar spine (post laminectomy or decompression). These were not listed because the applications are still under evaluation. Our goal in utilizing the modality of continuous passive motion is full range of motion. Initially we target for 0-40° of motion the first day, cycling the limb approximately one complete cycle per minute. Increase in ROM is aggressively addressed daily to pain tolerance. Since time minimums in CPM have not yet been established, patients are kept in passive motion except during meals, physical therapy, or bathroom use. The goal established for ROM of the knee and hip is 90+°. It was felt that if the joint could go through a passive 0-90 +° range pain free, and prior to discharge 0-90+° active range, that normal knee and hip motion could be achieved on an out-patient basis with aggressive physical therapy. Many factors influenced the outcome. Patient compliance and willingness to participate in this treatment plan is a major factor. Competent application and training in the use of continuous passive motion is also critical to the outcome. <h3>Cases</h3> Case 1 A twenty-nine year old male sustained a high caliber gunshot wound to the left knee (<a href="/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg">Fig. 4</a>), traversing the lateral femoral condyle through the joint space and through the lateral tibial plateau. Open reduction internal fixation (ORIF) and ligamentous repairs were made. Postoperatively, the patient was placed in a standard cast brace due to the inability to provide adequate medial-lateral stability of the knee surgically (<a href="/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg">Fig. 5</a>). The cast brace was attached to a continuous passive motion dynamic suspension system to restore and maintain motion (<a href="/files/original/c70f240f5eef716b30961b9ae75c899e.jpg">Fig. 6</a>). At the time of the initial cast bracing, the patient had considerable soft tissue edema about the knee. The use of passive motion quickly reduced that swelling to the point where the cast brace provided little support. After one week, the cast brace was reapplied with the addition of a varus producing strap (<a href="/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg">Fig. 7</a>) and the patient began ambulation training and was discharged. (If atrophy or swelling should continue, the varus producing strap can be easily adjusted to maintain force on the knee and another cast change would not be required). Case 2 A twenty-five year old female sustained a fracture dislocation of the left knee (<a href="/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg">Fig. 8</a>). The fracture and ligaments were internally fixed, and the patient was placed in a continuous passive motion dynamic suspension system utilizing a Mobilizing Brace (3 D) and a bootie (<a href="/files/original/dd41c84673e88dc6270e962c77261651.jpg">Fig. 9</a>). The patient achieved 0-90° of motion in two days and was maintained in passive motion for five days until she could achieve the same range of motion actively without excessive pain. The patient was then cast braced for increased medial-lateral stability, received gait training, and was discharged from the hospital. Case 3 A nineteen year old male sustained a distal fracture with a split condylar fracture to the right leg (<a href="/files/original/4575504d9fda222439f290f7163145af.jpg">Fig. 10</a>) and a lateral condyle fracture on the contralateral side (<a href="/files/original/91b675186e820e21469468d77ca70551.jpg">Fig. 11</a>). Fractures were stabilized, but were not internally fixed at time of admission because of emergency vascular repairs being required. Three days post injury, the patient underwent ORIF of his fractures (<a href="/files/original/ac9d622bf611e960cead91b85bba30b1.jpg">Fig. 12</a> and <a href="/files/original/554280c049e6a114db8463eaeefec20f.jpg">Fig. 13</a>). The right leg was placed in a free knee Mobilizing Brace and the left leg was placed in the rehabilitative free knee orthosis. A continuous passive motion dynamic suspension system was placed on the lower right extremity (<a href="/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg">Fig. 14</a>). The lower left extremity had normal pain free motion following surgery. The patient was kept in passive motion for five days and achieved 0-100° of pain free motion. A cast brace was applied on the right extremity; the patient received gait training and was discharged. Case 4 An eighteen year old male sustained bilateral femur fractures and bilateral patella fractures. The patient underwent bilateral closed inter-medullary (IM) rodding of the femur and the patellas underwent bilateral ORIF (<a href="/files/original/9696814c90d3a127b31bdde25d16906a.jpg">Fig. 15</a> and <a href="/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg">Fig. 16</a>). The patient was placed in a free knee Mobilizing Brace on the left leg and attached to a continuous passive motion dynamic suspension system immediately postoperatively. The right leg was maintained in a straight position and in a denotation boot to prevent the fractured femur from spinning on the IM rod. In two days, the left knee had 0-90° of pain free passive motion. Active motion on the right lower extremity was limited to 0-15° of motion. At that time, the patient's right leg was placed in a free knee Mobilizing Brace and bilateral passive motion began (<a href="/files/original/0be90617be2197739e9b7215c50adcc4.jpg">Fig. 17</a>). Right leg motion progressed to 0-90° passive motion in four days, while the left leg was maintained in the 0-90° range. (This passive motion device, providing bilateral application from one power source, can be adjusted for varying degrees of motion independent of each other by varying the tension on the attachment lines.) Ambulation training began utilizing the bilateral Mobilizing Braces with drop locks in position (<a href="/files/original/cdf2e11044f459004d4cc3bea3571520.jpg">Fig. 18</a>). The patient was fully ambulatory with this system, achieved full range of active motion in ten days, and was discharged. Passive motion was maintained for a longer period than normal due to the degree of articular damage to the patellas. <h3>Summary</h3> Passive range of motion has proven itself as a useful treatment modality for increasing or maintaining range of motion of the hip, knee, ankle, shoulder, and elbow. Clinically, we have observed improved wound healing and reduction of edema. Septic joints that are or have been opened and drained appear to clean up sooner than joints treated with only incision and drainage (I & D) and daily whirlpool. Patients are comfortable with reduced requests for pain medications. Patients also seem happier and this may be due to the fact that something is being done to help them get better on a continuous basis. Therapy time can now be devoted to improving muscle control and independent activity levels rather than painful ROM exercises. Of the 168 cases presented in this paper, all but two patients did or would have benefited from passive mobilization. The degree of success depended to a large extent on patient compliance. All patients who cooperated with this treatment modality improved their motion and reduced their hospitalization with two exceptions. One patient had undergone total knee replacement and was placed in CPM in the recovery room. Approximately 20° of motion was achieved initially. All attempts to increase her motion failed in that the 3D device would stall at a given point and reverse itself. The referring physician was contacted in order to report the difficulties. It was learned that the patient, some 40 years earlier, had undergone a spontaneous hip fusion probably due to infection. Conventional CPM can not be utilized for ROM of the knee if the hip is immobilized. The second failure was with a young sickle cell disease patient also having severe sepsis of the knee. All attempts of passive mobilization were painful and limited to less than 30° of flexion. The patient underwent arthrodesis of the knee and was later discharged with granulating wounds. Patients with fractures involving articular surfaces of the knee have done well with 0-90° of pain free active motion obtained in generally less than ten days. Depending on the degree of internal fixation or patient compliance, a cast brace was applied prior to discharge. As stated earlier, cast bracing and passive mobilization is a common treatment modality. References: <ol> <li>Burks. R.. Daniel. D,. and Losse. G.. "The effect of continuous passive motion on anterior cruciate ligament reconstruction stability." Amer. J. Sports Med., 212:323, 1984.</li> <li>Coutts, R.D., Toth C., and Kaita J.H., "The role of continuous passive motion in the rehabilitation of the total knee patient." Total knee arthroplasty-a comprehensive approach. Hungerford D. ed.. Baltimore: Williams & Wilkins, pp. 126-32. 1983.</li> <li>Dehne. E., Torp, R.P., "Treatment of joint injuries by immediate mobilization," Clin. Orthop. 77:218, 1971.</li> <li>Frank, C., Akeson, W.H., Woo, S.L.Y., Amiel, D., and Courts. R., "Physiology and therapeutic value of passive joint motion." Clin. Orthop., 100:113-125, 1984.</li> <li>Korcok, M., "Motion, not immobility, advocated for healing of synovial joints," J.A.M.A., 246:2005, 1981.</li> <li>Lynch, J.A., et al., "Continuous passive motion: A prophylaxis for deep venous thrombosis following total knee replacement," Scientific paper 143, AAOS 51st. meeting, 1984.</li> <li>Muller, "Influence of Training and of Inactivity on Muscle Strength." Arch. Phys. Med. Rehab., 51:449, 1970.</li> <li>Mooney, V., and Ferguson, A.B., "The influence of immobilization and motion on the formation of fibrocarti-lage in the repair granuloma after joint resection in the rabbit." J. Bone Joint Surg., 48A:1145, 1966.</li> <li>O'Driscoll, S.W., Kumar, A., and Salter, R.B., "The effect of continuous passive motion on the clearance of a hemarthrosis from a synovial joint: An experimental investigation in the rabbit," Clin. Orthop., 176:305-11, 1983.</li> <li>Perry, C.R., Evans, L.G., Rice, S., Fogarty, J., and Burdge, R.E., "A new surgical approach to fractures of the lateral tibial plateau," J. Bone J. Surg., 66A:1236, 1984.</li> <li>Richardson, W.J., and Garrett, W.E., Jr., "Clinical use of continuous passive motion," Contemp. Orthop., 10:75-79, 1985.</li> <li>Salter, R.B.: Presidential address, Canadian Orthopaedic Association, Halifax, N.S. J. Bone Joint Surg. 64B:251, 1982.</li> <li>Salter, R.B., and Hamilton, H.W., "Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: A preliminary report of a feasibility study," J. Orthop. Research, 1:325-342, 1984.</li> <li>Schebel, B.E., and Evans, J.P. "The use of continuous passive motion in the rehabilitation of total knee artho-plasty," Scientific poster, AAOS 52nd meeting, 1985.</li> <li>Steinberg, F.U., The Immobilized Patient, New York, Plenum, 1980.</li> <li>Strang, E.L., and Johns, J.L., "Nursing care of the patient treated with continuous passive motion following total knee arthoplasty," Orthop. Nursing, 3:27-32, 1984.</li> </ol> *Mel Stills, C.O. Mel Stills, CO., Instructor, Orthopedics, South Western Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235. *Dwain R. Faso, C.O. Dwain R. Faso, CO., Manager, Research and Development, 3D Orthopedics, 11126 Shady Trail, Dallas, Texas 75229. Page Number(s) 7 - 19 Year 1985 Volume 9 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Passive Mobilization: An Orthotist's Overview Creator An entity primarily responsible for making the resource Dwain R. Faso, C.O. * Mel Stills, C.O. * https://staging.drfop.org/files/original/502cd24e05dc13685ce6c563d104b2cb.pdf c70c27a74e2e66b798440e7ec879a61c https://staging.drfop.org/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg 951d63ffb5182b95b09608292e446731 https://staging.drfop.org/files/original/317321434223dd65228f625d548145c2.jpg 33aef1d70d11bb5ffc3b46cab9f52066 https://staging.drfop.org/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg a042157b9df13bf8aaf8981539c337b1 https://staging.drfop.org/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg 69bbd64c5529d66b42bce4a5ccfd1632 https://staging.drfop.org/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg 4beac600d40f940220fb8267dc991693 https://staging.drfop.org/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg e7c5d8fea44a345fc700a7ae696bd459 https://staging.drfop.org/files/original/a0c06126276a088136acdb56cfd72933.jpg 6eed0cb3b76b3a15c24cc44ef909fc88 https://staging.drfop.org/files/original/9b71e91d2b0275c07dda585373e86535.jpg 7777d3cc087d37eafb6b05901bd25113 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_02_019.pdf Text Any textual data included in the document <h2>Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics</h2> <h5>Kurt E.T. Oberg, M.D. <a style="text-decoration: none;">*</a></h5> This paper was presented for the American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Seminar, San Francisco, January 30-February 1, 1985. <h3>Swedish Cat/Cam History</h3> In the mid-70s, James Foort and some of his colleagues began to investigate the use of CAD/CAM principles in prosthetics and orthotics. Others had also started to work in biostereo-metrics. Some colleagues of mine in Sweden and I had initiated investigations in order to find modern technology which could be used in prosthetics and orthotics. Reports on this subject had already been published and showed promising possibilities for new techniques to be used. Interest in CAD/CAM, however, was very low in Sweden at this time. Prosthetists and orthotists were very skeptical of the value of this kind of technology as applied to the improvement of prosthetic and orthotic technique. Therefore, further attempts in developing CAD/CAM technology for prosthetics and orthotics in Sweden were dropped. This skepticism was understandable because at that time the new technique could not possibly give us as good quality results as was already possible with the traditional techniques. <h3>The Ispo World Congress In London</h3> During the 1983 ISPO World Congress in London, it became clear to Swedish prosthetists and orthotists who attended the congress that CAD/CAM techniques really had something to contribute to the field. The exhibition showed hardware such as measuring equipment and a milling machine which gave an example of the automated socket fabrication technique. As a result of the London Congress, the interest in CAD/CAM for prosthetics and orthotics became quite high in Sweden. <h3>Swedish Attempts</h3> There is now a definite interest in Sweden and Scandinavia to implement CAD/CAM techniques into the prosthetic and orthotic field. The large company, LIC, which provides over 60 percent of the prosthetic and orthotic service in Sweden, and which also has started service in other countries, has a clear intent to adapt CAD/CAM techniques to their work. The first area to be involved will be the orthopaedic shoe service. Another large prosthetic and orthotic service company, Een-Holmgren Orthopaedic Inc., is also following the work that is going on around the world in this field. There are some counties in Sweden that run prosthetic and orthotic services themselves and they, too, are very interested in following and adapting CAD/CAM techniques. They have decided to seek co-operation with the work that is done by the College of Health and Care in Munksjöskolan, Jönköping, Sweden. My intention is now to present the research and development activities in Jönköping. <a href="/files/original/3035cab4876d5e39dab2d7edc8f4280b.jpg">Fig. 1</a>: College of Health and Care Jönköping, Sweden <a href="/files/original/317321434223dd65228f625d548145c2.jpg">Fig. 2</a>: Relevant Laboratory Resources for CAD/CAM <a href="/files/original/0d927e9043f66bd3e3af11041dbd3773.jpg">Fig. 3</a>: Criteria on CAD/CAM in Prosthetics and Orthotics <h3>Competence And Educational Considerations</h3> The college runs the prosthetic and orthotic education programs for Sweden, Denmark, and Iceland. There are regular programs for orthopaedic engineers (2 1/2 years), prosthetic and orthotic technicians (two years), and orthopaedic shoe technicians (two years). Various types and lengths of special courses are also offered at the school. The educational program is connected to research and development activities and divided into three laboratories. One laboratory is called the Unit for Applied Orthotics and is testing and evaluating orthotic appliances for the Swedish Handicapped Institute. Another laboratory is the Orthotics Laboratory, which has been involved in the development of prosthetic and orthotic devices for more than 14 years. The newest laboratory is the Biomechanics Laboratory, which I started two years ago. There will be considerable consequences for a prosthetic and orthotic educational program when a technique like CAD/CAM is introduced into the orthotic and prosthetic field. The question for us is whether we should be passive and follow the development of techniques in different laboratories around the world, or whether we should be active in developing these techniques ourselves. The decision has been made that with regard to the resources and the competence we have in laboratories connected to the school, we should be active in development. There already are some relevant resources available at the laboratories. At the Biomechanics Laboratory there is equipment such as computers, digitizers, image processing equipment, and lasers. There is also experience with digital measuring technique, computer programming and prosthetic and orthotic biomechanics. The Orthotic Laboratory has a machine shop and design office experienced in prosthetic and orthotic development and the development of various instruments. <h3>Cad/Cam Philosophy Of The Biomechanics Laboratory</h3> The philosophy of CAD/CAM in prosthetics and orthotics at the college and at the Biomechanics Laboratory can be expressed by the following criteria: <a href="/files/original/0aec22109bbbab540a2b674c0f7b5c6d.jpg">Fig. 4:</a> The Principal Parts of the CAPOD System <a href="/files/original/c4eabe665ad4dd8ea652e3ce8c3d13c2.jpg">Fig. 5:</a> Specification of the Measuring Equipment <a href="/files/original/ecbbc4f77a47d1d78ba3db33d9c2c0bd.jpg">Fig 6:</a> Computer <ol> <li> The complete system should be available for each prosthetic and orthotic service shop. The alternative is a centralized organization where central units are put in place for the fabrication of the prosthesis from data and measurements taken at the clinics and sent to the central workshop. With this kind of centralized organization, the whole advantage of the CAD/CAM technique cannot be fully utilized. Patients change for various reasons and it is important to use the CAD/CAM system when there are changes or when modifications are necessary. This can increase the effectiveness of the service quite a lot. It also enables the prosthetist and orthotist to have a better control of the whole process when making a device. </li> <li> The system should require moderate investment. This criterion is only a consequence of the first criterion. </li> <li> Equipment of a very high specification (able to work to extremely close tolerances) should be avoided. Very high specification is generally not needed, but if it does not increase costs, it usually does no harm. However, machines or computer programs which are too generalized (that works to too coarse tolerances) can increase the cost of the system tremendously and consequently should be avoided. </li> <li> Individual 3-D shape sensing should be the basis for control of the numerically controlled (NC) milling machine. This is necessary in order to allow for individual variations that might occur, instead of working from more standard shapes, which is a simple but less effective way to work. </li> </ol> <h3>Objectives Of The Capod System</h3> There are potential possibilities for the use of CAD/CAM techniques in the whole prosthetic and orthotic field and the development that has been initiated at the Biomechanics Laboratory in Jönköping therefore uses the name CAPOD as an acronym of Computer Aided Prosthetic and Orthotic Design. The objective of this project is to develop a CAD/CAM system which fulfills the criteria mentioned above. The objectives of the CAPOD system are as follows: <ul> <li> To develop a CAD/CAM-system for prosthetics and orthotics as one complete unit based on a micro computer. </li> <li> The cost of the system should remain within the range of US$30-40,000. </li> <li> To allow commercially available video image processing equipment to be adapted for 3-D shape sensing. </li> <li> To encourage the development of a specially designed NC milling machine, costing less than US$12,000. </li> </ul> <a href="/files/original/a0c06126276a088136acdb56cfd72933.jpg">Fig. 7:</a> NC-Milling machine for CAPOD System <a href="/files/original/9b71e91d2b0275c07dda585373e86535.jpg">Fig. 8:</a> Principal Parts and Cost of the NC Milling Machine <h3>Technical Specifications And Project Status</h3> The principal parts of the CAPOD system will be a micro computer that controls both the measuring of the limb shape and also the NC milling machine by means of a measuring program, a CAD program, and a control program. Almost all these computer programs must be custom written. The fabrication cost of the whole system is estimated to be about $35,000. The principle of the shape sensing scheme is generally the same as that developed at the West Park Hospital in Toronto. The plan is to take a video recording of a laser illuminated contour of the limb at increments of one one-hundredth of a turn. The videogram will then be transferred to the computer via the MicroSight image processing system. The software in the computer then takes care of data reduction and will define the surface of a limb as a set of digital coordinates. The custom made CAD program will then modify the shape as specified by the practitioner in a manner that corresponds to the plaster cast rectification process that he does today. At present, a Victor micro computer from Victor Technologies, Inc. is being used. This computer is equipped with an Intel 8088 processor and has an internal memory of 256 Kb, which can be expanded to 896 Kb. It has 2 x 1, 2 Mb Floppy Disk, but a Hard Disk of 10,6 Mb is more likely to be used in the future. The monitor is 12" and has a graphic resolution of 800 x 400 pixels. It has been found that commercially available numerically controlled milling machines are not suitable in this application. They are too over-specified for our purpose and the objectives of the CAPOD system cannot be fulfilled with such machines. Early on it became quite clear that for our purposes, a specially designed milling machine had to be developed. After some investigations, a design proposal, as illustrated by the schematic drawing, has been developed. The cutting is controlled by the same type of coordinates as were used during the measuring procedure, i.e., the model will rotate in steps of one one hundredth of a turn. The X and Y coordinates of the cutter are then controlled by coordinates corresponding to the X and Y coordinates of the measured and modified contour. The travel of this stroke is such that models of torsos and whole legs can be made. An important feature of the machine is the high speed which has been achieved through the use of stationary motors. By using stationary motors and transmissions to power the cutter, the moving parts have quite low mass, which gives a low inertia and allows high speed. It would be possible to cut a model of about 30cm in length in two minutes. It is estimated that the fabricating cost of such a machine would be $10,000-11,000. Fifty percent of that cost is commercial parts—for instance, the control electronics for the stepper motors and the complicated transmissions. There are a few custom made parts, the whole chassis and assembling of the machine, which make up the other half of the cost. The specification of the system has been worked out in co-operation with the orthopaedic technical departments in Gothenburg and Boras. They are also deeply involved in the educational program. The development work has come into a practical and detailed phase, and the whole team is very enthusiastic and anxious to fulfill the objectives and make the CAPOD system a successful system. *Kurt E.T. Oberg, M.D. Dr. Oberg is Director of the Biomechanics Laboratory Jönköping City Council, Munksjöskolan, Box 1030-S-551, Jönköping, Sweden. Page Number(s) 19 - 23 Year 1985 Volume 9 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_019/1985_02_019-1.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 Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics Creator An entity primarily responsible for making the resource Kurt E.T. Oberg, M.D. * https://staging.drfop.org/files/original/b3a2c7a0584c7b41faa78f8463cf4268.pdf f252ffd28bf2d19a88c0995299dca5af 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_03_004.pdf Text Any textual data included in the document <h2>An Advanced Approach Toward Improved Prosthetic Fittings</h2> <h5>David F.M. Cooney, R.P.T., C.P.O. <a style="text-decoration: none;">*</a> Keith E. Vinnecour, C.P.O. <a style="text-decoration: none;">*</a></h5> The importance of amputation surgery and dedicated follow-up cannot be underestimated by those clinicians who deal with the amputee population. A prosthetist who receives a patient with a residual limb that is of the optimum configuration to receive a prosthesis and permits the lowest energy cost with maximum unilateral weight bearing comfort, is too often the exception. A concerted effort by all professionals involved—physicians, nurses, physical and occupational therapists, psychologists, social workers, and prosthetists—is required for truly successful rehabilitation. <h3>Delineation Of Level</h3> Successful primary healing in patients who have experienced a trauma related amputation is not as great a concern since the average age of this group is much younger than the dysvascular amputee. For the majority of patients who require prosthetic care due to vascular insufficiency, predictions for successful healing, and therefore level of amputation, is a critical consideration and of primary address here. The following discussion and techniques employed, however, can apply to all prosthetic fittings. In the dysvascular patient, the correct assessment of tissue viability and level of limb amputation is paramount to successful rehabilitation. Correct assessment also serves to reduce the length of the hospital stay and, therefore, costs. Patient morbidity and mortality are also reduced.<a></a> A number of methods are employed to determine amputation level. Absolute determinants include ischemia and necrosis. Skin temperatures, absence of hair, sensory deficits, and peripheral pulses are also clinical tools of relative, though unreliable, demarcation. A less direct way of determining level of amputation is the condition of the underlying tissues and skin bleeding during surgery.<a></a> Objectively defined methods are being used to more accurately determine surgical level. Doppler pressure measurements use systolic pressure differentials between the level of concern and brachial pressure. The literature cited offers relative values for prediction of successful healing,<a></a> but also points out the Doppler method's fallibility.<a></a> Two other non-invasive tests, segmental systolic pressure readings and pulse-volume recordings, can provide a reasonably valid prediction of primary wound healing, but should not be used as the sole indicators for amputation site.<a></a> Thermography has been used to estimate the optimal site of amputation. Infrared emissions from the involved extremity are displayed on a screen to show temperature differentials. One study claimed a 96 percent success rate with amputation levels recommended via thermography<a></a>. Skin blood flow by the Xenon-133 clearance techniques to predict primary healing levels in amputation surgery have shown positive results. A 100 percent primary amputation healing is claimed by these authors for surgeries where recommendations according to their standards were followed.<a></a> The choice of any of the above methods rests with the abilities of the institution. Though most non-invasive means are available throughout the medical community, invasive techniques using radioactive isotopes, like Xenon-133, require the availability of a nuclear medicine department. Clearly, not all facilities have this capability. Once the level of tissue viability and surgical healing have been determined, operative procedures commence. A residual limb offering optimal function should be a "well muscled, durable stump of effective length with a pliable skin cover that has adequate sensation." The means to this end requires careful attention to the handling of the bone, nerves, and soft tissues.<a></a> <h3>Surgery</h3> Subsequent to determining the amputation level is the actual surgical technique, which is an important adjunct to successful rehabilitation of the amputee. Handling of the bone requires close attention to the residual cortical shaping, and in standard practice it should be beveled to prevent sharp margins and potential socket problems.<a></a> The reaction of the bone to surgical handling of the periosteum is not fully understood, but when dealing with tissues that are compromised initially, one cannot fault a "kid-glove" approach to dissection and ligation. Delicate handling may avoid subsequent spurring along the bony margins.<a></a> It has generally been considered that fibular length should be less (approximately 2.0 cm.) than the length of the tibia.<a></a> The authors feel that fibular length should be equal to or no more than 5 mm. shorter than the cut tibia. It is felt that this improves prosthetic medio-lateral stability, provides greater distal bulk, and serves to prevent mature conical shaping and increase total tissue contact and weight-bearing. In the procedure described by Ertl,<a></a> the lengths of the two bones are equal. A bony bridge, or periosteal flap, is then created to afford an end bearing residual limb. This synostosis also prevents any relative motion of the two bones. The tibiofibular osteoplasty closes the open medullary canals and can recreate the normal conditions of direct weight bearing pressures and circulation in the long axis of the bone. This can help prevent degeneration in the joints proximal to the amputation.<a></a> It would seem that this procedure should warrant greater attention in appropriately selected patients (especially in light of the much improved fitting techniques now available). Establishing stabilization in the distal musculature at the selected site of amputation is important to provide a more physiologically effective residual limb. Where surgically feasible, the muscles should be sutured to each other as well as to the periosteum and/or bone without excessive tension or laxity. This allows for a well contoured and generally less prosthetically troublesome limb.<a></a> Nerve tissue should be handled meticulously to avoid residual problems once prosthetic wear is initiated. Each nerve should be individually dissected and have adequate traction applied. Severing of the nerve with traction maintained will cause it to retract far enough up into the soft tissue so as to be well protected and less threatened by weight bearing pressures.<a></a> Prosthetically crucial are the smaller sural and saphenous nerves, as they are sometimes neglected in lieu of the more major posterior tibial, deep and superficial peroneal nerves.<a></a> Redundancy of soft tissues should be avoided, but adequate coverage of the remaining structures is a must in order to provide a good limb for weight bearing. Closure of the wound should include careful suturing and handling of the already compromised tissues and care should be taken to avoid traction at the suture line so as to prevent contractures of the joint.<a></a> It has been shown again and again that immediate post-surgical fitting procedures can improve residual limb viability, reduce pain and edema, and prevent contractures.<a></a> Rigid dressings are common practice in immediate post-surgical fittings, but variations on this theme include the use of pneumatic devices that can also afford the advantages of their more rigid counterparts.<a></a> More tenuous situations that may not allow for early weight bearing and ambulation, secondary to healing problems, can be approached through the use of Una boot dressings<a></a> and an innovative removable rigid dressing technique.<a></a> Invariably, the independent and/or conjunctive use of any one of these methods can enhance the post-operative management of even the most difficult rehabilitation patient. By improving a patient's physical and mental status and by providing mobility through this approach, the clinical team can increase a patient's rehabilitation potential.<a></a> <h3>Prosthetic Evaluation</h3> Little has changed in the physical aspects of evaluation. Standard anthropometric measures are still used to provide an objective record for modifications and fabrication, and for comparative purposes related to future changes. Accurately determining the anatomical joint range of motion (both in the involved and uninvolved limb) and strength/stability can provide criteria for prescription and serve to mediate problems during fitting. One new tool in the evaluative process is Xeroradiography®. Xeroradiography® is a process that yields an x-ray image on an opaque background. The picture records are easier to store than their x-ray counterparts and provide a clear definition of both the bony anatomy and soft tissue. Evidence of bone spurring, vessel calcification, and presence of vascular surgery staples is readily observed. Measurements are also easy to glean. The use of this information in the treatment of the amputee is obvious and can significantly improve and objectify the prosthetist's skills and, ultimately, improve patient management.<a></a> <h3>Casting</h3> Adopting a "hands-on" technique in the quest of obtaining an anatomical replica of the residual limb should be the goal of the prosthetist. A careful volume study of the involved limb can serve to optimize the definitive results. The growing use of static and dynamic test sockets, and the information provided by them, has yielded a twist on the time tested practices utilized by many prosthetists. The technique of automatic build-ups over sensitive areas has been found to be less than necessary. Reversing this thought process to promote negative model modifications over areas of weight bearing can provide better total-contact, total-weight bearing sockets. Doing this in the molding process can reduce the amount of relatively educated guesswork necessary in cast modification by producing better initial cast molds. Methods which have been developed to aid in this pursuit include vacuum casting<a></a> or a three to four stage alginate casting technique.<a></a> Another method to improve fit from the initial casting is to work toward a more dynamic casting method. As the casting is predominantly done under non-weight bearing conditions, working toward more "dynamic" casting methods which equalize the weight bearing pressures is warranted consideration. Where an Ertl procedure has been performed, distal weight bearing casting is preferred to achieve maximum results. The same intent should be attempted with the non-Ertl distal end as well. Ultimately, the better the quality of the cast and the less initial modification guesswork, the better the test socket fitting. <h3>Test Socket</h3> Use of clear test sockets for improving fit is well documented in the literature cited. Though the technology for transparent test sockets has been available since the 1950's, the current practice of direct weight bearing modifications to the socket are relatively new.<a></a> During the initial static weight bearing period, areas of the residual limb are demarcated according to weight distribution and, therefore, load. This is evidenced by varying degrees of blanching or redness. The goal of a total tissue bearing socket is then pursued to decrease areas of excessive pressure (blanching) and to increase areas of inadequate loading (redness). This goal can be met through either static or dynamic test socket volume changes, or cast model modifications. Under weight bearing conditions, loose areas are marked by redness, and tension analysis is accomplished via "poking" the tissue through holes made in the socket. Various injectable materials (glycerine, alginate, pour-a-pad) are then added to equalize weight bearing pressures. Areas of excessive weight bearing, if not relieved by the weight borne by the newly injected materials, are either relieved in the socket or modified on the master mold. By achieving a careful stump-socket interface tension analysis as described, greater confidence in he ultimate result and an optimum fit is possible. Difficulty of fit dictates the number of check socket fittings. Unfortunately, fittings are also affected by the reimbursement source. The fact is undeniable, however, that a transition to the use of transparent test socket fittings can increase the level of prosthetic expertise and elevate the profession to a higher plateau of fitting success. <h3>Dynamics</h3> Advancements in prosthetic componentry and gait analysis techniques, when used in conjunction with improved evaluation tools and fitting methods, provides a greater arsenal for the prosthetist seeking to optimize his patient's abilities. An exciting variety of new techniques are surfacing throughout the country which not only render prosthetics more professionally demanding to the practitioner, but also challenging to the patient. Different socket styles and theoretical bends are adding to current thought and practice. The above-knee amputee now has a variety of alternatives in not only socket material and construction, but in functional design as well. The Swedish flexible socket offers a lighter weight, more "natural" feeling socket to the AK amputee. It also allows for greater transmission of heat via the polyethylene or Surlyn® material, and therefore a cooler feeling. The flexibility of the socket also encourages physiological muscle activity and provides sensory feedback through the thin material.<a></a> Contoured Adducted Trochanteric Controlled Alignment Method (CATCAM) is an exciting new above-knee socket design. Proponents claim it increases comfort secondary to total soft tissue weight bearing, because the ischial tuberosity is no longer on the "seat" of the conventional quadrilateral design, but contained within the socket. The CATCAM also allows for more natural muscle activity by virtue of both the flexible design (a la Swedish flexible socket) and inherent socket mechanics. By improving the socket's purchase on the femur, whereby the ischium, trochanter, and adductor longus tendon are in essence "locked-in," stabilization increases, which then decreases the Trendelenberg tendencies experienced by many above-knee amputees. By obtaining a definite position of adduction of the femur, one can take advantage of the muscle stretch of the gluteus medius and therefore increase pelvic control with unilateral weight bearing.<a></a> Ultralight weight components continue to be preferred in the above-knee prosthesis. The availability of titanium, carbon graphite, and higher density plastics in the manufacturing of the pylons, joints, and attachment plates allow for lighter weight limbs and, ultimately, decreased energy costs for the amputee. The below-knee amputee has a varied repertoire of options. A greater array of suspension methods—latex rubber, neoprene sleeves, total suction prostheses—are now available. The Flex-foot prosthesis<a></a> utilizes a sleeve suspension and is comprised of a carbon graphite and fiberglass pylon and a heel that is very strong, light weight, waterproof, and energy cost effective. The Flex-foot design provides "stored energy" upon weight bearing that "propels" the amputee forward, mimicking "normal" muscle activity in gait. This can also be used for the above-knee amputee. The Flex-foot is proving to be a great advance toward increasing the abilities of the athletic amputee and shows great promise for the elderly and less physically challenged. New liner materials have also provided alternatives for the below-knee amputee, with greater comfort as a result. Silicone gel and leather liners,<a></a> Ipocon gel,<a></a> and injection molded silicone gel liners<a></a> offer the amputee who has minimal tissue coverage and/or scarring the benefit of shock absorption and a "new skin" type feel. The active, athletic below-knee amputee also captures the benefit of the gel system and suffers less trauma as a result. Prosthetic feet, such as the Seattle<a></a> foot and S.A.F.E.<a></a> foot, appear to offer better gait characteristics and function, and also allow for increased activity by virtue of their functional, flexible designs. Ancillary methods of evaluating and improving gait performance are making their way into the more aggressive practices. John Sabolich, C.P.O.<a style="text-decoration: none;">*</a> in Oklahoma City has been utilizing a bio-feedback device with his above-knee patients in an attempt to re-educate the gluteus medius muscle during gait training. Utilizing the system in a dynamic fashion, i.e. patient ambulating with the electrodes over the targeted muscle, provides the patient audible feedback of muscle activity. Use of a video tape camera also provides patients with optimum benefits during the alignment and gait training period.<a></a> Careful analysis of the saggital and frontal views provides the practitioner with a better opportunity to critically analyze and improve his patient's gait. Improved problem-solving subsequent to delivery is also a benefit of this technique. The film serves as a learning tool for the new amputee and the practitioner, and also serves as a record of a patient's progress and delivery status for ironing out future fitting problems relative to gait induced complaints. The Computer Aided Design, Computer Aided Manufacturing (CADCAM) technique<a></a> is presently available for use in designing below-knee prosthetic sockets and will soon be available for design of above-knee prosthetic sockets as well. Measurements are taken from the residual limb and entered into the program. A screen display then allows for modifications to be made relative to the entered data and design scheme. Once the design is created, the information is transmitted to a computerized milling device that then carves out a model of the residual limb. From this model a socket is fabricated from polypropylene. In the future, "shape-sensing" will allow for modifications from the sensed data rather than the standard methodology. The ability to draw from the digitalized information of Computerized Axial Tomography (CATSCAN) or x-rays is also in the offing. This system is also an excellent, accurate record keeping tool. The potential to "sense" size and shape, store the information, recall, modify, or duplicate as desired is an enticing prospect. Further research is both warranted and forthcoming. <h3>Conclusion</h3> With the advent of better technology and methods, a concomitant increase in prosthetic professionalism occurs. Improved education must also follow. Industry-wide attention to continuing the trend will help prevent our field from lapsing into the mundane. The practice of this increased professionalism and improved techniques also commands a higher cost. Jan Stakosa, C.P.'s<a style="text-decoration: none;">*</a> method of using a wide variety of componentry per patient during the fitting and alignment phases in order to optimize function not only serves to improve the patient's quality of life, but carries with it an increased time commitment and cost. Due to this increased input and component variability, thorough education of the public and professionals per the costs involved is required. Ultimately, third party payers and the government will also have to be addressed. Until such time as these practices and advancements become standard, there will not be reimbursement for them.<a></a> How do you value human needs in a marketplace in which the trend is toward price reduction? The reality is that all these advances will increase the cost of prosthetic care. Prosthetists, the public, third party payers, and the government will need to be willing to improve the quality of life for this sector of the population, who deserve to be rehabilitated to the maximum and be allowed to perform as well as any able-bodied individual. It is our hope that the prosthetic industry will take up the challenge to advance the profession and invest the time in testing preferred methods and improvements. Equally important is the quest to participate in their creation. Through improved knowledge of the mechanics of amputation surgery and the variables of follow-up care, combined with mutual professional dialogue, we can better serve the amputee population. References: <ol> <li>Barnes, R.W.; Shanik, G.D.; and Slaymaker E.E., "An index of healing in below-knee amputation: Leg blood pressure by Doppler ultrasound," Surgery 79(1):13-20, 1976.</li> <li>Bonner, F.J. and Green, R.F., "Pneumatic airleg prosthesis: Report of 200 cases," Archives of Physical Medicine and Rehabilitation, 63:383-385, 1982.</li> <li>Burgess, E.M., "General principles of amputation surgery," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, Ch. 2, p.p. 14-18, 1981.</li> <li>Burgess, E.M., "Postoperative management," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, Ch. 3, p.p. 19-23, 1981.</li> <li>Burgess, E.; Hittenberger, D.; Forsgren, S.; and Lindh, D., "The Seattle foot," Orthotics and Prosthetics, 37(1):25-31, 1983.</li> <li>Campbell, J. and Childs, C, "The S.A.F.E. Foot," Orthotics and Prosthetics, 34(3):3-16, 1980.</li> <li>Cary, J.M. and Thompson, R.G., "Planning for optimum function in amputation surgery," Atlas of Limb Prosthetics: Surgical and Prosthetic Principles, St. Louis, MO, Mosby, p. 28, 1981.</li> <li>Ertl, J., "Uber amputationstumpfe," Chirurg., 20:218, 1949.</li> <li>Gibbons, G.W.; Wheelock Jr, F.C.; Hoar Jr, CS., et al, "Predicting success of forefoot amputations in diabetics by noninvasive testing," Archives of Surgery, 144:1034, September, 1979.</li> <li>Graves, J., "Selectively placed silicone gel socket liners," Orthotics and Prosthetics, 34(2):21-24, 1980.</li> <li>Hanak, R., "Fabrication procedures for the ISNY above-knee flexible socket (instruction manual)." Course at New York University, Post-Graduate Medical School, Prosthetics and Orthotics, January, 1984.</li> <li>Henderson, H.P. and Hackett, M.E.J., "The value of thermography in peripheral vascular disease," Angiology, 29:65-71, 1978.</li> <li>Hittenberger, D.A. and Carpenter, K.L., "A below knee vacuum casting technique," Orthotics and Prosthetics, 37(3): 15-23, 1983.</li> <li>Ipocon Silicon Liner Technical Manual. IPOS, Lune-berg, West Germany.</li> <li>Kerstein, M.D., "Utilization of an air splint after below-knee amputation," American Journal of Physical Medicine and Rehabilitation, 53(3): 119-126, 1974.</li> <li>Koniuk, W., Personal communication. San Francisco Prosthetic-Orthotic Service, Inc., San Francisco, 1985.</li> <li>La Noue, A.M., "More on Ertl tibiofibular synostosis," Newsletter . . . Amputee Clinics, (V)4:3-4, July, 1973.</li> <li>Leal, J., "The Flex-foot prosthesis" (instruction manual). Presented at UCLA Prosthetics Education Program, Advanced Below Knee Prosthetics Saturation Seminar, October, 1984.</li> <li>Loon, H.E., "Below-knee amputation surgery," Selected Articles from Artificial Limbs, January 1954 - Spring 1966. Huntington, NY, Krieger, p.p. 305-318, 1970.</li> <li>Malone, J.M.; Leal, J.M.; Moore, W.S.; et al., "The Gold Standard for amputation level selection: Xenon-133 clearance," Journal of Surgical Research, 30:449-455, 1981.</li> <li>Malone, J.M.; Moore, W.S.; Leal, J.M. and Childers, S.J., "Rehabilitation for lower-extremity amputation," Archives of Surgery, 116:93-98, January, 1981.</li> <li>Mehta, K.; Hobson II, R.W.; Jamil, Z; et al., "Fallibility of Doppler ankle pressure in predicting healing of transmetatarsal amputation," Journal of Surgical Research, 28:466, 1980.</li> <li>Mooney, V. and Snelson, R., "Fabrication and application of transparent polycarbonate sockets," Orthotics and Prosthetics, 26(1):1-13, 1972.</li> <li>Moore, W.S.; Henry, R.E.; Malone, J.M.; et al., "Prospective use of Xenon Xe 133 clearance for amputation level selection," Archives of Surgery, 116:86-88, January, 1981.</li> <li>Pike, A.C. and Black, L.K., "The orthoglas transparent test socket-an old idea, a new technology," Orthotics and Prosthetics, 36(4):40-43, 1982-83.</li> <li>Pollack Jr, S.B. and Ernst, C.B., "Use of Doppler pressure measurements in predicting success in amputation of the leg," American Journal of Surgery, 139:303, 1980.</li> <li>Reger, S.I.; Letner, I.E.; Pritham, CH.; et al., "Applications of transparent sockets," Orthotics and Prosthetics, 30(4):35-39, 1976.</li> <li>Sabolich, J. and Guth, T., "The C.A.T.C.A.M. above knee prosthesis pilot course" (instruction manual). Course at UCLA Prosthetic Education Program, March, 1985.</li> <li>Saunders, C.G., "Computer-aided socket design: A computer-aided design and manufacturing package for fitting below-knee amputees with sockets," Medical Engineering Resource Unit, Shaughnessy Hospital, Vancouver, BC, Canada, March, 1984.</li> <li>Saunders, C.G. and Fernie, G.R., "Automated prosthetic fitting." Proceedings of the 2nd International Conference on Rehabilitation Engineering, Ottawa, 1984.</li> <li>Schmitter, E.D., "Surgical principles and practice: Lower Extremity amputations." Lecture-Prosthetics and Orthotics Course for Physicians and Therapists. Provided by Prosthetic-Orthotic Education Program, School of Medicine, Department of Surgery (Orthopaedics). University of California, Los Angeles, April 5-9, 1982.</li> <li>Staats, T.B., "Advanced prosthetic techniques for below knee amputations," Orthopedics, 8(2):249-258, 1985.</li> <li>Stakosa, J.J., "Prosthetics for lower limb amputees," Vascular Surgery: Principles and Techniques, Norwalk, CT, Appleton-Century-Crofts, p.p. 1143-1162, 1984.</li> <li>Sterescu, L.E., "Semirigid (Una) dressing of amputations," Archives of Physical Medicine and Rehabilitation, 55:433-434, September, 1974.</li> <li>Varnau, D.; Vinnecour, K.E.; Luth, M.; and Cooney, D.F., "The enhancement of prosthetics through Xerora-diography," Orthotics and Prosthetics, 39( 1): 14-18, 1985.</li> <li>Whipple, L. and Stakosa, J., "The not so simple ABC's of high technology," Disabled USA, Washington, D.C., July, 1983.</li> <li>Wu, Y.; Keagy, R.D.; Krick, H.J.; et al., "An innovative removable rigid dressing technique for below-the-knee amputation," Journal of Bone and Joint Surgery, 61-A(5):724-729, 1979.</li> </ol> <div style="width: 400px;">Footnote Jan Stakosa, C.P. is Director of the Institute for the Advancement of Prosthetics, Lansing, Michigan. John Sabolich, C.P.O., is Vice-President of Sabolich Orthotics-Prosthetics Center, Oklahoma City, Oklahoma. </div> <div style="width: 400px;">*Keith E. Vinnecour, C.P.O. Keith E. Vinnecour, C.P.O., is owner and president of Beverly Hills Prosthetics Orthotics, Inc., Beverly Hills, California. *David F.M. Cooney, R.P.T., C.P.O. David F.M. Conney, R.P.T., C.P.O., is a senior vice-president at Beverly Hills Prosthetics and Orthotics, Inc. </div> Page Number(s) 4 - 9 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Advanced Approach Toward Improved Prosthetic Fittings Creator An entity primarily responsible for making the resource David F.M. Cooney, R.P.T., C.P.O. * Keith E. Vinnecour, C.P.O. * https://staging.drfop.org/files/original/cc46ad414ca9f0d932c9c1bd427dabc4.pdf 497441a68e5f2a4eef555521963106c4 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_03_010.pdf Text Any textual data included in the document <h2>The New Revolution</h2> <h5>Timothy B. Staats M.A., C.P. <a style="text-decoration: none;">*</a></h5> The recent development and proliferation of advanced and precision fitting techniques in prosthetics have caused many prosthetists to reevaluate those principles which were held sacred for the past twenty years. In the last three years in particular, both below-knee and above-knee prosthetics have undergone tremendous changes. Many progressive practitioners recognize that the term "Patellar Tendon Bearing (PTB)" is no longer considered descriptive of a well designed below-knee socket and use the term only in a historical sense. The term Total Surface Bearing better describes what has superseded PTB philosophy. In above-knee prosthetics, a greater revolution is in the offing. Now the CATCAM (Contour-Adducted-Trochanteric-Controlled Alignment Method) socket is shaking the underpinnings of the Quadrilateral above-knee socket design. For those of us who are "dyed-in-blue-and-gold-UCLA-Quad-socket" prosthetists, it is both difficult and exciting to see the development and confusion a rival design causes throughout the profession. I am sure that thirty years ago the "wood-socket-plug-fit" prosthetists shared a similar feeling when the quadrilateral socket and later the introduction of plastics caused their world to turn upside down. The point is that change and improvement are inevitable. You can fight it and it will flow over you like a river, or you can go with the flow and learn to adapt to new techniques. I have been asked repeatedly what I think about the use of multiple check socket fittings, CATCAM, alginated check sockets, and the Flex-Foot. The list goes on and on. American prosthetists in particular must understand that we are in the midst of a full blown revolution and the results of this revolution will set the path we follow for the next couple of decades. Rather than question what is right or wrong without really having proof of either, I have chosen a path as the director of a prosthetics education program of "pouring fuel on the fire." What better time or place for controversy than at UCLA, where the first school was started over thirty years ago. Is all this extra precision and care really necessary to accurately fit an artificial limb? The answer is quite simple, and if you are an amputee the question is repulsive. If superior techniques that can improve the quality of the care provided to amputees are available but are not used, it is nothing less than criminal. There are those who would question: how much of a good thing is enough? That is a question that the patient must answer and the prosthetist must decide based on knowledge and education. The fact that many of the newer techniques and fitting regimes demand more time and effort than methods which have been in use for twenty years is entirely a separate issue. While it may not be possible to provide these services for the reimbursements, which are now received from payment sources, this does not mean that the techniques do not work or are wrong. It only means that the third party payers are ignorant of changes which have occurred in our profession and must be introduced to the benefits of new procedures. This same principle applies to prescribing physicians. It is totally fair to say that a physician who took his prosthetics-orthotics training over five years ago is now out of date. The same is true for practitioners who have not upgraded their practices through educational opportunities during this period. It is always uncomfortable when you begin to wonder whether you are doing the best you can for your patient. It is even more uncomfortable when you know you are not. We should never be satisfied with our work and never doubt that a better job can be done. With such a philosophical upheaval running rampant through our profession, the time for learning is now. Are you satisfied with application of outdated techniques, or are you willing to enter a new era of prosthetic and orthotic practice? The choice is yours. *Timothy B. Staats M.A., C.P. Timothy Staats, M.A., CP., is Adjunct Assistant Professor and Director of the Prosthetics &Orthotics Education Program at UCLA, Rehabilitation Center, 1000 Veteran Avenue, Rm 22-41, Los Angeles, CA 90024. <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The New Revolution Creator An entity primarily responsible for making the resource Timothy B. Staats M.A., C.P. * https://staging.drfop.org/files/original/ff3340abee0b201874784eb994f1540f.pdf c2e3cc34fa9285809d54831e90850af8 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_03_011.pdf Text Any textual data included in the document <h2>The Role of Test Socket Procedures in Today's Prosthetic Practices</h2> <h5>Michael J. Quigley, C.P.O. <a style="text-decoration: none;">*</a></h5> The proper role of a test socket procedure is a controversial topic in today's practice of prosthetics. A test socket procedure can be defined as that stage in the design of a prosthesis when a socket is fabricated solely for the purpose of determining proper socket fit. Although test sockets were originally used for upper limb prostheses, the true advent of the test socket was in 1972 when Mooney and Snelson<a></a> described the polycarbonate clear test socket as developed at Rancho Los Amigos Hospital. During the 13 years since that article, the proper role of the test socket procedure has still not been defined. There are several reasons for the controversy over test sockets. First, when a test socket procedure is done, there is an implication that the mold, mold modifications, and socket design principles instilled in the prosthetist may not be correct. After all, if the prosthetist's techniques were perfect, the socket would fit perfectly and the need for a test socket would be obviated. However, any time a clear test socket is used, the prosthetist immediately notices a few things he would like to change in the definitive socket or, in some cases, the next test socket. It is safe to say that the majority of United States prosthetists believe in the value of test sockets and use them on a regular basis. Indeed, insurance companies and most other third party reimbursers, including Medicare, pay for test sockets, thereby recognizing twin values. A test socket procedure makes good sense, and there is no question that it improves prosthetic fitting. However, it is also true that many prosthetists do not use these sockets, or use them only rarely. The group that does not use test sockets feels that they can fit nearly all prostheses well without test sockets and do not want to spend the additional effort that test sockets require, or they simply do not want to change the methods they learned many years ago. The present Veterans Administration's (VA) procedure for obtaining approval for test sockets seems to favor this latter group, since it is an intentionally cumbersome system that, in effect, discourages test socket procedures on VA patients. Test socket users also include prosthetists who routinely use multiple test sockets on every patient, with the principle that each successive socket brings you one step closer to the perfect fit. If one test socket procedure is good, shouldn't two be better? Or three? Or more? This is a major area of controversy that could be discussed here but not resolved. Probably the best example of this use of test sockets is at the Institute for the Advancement of Prosthetics (IAP) in Lansing, Michigan (although a number of other prosthetic practices are also using multiple test sockets, or featuring them as a type of "first class" service). An average of six test socket procedures are done on each patient in Lansing: beginning with static fittings in clear sockets with the patient wearing no prosthetic socks, going on to clear socket dynamic (walking) fittings, and progressing to a definitive socket with a gel liner for below knee amputees. The patient is seen every day for two to three weeks until the socket fit is perfected, and only then is the prosthesis finished. This, of course, is an expensive undertaking, but it seems logical to assume that with so much time and energy spent, the patient would end up with a better fit. The multiple test socket users lead an Utopian existence, seeking the perfect fit, and see only one or two patients every week or continue fittings for many months if they are seen only on a weekly basis. For the average prosthetist who fits 100 or more patients alone each year, the sheer logistics of using multiple test sockets on every patient is staggering. Another area of controversy regarding test sockets is that they provide an incentive for prosthetists to delay being satisfied with the socket fit if they are paid separately for every test socket used. If they fit six test sockets, they are paid six times more than if they fit one test socket. The only response to this problem is that there are a few difficult cases where the only way a good fitting can be achieved is with multiple sockets, and the prosthetist should be reimbursed for his effort. On the other hand, there are always the few people who will abuse the system. In practice, less than five percent of all prosthetists have the time or inclination to routinely use multiple test sockets. After all, there are also very few patients or insurers who want to bear the expense, are able to make all the appointments necessary, and are willing to wait the many months for a finished prosthesis when multiple test sockets are used. Before summarizing, one final comment is necessary. Having test socket procedures available and using test sockets properly are two different things. There are no standardized, recommended, or documented procedures for the proper use of a test socket. Some people use clear sockets, some do not. Some use "wet fit" procedures with no prosthetics socks; others use prosthetic socks. Some test sockets are used statically, others dynamically. Alginate procedures are used in some areas. Even when a clear socket is used directly against the skin, how do we interpret what we are seeing? The result of the confusion over the proper use of a test socket is that the prosthetist converts one of the few objective tools he has available (a clear socket) into a subjective one by having to use educated guesses to determine the modifications needed to improve socket fit. The whole area concerning the optimum use of test socket procedures is in great need of study and documentation. In summary, test socket procedures are good procedures. When a prosthetist knows that the socket he is fitting is not the final product, he is more likely to make major socket modifications and, therefore, less likely to provide a poor fitting prostheses. Multiple or successive test sockets will always be required on a few difficult cases. In some areas, the patient and prosthetist will afford the luxury to use successive test sockets to try to achieve the perfect fit, but this will probably include less than one percent of the patient population. It is obvious that these socket procedures are here to stay and that the use of test sockets will increase as new materials and techniques are introduced. Hopefully, some meaningful documentation will be developed to enable prosthetists to obtain as much information as possible from a test socket procedure. Without a true understanding of how to properly use a test socket, each prosthetist is left to practice and develop his own technique, and the art of prosthetics again overwhelms the science. References: <ol> <li>Mooney, V. and Snelson, R., "Fabrications and Applications of Transparent Polycarbonate Sockets," Orthotics and Prosthetics, 26 (1), p.p. 1-13, March 1972.</li> <li>Personal communication, Jan Stokosa, CP., May 6, 1985, Lansing, Michigan.</li> </ol> *Michael J. Quigley, C.P.O. Michael J. Quigley, C.P.O. is President of Oakbrook Orthopedic Services, Ltd. 1 South 132 Summit Ave, Ste 102, Oakbrook Terrace, IL 60181.   Page Number(s) 11 - 12 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of Test Socket Procedures in Today's Prosthetic Practices Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/3c4ac589e8903780aa0da08c35aaeb58.pdf c97b050714fb3e489b9de161df583e40 https://staging.drfop.org/files/original/e764f2e58593ada37005d3d671580fcc.jpg e1b3b3b57afea255233eea6635c36111 https://staging.drfop.org/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg 6fcb2c844c796a0566c819a3ec665430 https://staging.drfop.org/files/original/3f65a33756d243d9afabd2712fe9240b.jpg 7e2a8536aa8f9635302e070c9e7f99ca https://staging.drfop.org/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg 95b1799693489eae13885500343e64d2 https://staging.drfop.org/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg c17a38b68b4a2e9a28ba4bfc88b46ab0 https://staging.drfop.org/files/original/a9f74838bb3d260e38168c79e38c620a.jpg c910911d2c29aac18ef5344138533538 https://staging.drfop.org/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg 29990018762f14ec45b71e8106effaaf https://staging.drfop.org/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg f505f6705bbc9e93d3772e72f9a5b118 https://staging.drfop.org/files/original/f88f0a978929d9669ad1e8001308498d.jpg 2ed82df089dc35c181a50d43ec37a98e https://staging.drfop.org/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg 560f2db154b03d37f12eb9b6d864e7d2 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_03_013.pdf Text Any textual data included in the document <h2>A Below-Knee Weight-Bearing Pressure-Formed Socket Technique</h2> <h5>Robert F. Hayes, CP. <a style="text-decoration: none;">*</a></h5> I'm pleased that the Academy has requested that I update and rewrite the Below-Knee Weight-Bearing, Pressure-Formed Socket Technique article I originally wrote in 1975. It's hard to believe that ten years have passed since the original publication of this paper. I haven't made any significant changes regarding the principles or application of this procedure, but let's go back to some of the reasons this concept was developed. <a href="/files/original/e764f2e58593ada37005d3d671580fcc.jpg">Fig. 1.</a> Place a sheet of plastic wrap, such as Saran, over the patient's stump to keep it clean and to ease removal of the cast. As I explained in the original article, my son was being fitted for ski boots and it occurred to me that we might make use of some of the techniques used by ski boot designers. The ski boot had an inflatable inner bladder. With the foot under weight-bearing, a conforming material similar to certain silicone compounds was injected into the bladder to give a perfect form-fitting in the attitude of weight-bearing. The incentive to apply this technique to limb prosthetics was reinforced while I was casting a below-knee patient who was a dentist. We exchanged thoughts on molds and changes when pressures are applied. Dentists take one mold for a cast which is filled with dental impression cream (similar to alginate). This is applied to the patient under pressure to give a more accurate impression, and then this is filled to form the definitive positive mold. The standard method of fitting a below-knee amputee involves taking a negative cast in a non-weight-bearing condition, forming a positive model, modifying it in size to present dimensions by removing material to create pressure, and applying material to relieve pressure on the stump as appropriate. A socket is then molded over this model with the hope that, with small adjustments, it will fit the patient. Wouldn't it be wiser to develop a socket under pressure that will adjust to and fit the patient, rather than fit the patient to the socket? In trying to answer this question, the procedure described here was developed. <a href="/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg">Fig. 2</a>. Apply cast sock and felt relief pads. <a href="/files/original/3f65a33756d243d9afabd2712fe9240b.jpg">Fig. 3.</a> Using Plaster-of-Paris, wrap the residual limb in the usual manner. <a href="/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg">Fig. 4</a>. Remove the tube gauze and felt buildup from the negative cast. <a href="/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg">Fig. 5.</a> Pour and modify the positive model. <a href="/files/original/a9f74838bb3d260e38168c79e38c620a.jpg">Fig. 6</a>. Build up the distal end of the positive model at least 1". <h3>The Procedure</h3> Measure the patient in the usual manner. Place a sheet of plastic wrap material, such as Saran, over the patient's stump to keep it clean of indelible pencil, and to make removal of the cast easy. If a wool sock is to be used, apply it, and then apply the plastic wrap. Apply a cast sock or tube gauze over the stump. Bond 1/4" felt over all pressure-sensitive areas: the crest of the tibia and the head of the fibula. Keep in mind that all areas being built up will be filled with alginate to give contact, yet minimizing pressure. There are some prosthetists who have adopted this technique and claim they apply direct pressure over the crest of the tibia. My experiences do not agree with that. In particular, since many of our patients are diabetic with very thin skin, extra caution should be taken to reduce pressure and especially friction over all bony prominences. Using elastic Plaster-of-Paris bandage 4" wide, wrap the stump in the usual manner, and reinforce with 3" or 4" wide regular plaster bandage. Remove the cast and remove the tube gauze and felt buildup from the negative cast. Pour the positive model, remove the negative cast, and modify in the usual manner, but do not touch areas that were covered with felt. Build up the distal end of the positive model at least 1". <a href="/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg">Fig. 7.</a> Set up the transparent check socket for dynamic alignment. <a href="/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg">Fig. 8.</a> Pour the alginate and let it escape through the distal holes until the patient is lowered into the socket to the proper level at which time the holes are blocked. The alginate will then escape along the proximal brim of the socket. Make a check socket. This is a perfect application for vacuum-forming. Plaster bandages or laminates can, of course, be used. Drill two holes 1/4" in diameter in the distal end and rough up the inside surface of the socket. For the first fitting, apply the stump sock of choice, and place plastic "wrap" over the stump sock to act as a separator. An invaginated balloon will not work because it adheres to the alginate that is to be used later. Some prosthetists apply the check socket to the patient's bare stump (no socks) for visual inspection. It bothers me to think what happens to the fit of this socket when the prosthesis is finished from this exact mold and the patient applies the usual stump sock of 3-ply or 5-ply. When the check socket is applied on new patients, I recommend using a thin-fitting sock in anticipation of stump atrophy. On seasoned, well-shaped stumps, I use the same sock that the patient usually wears. When using inserts that tend to compress, i.e. Pelite®, you may use a 3-ply and, after several weeks of prosthetic use, the socket should accommodate a 5-ply sock. Of course, there are many factors to be considered, and this is the area where the prosthetist's knowledge and experience will play the major role as to how well his or her patient does. Mix about 1/2 pint of dental impression cream or alginate (which is more economical). Pour about 1/3 of the total amount in the distal part of the socket and, with a spatula, spread the rest around the remaining surface of the socket. It is necessary to work quickly at this point. Place the socket on a fitting stool adjusted for height. Use some sort of pad to prevent slipping and cover the drilled holes in the socket with your thumb and forefinger. Have the patient place his stump in the socket. Let the alginate escape through the distal holes until the patient is lowered into the socket to the proper level, at which time the holes are blocked. Alginate will now escape along the proximal brim of the socket. <a href="/files/original/f88f0a978929d9669ad1e8001308498d.jpg">Fig. 9.</a> The completed socket. <a href="/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg">Fig. 10</a>. The completed socket. As soon as the alginate has set up, remove the stump from the socket and immediately fill the socket with plaster. The rigid socket and alginate are removed by using a cast cutter. The mold resulting is a perfectly smooth, pressure-formed, positive mold that can be used in any method of fabrication desired. When this technique is used, patients can be fit with sockets without soft liners. Only a minimal amount of additional time is required. I feel that the technique allows better fitting of "problem" stumps and that it may be used as a routine procedure to advantage, especially in central fabrication systems. Vacuum-forming procedures recently introduced make this approach to fitting even more attractive. We have since switched to clear plastic check sockets for the obvious advantage of visual inspection and also the ability to adjust check socket pressure areas with a heat gun on some plastics. We also now fit the check socket on the adjustable leg, rather than the fitting stool. This better simulates the pressures exerted on the stump by the definitive prosthesis, since we all agree that socket alignment greatly affects the application of pressure. I know that this procedure has been used by many prosthetists in various parts of the country, and I have received many favorable comments about the benefits to the patient. This pleases me because this is the goal of the process. I'm sure that in the future new devices and innovations will continue to add to and improve this concept to even greater benefit of the patient. *Robert F. Hayes, CP.President of Hayes Prosthetics, Inc., 1309 Riverdale Street, West Springfield, Massachusetts 01089. Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Below-Knee Weight-Bearing Pressure-Formed Socket Technique Creator An entity primarily responsible for making the resource Robert F. Hayes, CP. * https://staging.drfop.org/files/original/02b69054e99fc08b4b12033c4c735d90.pdf a11820a4a41bad505f07eb0c2b9d0fc9 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_03_017.pdf Text Any textual data included in the document <h2>Gait Analysis</h2> <h5>Ronald F. Altman, C.P.O. <a style="text-decoration: none;">*</a></h5> The following series of articles on Gait Analysis were based on a project which was supported by the Newington Children's Hospital Research Fund. The following series of articles all have to do with using gait analysis, in orthotics as well as prosthetics, to improve function. The Gage/Hicks study traces gait analysis in prosthetics from Inman forward, and the individual articles illustrate contemporary laboratory approaches to the objective assessment of gait. Fundamental to optimal lower-extremity prosthetic/orthotic service is an analysis of the gait of the patient. To the extent the method of analysis fails to provide adequate objective or useful information about gait, it allows for the possibility and probability that a less than optimum fit and/or alignment configuration has been or will be achieved. While gait analysis has long been an established procedure of varying objectivity in prosthetics, in orthotics the use of gait analysis has been rather ineffectual in assisting to optimize gait, a process which for the most part fails to go beyond a most rudimentary observation. This is due in part to the rudimentary functional characteristics of most orthoses. Advances in our profession as well as technology and materials can and do result in more functional orthoses. If we are going to provide the optimal orthotic design configuration for any given patient, it is essential that we define gait characteristics more precisely and reliably. Though not yet universally available, the increasing number of gait analysis facilities will soon benefit us all—patients and practitioners alike—as we gain access to the resulting information flow in formats readily usable by orthotists and prosthetists. *Ronald F. Altman, C.P.O. Director of Orthotics/Prosthetics Department at Newington Children's Hospital in Newington, Connecticut. Page Number(s) 17 - 17 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis Creator An entity primarily responsible for making the resource Ronald F. Altman, C.P.O. * https://staging.drfop.org/files/original/681729931d4cfc067bfb635d350a0038.pdf 08c883182b90889c54a46553cb7eb012 https://staging.drfop.org/files/original/e3d52b0be7f8bf314487219accc7c636.jpg 533dd7911eac0f2103f63f55a2974f2e https://staging.drfop.org/files/original/88d35e0e098d1d592a33914182995d15.jpg 01b25278628c187bfd931c739f3f8d09 https://staging.drfop.org/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg 0e95b44fd8762f309bc14b7344472c45 https://staging.drfop.org/files/original/504357506176edb60a65b7ae82059220.jpg 0a53764bf308ba3a7a6cb38844c982d5 https://staging.drfop.org/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg d6f074b0d9ad6cb75e44c3c67e36f961 https://staging.drfop.org/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg 79827f16dc5d8ac8a0d99d9def75de42 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_03_018.pdf Text Any textual data included in the document <h2>Gait Analysis in Prosthetics</h2> <h5>James R. Gage, M.D. <a style="text-decoration: none;">*</a> Ramona Hicks, R.P.T., M.A. <a style="text-decoration: none;">*</a></h5> <h3>Review</h3> Objective measurement systems which quantify locomotion have been in use for the past century. But not until World War II, when thousands of men returned home to the United States with amputations, was technology really applied to the understanding of prosthetic gait. Inman and colleagues<a></a> founded the Biomechanics Laboratory at the University of California to establish fundamental principles of human walking, particularly in relation to problems faced by lower limb amputees. Inman's measurement techniques included motion pictures of coronal and sagittal views, as well as transverse rotations from below using a glass walkway. Using interrupted light photography, the Biomechanics Laboratory team studied the motion of body segments during gait. Force plates measured the subject's ground reaction forces, and muscle activity was recorded using electromyography (EMG), which measures the electrical signals associated with contraction of a muscle. Prior to Inman's fundamental studies prostheses were customized for the individual amputee, without any particular regard to rational structural design. Inman's goal was to provide fundamental data essential for the design of prosthetic limbs. By analyzing normal human walking, he and his colleagues laid the groundwork for biomechanical analysis of amputee gait.<a></a> Since that time, numerous techniques have been developed to study human locomotion,<a></a> and numerous studies have been undertaken to evaluate prosthetic gait. <h3>Research Applications</h3> Eberhart, et al.<a></a> described the locomotor mechanism of the above-knee amputee from kinematic and kinetic data. They compared lateral stick figures of amputees to normal subjects as a means to objectively identify gait deviations in the sagittal plane. Force plate data were used to compare the weight-bearing characteristics of the prosthetic limb and the sound limb. From these comparisons, the authors identified amputees who walked well with their prostheses and those who were less adept. Eberhart believed that ultimately "optimal" patterns of gait could be determined for amputees and used as a reference for evaluating prosthetic gait. Zuniga, et al.<a></a> studied gait in 20 above-knee amputees by using electrogoniometers attached to the knee and foot switches. Their data documented asymmetry in the stance and swing phase times between the prosthetic and sound limb. In similar investigations, James and Oberg<a></a> and Murray, et al.<a></a> studied temporal stride parameters and knee flexion-extension angles, and also examined above-knee gait at various speeds. They confirmed the stance and swing phase asymmetry between the prosthetic and sound limb. They also showed that the asymmetry was present regardless of the speed of walking. The collection of baseline data in above-knee amputees clearly demonstrated some shortcomings in prosthetic gait. One of these, the longer swing time which is required on the prosthetic side, has led to the development of dozens of prosthetic knees. Gait analysis laboratories have been used to evaluate some of these prosthetic designs. Godfrey, et al.,<a></a> in a limited study that compared gait with six cadence-responsive knee units, found no significant differences among them. Murray, et al.<a></a> compared the gait of above-knee amputees with hydraulic knee units versus constant friction knee units. Temporal and kinematic data, which were collected at slow, free, and fast speeds, showed that the hydraulic knees improved the symmetry between the prosthetic limb and the sound limb, especially at the fast and free speeds. This finding was true for both cadence and the amount of knee-flexion at swing phase. Hoy and colleagues,<a></a> in one of the few studies on gait in juvenile amputees, collected kinematic data at various speeds to compare the solid ankle cushioned heel (SACH) foot to a Child Amputee Prosthetic Project (CAPP) experimental foot. The authors found hip range of motion to be closer to normal and significantly less with the CAPP foot than the SACH foot. Hannah and Morrison<a></a> studied the effect of alignment of the below-knee prosthesis on gait. Using electrogoniometers to measure hip and knee joint rotations in the coronal, sagittal, and transverse planes, they found that malalignment of the prosthetic foot was the most crucial for gait symmetry. Grevsten and Stalberg<a></a> used electromyography to compare muscle activity in below-knee amputees walking with patellar tendon-bearing (PTB) and PTB-suction prostheses. Surface electrodes were placed over the tibialis anterior and gastrocnemius muscles which, in normal gait, usually fire at opposite phases. The data showed that these muscles contracted for longer periods when the PTB prosthesis was used than with the PTB-suction prosthesis, suggesting that the suction mechanism improved the adaptation to the prosthesis. Thiele, et al.<a></a> investigated possible neuro-physiological reasons for weakness in above-knee amputees by recording electromyographic activity of the quadriceps during gait. They did not find abnormal recordings and concluded that muscle weakness was secondary to biomechanical, rather than neurophysiological, factors. <h3>Clinical Applications</h3> Until the present, gait analysis has been applied to prosthetics only for research purposes. Routine prosthetic fitting and checkout are still done by means of observational gait analysis. However, observational gait analysis has many disadvantages. In the first place, even normal human walking is extremely complex. With each step, more than 30 major muscles have to contract and/or relax synchronously in each lower extremity. Also, normal human gait is rapid (approximately 105 steps per minute), and the human eye is not fast enough to separate the various components of gait at this speed. Krebs, et al.<a></a> have shown that data vary widely when different examiners have observed a person's gait and that observational analysis is only a moderately reliable technique. The variations between observers may be due to the preconceptions of individual observers, to limitations of human perception, or to problems in transmitting the information or data to colleagues. In light of these findings, it is not surprising that the fit and quality of the limbs fabricated by different prosthetists vary greatly. Technology has now progressed to the point where automated gait laboratories can be built. Their capabilities vary, but most labs monitor one or more of the following parameters: <ol> <li> kinematics or movement measurements through a motion analysis system, </li> <li> evaluation of ground reaction forces via force plates or pressure sensitive switches, and </li> <li> dynamic electromyography (monitoring the electrical activity of contracting muscles). </li> </ol> The advantage of an automated motion measurement system is that automated data entry and rapid processing allow routine clinical use at a reasonable cost. Since the sampling rate of most automated motion systems is in excess of 50 Hz (50 samples/second), all movement in the lower extremities during walking can be examined in detail and with excellent reproducibility. Thus, the analysis of walking becomes objective, rather than subjective, and a record of this objective analysis is produced by the computer in such a fashion that preconceived biases and communication errors between observers are minimized. Furthermore, some of the more modern gait analysis facilities have the ability to compare records, for example, of a patient's gait pre- and post-operatively, or of an amputee's gait with two different prosthetic devices or components. Through comparisons like these, the presence or absence of benefit can be determined objectively. <h3>Kinesiology</h3> The field of prosthetics can make use of the new science of kinesiology, or the study of movement. Kinesiology consists of two major fields: <ol> <li> kinematics, the study of motion exclusive of the influences of mass or forces, i.e., without regard to the underlying cause of the motion; and </li> <li> kinetics, which deals with the forces that produce motion. </li> </ol> Kinematic Data Kinematic data can be gathered in a variety of ways—through interrupted light photography, cinefilm, video systems, and/or electro-goniometers—and it can be displayed in many ways. Stick figures provide a visual display of the subject walking. <a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Fig. 1</a> is a stick figure representation of an 11 year old girl with a right knee disarticulation. The stick figures facilitate the identification of gait deviations, e.g., knee hyperextension on the prosthetic side at stance phase. With observational gait analysis, this gait deviation might be missed, or two examiners might argue about its presence. With objective gait analysis, we can prove the deviation's existence by viewing the stick figures, and we can identify the cause of the deviation by reviewing the graphs that depict motion. These graphs display motions of each joint of the lower extremities in all three planes during a representative gait cycle. <a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Figure 1.</a> Lateral stick figures of the right gait cycle of an 11-year-old-girl with a right knee disarticulation. <a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Fig. 2</a> is a graph showing knee flexion-extension of the same child with a knee disarticulation. The child's sagittal knee motion is compared with the mean or average flexion-extension of seven other above-knee amputees. <a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Figure 2</a>. Comparison of knee flexion-extension motion in one above-knee amputee with an average composite of knee flexion-extension in seven above-knee amputees. Although all above-knee amputees hyperextend their knees slightly during stance phase, this patient has 10 degrees more hyperextension than average. Following the gait analysis, it was discovered that the knee extension bumper was too soft, and it was replaced with a suffer one. Kinematic data can also be used to compute temporal data, such as stride length, cadence, and walking velocity. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Fig. 3</a> compares the temporal data of the child with knee disarticulation with "normal" children the same age. Notice that the stride length is normal but that the walking velocity and cadence are less than normal. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Figure 3.</a> Linear measurements of an 11-year-old girl with a knee disarticulation compared with a composite of linear measurements of normal children. Kinetic Data The forces that cause movement are usually collected through pressure sensitive switches or paper, or with commercial force plates, which are designed to break down the ground reaction forces into their components (X,Y,Z force, and X,Y,Z moment). The software of a modern gait analysis laboratory is able to combine force plate data with motion analysis data to produce meaningful graphic outputs. <a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Fig. 4</a> shows the vertical ground reaction force (Z force) for walking barefoot compared with walking with shoes in a 9 year old boy with a Symes prosthesis. Notice the improved symmetry at push-off between the prosthetic and sound limb when shoes are worn. <a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Figure 4.</a> Graphic display of the vertical ground reaction forces in a 9-year-old boy with and without shoes. Force plates can also be used to compute the location of the center of pressure on the foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Fig. 5</a> compares the foot force progression pattern of a SACH foot to a multi-axis foot in a 27 year old male with a below-knee amputation. From these data, one can see that the foot force progression pattern is more lateral with the multi-axis foot than with the SACH foot. Also, notice with the SACH foot how the initial forces move from an anterior to posterior direction as the heel compresses. This pattern is not seen in the multi-axis foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Figure 5</a>. Path of the center of pressure on the foot in a 27-year-old below-knee amputee with a SACH foot and with a multi-axis foot. <h3>Dynamic Electromyography</h3> Dynamic electromyography is a valuable tool for measuring the time duration of muscle activity, which is recorded through electrodes, either surface or indwelling. However, since voluntary muscle activity results in an electromyographic recording that increases in magnitude with the tension, other variables can also influence the signal, limiting the accuracy of EMG as a predictor of muscle tension. Electromyographic data can be displayed in several ways. When used to analyze a gait cycle, the data show which muscles are active during each phase of gait. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Fig. 6</a> compares muscle activity during gait of the subject walking with the SACH foot compared with the multi-axis foot. The hamstrings and quadriceps muscle groups were sampled and show the same firing patterns regardless of the type of foot that is worn. What is interesting is that the hamstrings are firing just before toe-off when they are usually silent and the quadriceps are inactive at this time when normally they fire to restrain knee flexion and prevent excessive heel rise. As might be expected, this patient walks with exaggerated knee flexion at swing phase. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Figure 6.</a> EMG activity of the hamstrings and quadriceps muscles during gait in a 27-year-old patient with a SACH foot and with a multi-axis foot. <h3>Summary</h3> Gait analysis is useful in evaluating an amputee's prosthesis by providing objective measurements and a permanent record of the patient's status. Kinematic, kinetic, and EMG data assist the clinician and prosthetist in identifying specific problems encountered by the amputee and in identifying the causes. Gait analysis also allows comparison of different prosthetic designs or different alignments of the same prothesis. Most importantly, however, the record provided allows examiners to objectively discuss the problems and their potential solutions. <h3>Future Applications</h3> The field of prosthetics will begin to change rapidly with the application of kinesiology. Soon, optimal standards of gait will be established for each prosthetic level. With the widespread availability of low-cost motion analysis, kinematic analysis will be routinely incorporated into dynamic alignment of each new prosthesis, helping to insure appropriate alignment and fit. Finally, prosthetic research, using both kinematics and kinetics, will continue as we seek to identify and rectify the problems created by loss of the body's normal limb. The ultimate outcome of this research will be the development of components that will be stronger, lighter in weight, and much more functional than those used now. <div style="width: 400px;"> <div style="width: 400px;">*Ramona Hicks, R.P.T., M.A. Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111. *James R. Gage, M.D. Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</div> </div> <div style="width: 400px;"></div> References: <ol> <li>Fundamental Studies of Human Locomotion and Other Information Relating to Design of Artificial Limbs. Subcontractor's Report to the Committee on Artificial Limbs. National Research Council. Prosthetic Devices Research Project, College of Engineering, University of California, Berkeley. Serial No. CAL 5. 2 vols. The Project, Berkeley, 1947.</li> <li>Radcliffe, C.W., "Functional considerations in the fitting of above-knee prostheses," Selected Articles From Artificial Limbs, Huntington, NY, Kreiger Publishing Co, Inc, 1970, p.p. 5-30.</li> <li>Winter, D.A., Biomechanics of Human Movement, New York, John Wiley & Sons, 1979, p.p. 9-46.</li> <li>Eberhart, H.D.; Elftman, H.; and Inman, V.T., "The locomotor mechanism of the amputee," Klopsteg PE, Wilson PD, et al (eds): Human Limbs and Their Substitutes, New York, Hafner Publishing Co, 1968, p.p. 472-480.</li> <li>Zuniga, E.N.; Leavitt, L.A.; Calvert, J.C.; Canzoneri, J.; and Peterson, C.R., "Gait patterns in above-knee amputees," Arch Phys Med Rehabilitation, 53:373-382, 1972.</li> <li>James, U. and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," Scand J Rehabil Med, 5:35-50, 1973.</li> <li>Murrary, M.P.; Sepic, S.B.; Gardner, G.M.; and Mollinger, L.A., "Gait patterns of above-knee amputees using constant-friction knee components," Bull Prosthet Res, 17(2):35-45, 1980.</li> <li>Godfrey, C.M.; Jousse, A.T.; Brett, R.; and Butler, J.F., "A comparison of some gait characteristics with six knee joints," Orthotics and Prosthetics, 29(3):33-38, 1975.</li> <li>Murray, M.P.; Mollinger, L.A.; Sepic, S.B.; Gardner, G.M.; and Linder, M.T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs constant-friction knee components," Arch Phys Med Rehabil, 64:339-345, 1983.</li> <li>Hoy, M.G.; Whiting, W.C.; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," Arch Phys Med Rehabilitation, 63:74-82, 1982.</li> <li>Hannah, R.E. and Morrison, J.B., "Prostheses alignment: Effect on gait of persons with below-knee amputations," Arch Phys Med Rehabil 65:159-162, 1984.</li> <li>Grevsten, S. and Stalberg, E., "Electromyographic study of muscular activity in the amputation stump while walking with PTB- and PTB-suction prosthesis," Ups J Med Sci, 80:103-112, 1975.</li> <li>Thiele, B.; James, U.; and Stalberg, E., "Neuro-physiological studies on muscle function in the stump of above-knee amputees," Scand J Rehabil Med, 5:67-70, 1973.</li> <li>Krebs, D.E.; Edelstein, J.E.; and Fishman, S., "Reliability of observational kinematic gait analysis," Accepted for publication in J Phys Ther, 1985.</li> </ol> <div style="width: 400px;"></div> Page Number(s) 18 - 23 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis in Prosthetics Creator An entity primarily responsible for making the resource James R. Gage, M.D. * Ramona Hicks, R.P.T., M.A. * https://staging.drfop.org/files/original/7cf119166ad87eb06c27bf19aa14601f.pdf 1c96a3b3328679e9ce5c00a407f461c9 https://staging.drfop.org/files/original/7a03de2fa3abd6434dbf35ea90f8a24f.jpg 9a3b91d6d25d0ea128bd129f72052d5c https://staging.drfop.org/files/original/41d2e99ef2712e6bf37fd90b99884729.jpg e365f90de9bf9d37b3e930728b987afe https://staging.drfop.org/files/original/45f9ecdd3583fca4a9b40e43d40b8fcb.jpg a3a4b242703db91a587f408c2738acdf https://staging.drfop.org/files/original/f25d2a79d7de53b2ee49b4c388895c22.jpg 792d3c81e1d5d48a515061f80fe3204a https://staging.drfop.org/files/original/c8ecb78314e07610c4b41af0358a23f4.jpg 68b404353e59f1a8fcdfd73e57d06d44 https://staging.drfop.org/files/original/e0db5f9e5fb35400f61e401dd85599b9.jpg e0b92835fd4de23f0c8bb8fb5d1635fa https://staging.drfop.org/files/original/7aa1f8cbe0e245431055b7fe9d6d2d6f.jpg 4bdf0fe2fee9272b3e8bb7c7a4fd1960 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_03_023.pdf Text Any textual data included in the document <h2>Evaluation of a Prosthetic Shank with Variable Inertial Properties</h2> <h5>Scott Tashman, M. Eng. <a style="text-decoration: none;">*</a> Ramona Hicks, R.P.T., M.A. <a style="text-decoration: none;">*</a> David J. Jendrzejczyk, CP. <a style="text-decoration: none;">*</a></h5> Above-knee amputees walk slower than the normal population. This has been documented in adults<a></a> and children.<a></a> It has been suggested that the prolonged swing phase of the prosthesis forces a slower cadence and, therefore, a slower walking speed.<a></a> Since children rely on a fast cadence to obtain an adequate walking speed,<a></a> a prolonged swing phase can be a major obstacle to comfortable, efficient normal-speed walking. To date, most efforts to reduce prosthetic swing phase time have been directed towards the prosthetic knee joint.<a></a> Various mechanisms have been designed to accelerate the extension of the prosthetic knee. Mechanical, hydraulic, and pneumatic systems have been developed in an effort to provide a more favorable gait.<a></a> Hydraulic knee units have been shown to provide a more normal cadence and walking speed for adults than simple constant friction knee units.<a></a> Most of the prosthetic knee unit research has been directed towards the adult amputee population. Pediatric hydraulic knee units have been considered impractical because of size and weight limitations. Pediatric above-knee amputees are generally fitted with constant friction knee units because they are simple, light in weight, low in cost, easy to install and adjust, and require little maintenance.<a></a> It has often been presumed that adjustments in the knee joint friction could be used to provide an optimum cadence for the amputee with a constant friction knee joint. A study was performed at the Newington Children's Hospital Kinesiology Laboratory to test this assumption.<a></a> When subjects were asked to walk at a comfortable speed, no significant changes were observed in cadence or actual prosthetic shank swing time as the knee joint friction was varied over a wide range. In all cases, the swing period of the prosthetic shank was close to the natural swing period of the shank measured off the patient. This indicates that the physical properties of the prosthetic shank play a significant role in determining the natural cadence of the above-knee amputee with a constant-friction knee joint. To force the shank to move at a frequency different from its natural frequency requires significant input of energy in the form of applied torque at the knee joint (from hip or pelvic muscle force). The test subjects, when asked to walk at a comfortable speed, did not supply the extra energy needed for a faster cadence; they instead aligned their cadence with the natural frequency of the shank. <h3>Purpose</h3> The above results led to the current project: the design and testing of a prosthetic shank with variable physical properties. The purpose of this study was to test the following hypotheses: <ol> <li> If the physical properties of the shank section of an above-knee prosthesis with a constant friction knee unit are changed in such a way as to alter the natural swing period, the swing period of the shank during gait will also be altered. </li> <li> Reducing the swing period of the shank will increase natural cadence and walking speed. </li> </ol> <h3>Methods</h3> Design The principal design goal for the shank was to reduce the natural swing period as much as possible. If the shank/foot is considered as a physical pendulum, it has a period T equal to: T = 2pi(I/Mgd)^(1/2), I is proportional to Md2. Where: <blockquote> T = natural swing period of shank as a pendulum I = rotational inertia of shank/foot above knee pivot g = acceleration due to gravity d = distance from knee pivot to center of mass M = mass of shank/foot </blockquote> These equations indicate that changes in mass alone will not reduce the swing period of the shank; the center of mass must be shifted proximally (towards the knee joint) to significantly reduce the period. With reducing distal weight as the primary goal, an experimental shank was constructed for the test subject, a 13 year old male knee disarticulation patient with a "good" amputee gait pattern. Since the limb was to be used for laboratory testing purposes only, some strength was sacrificed in order to obtain the maximum possible reduction in distal weight while still using readily available materials. The shank was thin and hollow, with layers of polyester resin and one layer of carbon filter cloth laminated over a plaster mold. Excess material was ground away wherever possible. In addition, the prosthesis was set in correct alignment using a heel build-up on an ultra-light SACH foot to eliminate shoes and further reduce distal weight. To enable changes in the natural swing period, a lead mass which attached to a metal rod could be placed proximally or distally inside the shank. The additional mass was chosen so that the experimental shank/foot would weigh the same as the patient's standard prosthesis. The completed prosthesis is shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg">Fig. 1.</a> With the moveable mass placed distally, the shank had a center of mass positioned similarly to the patient's original shank. Shifting the mass proximally caused the center of mass to move proximally by 13 centimeters. To determine the effect of changing the mass position, the pendulum swing period of the shank was measured by timing the swing of the shank, which was suspended by a metal rod through the knee joint axis. The light weight shank, with the mass placed distally, exhibited inertial properties very close to those of the patient's original shank. Shifting the mass to the proximal position reduced the pendulum swing period by 0.20 seconds or 15 percent (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg">Table 1</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg">Figure 1. Completed experimental prosthesis; shown during testing in the Kinesiology laboratory.</a> Evaluation The Newington Children's Hospital Kinesiology Laboratory measured the effect on the gait of the changes made in the position of the center of mass of the experimental prosthesis. An automated video system was used to acquire three-dimensional kinematic data from 26 retro-reflective markers placed at designated positions on the body.<a></a> The kinematic data were used to determine the motions of all major body segments and calculate dynamic lower extremity joint angles in three planes. Linear movement and temporal measurements, such as stride length, single stance time, swing phase time, cadence, and walking speed were also determined. Swing time was determined by measuring the time from toe-off to heel strike. The shank pendulum time was determined by measuring the time required for the prosthesis to go from full extension into flexion and back to full extension; this is equivalent to one half of the period of the shank measured as a free-swinging pendulum. Kinematic data were acquired for two walks with the subject walking at: <ol> <li> normal speed, weight proximal </li> <li> fast speed, weight proximal </li> <li> normal speed, weight distal </li> <li> fast speed, weight distal </li> </ol> For the normal speed walks, the subject was asked to walk at a speed that was comfortable; no further prompting was given. For the faster speed walks, the subject was instructed to walk as fast as was comfortable; again, no further instructions were given. For each mass position, the knee joint friction was set to "clinically optimal" by matching the prosthetic side heel rise to the normal side heel rise at normal speed, and the patient was allowed to walk around for a while until he seemed reasonably comfortable with the altered characteristics of the limb. <h3>Results</h3> Stride Parameters Stride parameters measured during the four different conditions are shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg">Table 2</a>. This data represents the first walk acquired for each condition; the variation between the first and second trials for all conditions was less than five percent. Cadence, stride length, and walking speed were all essentially the same at the "normal" walking speed with the mass placed proximally or distally. At the "fast" walking speed, the subject walked seven percent faster with the mass placed distally than with the mass placed proximally, due to both a faster cadence and a longer stride length. Shank Swing Dynamics At the normal walking speed, the shank pendulum time was reduced by eight percent with the weight placed proximally, resulting in an eight percent reduction in the swing phase time for the prosthetic limb (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg">Table 3</a>). Since the swing phase time for the normal side stayed the same, the swing asymmetry (prosthetic side vs. normal side) was reduced from 19.5 percent to 9.1 percent. A similar reduction in swing asymmetry was seen during the fast walk (from 32.4 percent to 19.6 percent). During fast walking with the proximal weight placement, the swing phase time was increased by five percent for the normal limb and reduced by eight percent for the prosthetic limb. The reduction in pendulum swing time was much greater (16 percent). <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg">Table 4</a> The dynamic knee joint motion is shown for both weight positions (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg">Figure 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Fig. 3</a>). The peak knee flexion was reduced from 64 degrees to 54 degrees at the normal walking speed and from 84 degrees to 62 degrees at the fast walking speed with the weight placed proximally. The plots also indicate delayed initiation of knee flexion and faster motion of the limb with the proximal weight placement. <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg">Figure 2. Knee flexion-extension angle vs. percent of gait cycle: normal walking speed, proximal and distal weight placement.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Figure 3. Knee flexion-extension angle vs. percent of gait cycle: fast walking speed, proximal and distal weight placement.</a> <h3>Discussion</h3> As expected, proximal weight placement in the shank produced a shorter shank swing time during gait. This subsequently resulted in a shorter swing phase (toe-off to heel-strike) for the prosthetic limb. At normal speed, the decrease in swing phase was equal in time to the decrease in shank swing time (eight percent). At a faster walking speed, the same eight percent decrease in swing phase was observed, but the shank swing period was reduced by a much greater amount.<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"> Fig. 3</a> illustrates the effect of this discrepancy: the limb reaches full extension well before heel strike. One explanation for this is that the subject did not have sufficient time to fully adjust to the new limb; further use should enable the subject to reduce swing phase as much as the shank swing period was reduced. A less expected outcome was the similarity in walking speed and cadence between the two different weight placements. The reduced swing phase did not result in a reduced gait cycle time; the subject instead lengthened his stance phase to balance the decrease in swing phase. This resulted in a smoother, more symmetric gait. <h3>Conclusions</h3> Limited conclusions can be made based on this single-subject study. However, it appears that decreasing the natural swing period of the shank by shifting the center of mass proximally results in a faster swing phase during gait. In one subject this led to an increase in stance phase for the prosthetic side towards normal values, and considerably reduced left-right asymmetry for this subject. Improved symmetry should lead to a more energy efficient, natural appearing gait. No increase in cadence or walking speed was observed. It is possible that longer wear of the limb might have permitted the subject to naturally increase his cadence; this could not be evaluated with the present limb design. The outcome of this study indicates that weight distribution in the prosthetic shank/foot has a significant impact on gait. This suggests that future prostheses should be designed to minimize distal shank/foot weight. *David J. Jendrzejczyk, CP. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. *Ramona Hicks, R.P.T., M.A. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. *Scott Tashman, M. Eng. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. References: <ol> <li>James, U., and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," Scand J Rehab Med, 5:35-50, 1973.</li> <li>Godfry, C. M.; Jousee, A. T.; Brett, R.; and Butler, J. F., "A comparison of some gait characteristics with six knee joints," Orthotics and Prosthetics, 29(3):33-38, 1975.</li> <li>Murry, M. P., "Gait patterns of above-knee amputees using constant-friction knee components," Bull Prosthet Res, 17(2):35-45, 1980.</li> <li>Hoy, M. G.; Wiring, W. C; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," Arch Phys Med Rehabil, 63:74-81, Feb 1982.</li> <li>Drillis, R., "Objective recording and biomechanics of pathological gait," Ann NY Acad Sci, 74:86-109, Sept 1958.</li> <li>Sutherland, D. H.; Olshen, R.; Cooper, L.; and Woo, S., "The development of mature gait," J Bone Joint Surgery, 62A:336-353, April, 1980.</li> <li>Zarrugh, M. Y., and Radcliffe, C. W., "Simulation of swing phase dynamics in above-knee prosthesis," J Bio-mech, 9:283-292, 1976.</li> <li>Wallach, J., and Saibel, E., "Control mechanism performance criteria for an above-knee leg prosthesis," J Bio-mech, 3:87-97, 1970.</li> <li>NYU Medical Center, Lower-Limb Prosthetics, pp. 145-163. Prosthetics and Orthotics, New York University Post-Graduate Medical School, 1980 revision.</li> <li>Murray, M. P.; Mollinger, L. A.; Sepic, S. B.; Gardner, G. M., and Linder, M. T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs. constant-friction knee components," Arch Phys Med Re-habil, 64:339-345, 1983.</li> <li>New York University Medical Center, "The ISNY PTB Socket," Lower-Limb Prosthetics, 1980 revision, pp. 107-108.</li> <li>Hicks, R.; Tashman, S.; Cary, J. M.; Altman, R. F.; and Gage, J. R., "Swing Phase Control with knee friction in juvenile amputees," In press, J Orthop Res.</li> <li>Gage, J. R., "Gait Analysis for decision-making in cerebral palsy," Bull Hosp Joint Des, 43:147-163, 1983.</li> <li>Gage, J. R.; Fabian, D.; Hicks, R.; and Tashman, S., "Pre- and postoperative gait analysis in patients with spastic diplegia-a preliminary report," J Ped Orthop, 4:715-724, 1984.</li> </ol> Page Number(s) 23 - 28 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of a Prosthetic Shank with Variable Inertial Properties Creator An entity primarily responsible for making the resource Scott Tashman, M. Eng. * Ramona Hicks, R.P.T., M.A. * David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/ba789f483ace72e6c0f63c6846e6c081.pdf 519c0ffb1b60b8ec2558c4682b78c1b1 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_005.pdf Text Any textual data included in the document <h2>Basic Changes in Lower Limb Prosthetics</h2> <h5>Alvin L. Muilenburg, C.P.O. </h5> After several years of very little change in above knee amputee fitting, we now have a C.P.O. issue with four papers on current advanced clinical practice in lower limb prosthetics. Some of these advances can be brought into use without too much difficulty while others require much more training and careful follow-up. The techniques that involve materials and fabrication are usually not too difficult to try, but changes in these techniques can give us problems that we didn't expectand require extra caution during initial use. Alterations of socket shape to adapt to more difficult amputations or congenital deficiencies is something where we also look for improvements. Papers that are written giving experience and suggestions on how to solve these problems give us help that is needed in our day to day fitting. This usually does not alter our basic method of alignment and cast model alterations. The discussions concerning basic changes in socket shape and alignment cause us much more concern by whatever name they may be given. There is a new way to fit an AK amputation, that is certain. I cannot question the results; patient acceptance has been proven. New information, however, does not always come easily. These new methods have been brought to the public view only through a considerable amount of publicity, which then stimulates us to get more information. Traditionally, information and results have been passed on from one prosthetist to the other; usually by visiting the developers and exchanging new ideas. Educational institutions have provided a valuable learning ground. U.C.L.A. had a one week course in March and a few seminars have been held elsewhere. However, many details on how to teach the new methods have created controversy. We must support our educational institutions and help them to determine what should be taught. I believe we need a working group of a few prosthetists who are already involved in the new methods to develop guidelines for teaching. Perhaps the Academy could organize this. Clinical evaluation programs have been discussed but communication between prosthetists involved seems to have adequately covered that area. I want to express my appreciation to the publishers in this issue for all the work that has been done. Having this information published enables us to sort it out and make better decisions on improving our own care of the AK amputees. Page Number(s) 5 - 5 Year 1985 Volume 9 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Basic Changes in Lower Limb Prosthetics Creator An entity primarily responsible for making the resource Alvin L. Muilenburg, C.P.O. https://staging.drfop.org/files/original/bd46617c235c4772e936e7d1a60ba734.pdf 579389d66872bebcf4e498a65ae678ea https://staging.drfop.org/files/original/455ecf115629123392857fe8469670c3.jpg 83423844a564fec85ce56c817a3f5ec7 https://staging.drfop.org/files/original/741a3625b8142c75ec6b345c5bfffc5d.jpg 03abbdb99e38076f14d95a0e59f913a2 https://staging.drfop.org/files/original/1138499b4a4ed059bcd0c8b24e6f8680.jpg 710defbe06f6ae092234a49207f4415e https://staging.drfop.org/files/original/0c94fac2ea4e7c0aacd0c52cbcb94002.jpg 95ae51859297d017d7d6e2924646f528 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_006.pdf Text Any textual data included in the document <h2>Beyond the Quadrilateral</h2> <h5>Hans Richard Lehneis, Ph.D., C.P.O. <a style="text-decoration: none;">*</a></h5> Earlier this year I had the pleasure to be invited to the Academy Midwest Chapter Symposium entitled, "AK Design Principles: Beyond the Quadrilateral." I found the latter half of the title so intriguing and expressive of contemporary thinking and rethinking in AK socket prosthetics that I chose it as the title of this commentary. I hope that the organizers of the Chicago Symposium do not mind my borrowing this title. One of the earliest and major break throughs in AK socket design in this century was the concept of ischial weight bearing. At first glance this appears to be a sound approach and certainly one that has improved general comfort over other sockets. If, however, one analyzes that concept more closely, i.e., biomechanically, it becomes clear that ischial weight bearing is not a reality through all phases of gait. It must be appreciated that the socket and, thus, the prosthesis as a whole during walking is controlled by movement emanating from the center of rotation of the residual hip joint. At heel strike, when the hip is flexed, the distance from the ischial tuberosity to the ischial seat of the socket increases with the angle of hip flexion (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg">Fig. 1</a>). Obviously, at this point in the gait cycle, there cannot be any ischial weight bearing. Yet, the need to support weight is greater than at any other point during locomotion. Body weight, plus the force of impact must be transmitted. How is this possible without direct skeletal support? I believe that, by what in German is called "verspannung" of the musculature, a stable interface is achieved. This is a phenomenon which every AK amputee must learn to prevent the prosthetic knee from buckling. Unlike normal locomotion in which there is phasic interaction of the musculature to produce controlled hip and knee flexion (eccentric contraction), the AK amputee must learn out-of-phase contraction of the hip musculature, i.e., the hip joint must produce an extension moment prior to heel strike so that the knee joint is in full extension at heel strike. Such muscular activity causes "verspannung," an increase in cross sectional volume, which in turn increases the tangential forces in the socket to equal the vertical forces generated at this point in the gait cycle. While it is clear that reasonably comfortable ischial weight bearing is indeed possible in the midstance phase, ischial weight bearing cannot be comfortably maintained at heel off. When the hip joint is extended, the perpendicular distance between the axis of rotation of the hip and the ischial seat of the socket is less than in the mid-stance phase (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg">Fig. 2</a>), yet the distance from the hip joint to the ischium remains constant throughout all phases. Thus, hip extension causes increasing pressure on the ischial tuberosity, which now becomes the fulcrum about which the prosthesis tends to rotate. This results in the stump being pulled out of the socket, gapping of the anterior brim, elevation of the body on the involved side, and discomfort. Clinically, prosthetists have relieved this problem by increasing the radius of the anterior portion of the ischial seat. This maneuver allows the socket and seat to move posterior to the ischium as the hip is extended. Personally, I have always advocated that the ischial seat is sloped forward and downward such that it is tangent to a radius from the hip joint to the ischium (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg">Fig. 3</a>). This not only increases comfort at heel strike, since it reduces the sharpness of the anterior portion of the ischial seat, but at heel off, it allows the ischial tuberosity to be inside the socket and pressure to be transferred to the much larger part of the ischium and gluteus maximus. Placing the ischial tuberosity on the anterior portion of the ischial seat also results in greater comfort, since it reduces skin tension in that area. While one might argue that placing the ischial tuberosity squarely on the seat was a necessity with open-end sockets; it is amazing that this theory continued to persist past the advent of total contact sockets. Under certain conditions, Pascal's law may be applied to total contact sockets, i.e., a hydrostatic condition exists which would eliminate the need for ischial weight bearing. In other words, the quadrilateral shape of AK sockets has remained unchanged despite the fact that total contact has resulted in a different application of the laws of physics which makes ischial weight bearing less important than originally conceived. Practitioners familiar with the fitting of prostheses to patients with Proximal Femoral Focal Deficiency (PFFD) know that the quadrilateral socket is inappropriate for these patients. A more appropriate socket shape resembles that of a flower pot in which the ischium is contained within the socket. In addition, the largest patient population for which the quadrilateral shape must be revised is the geriatric AK amputee. These patients, as a rule, become amputees due to Peripheral Vascular Disease (PVD), often compounded by diabetes. They usually present diminished sensation, reduced muscle tone, poor skin quality, and sometimes senility. Generally, they suffer from great discomfort when fitted with a prosthesis. Although most of this can be ascribed to the problems presented, it appears that some of this discomfort is due to the quadrilateral socket shape, particularly when the patient is provided with a manual knee lock. Unlike amputees who are fitted with an open knee and who must, and are able to, contract the residual muscles prior to heel strike, the geriatric amputee with a manual knee lock simply steps on the prosthesis. This simulates the effect of stepping on a rake (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg">Fig. 4</a>). As a result, the tissue below the ischium is compressed (poor muscle tone), resulting in excessive skin tension, anterior proximal gapping of the socket, and the ischium to be far posterior to the socket. In summary, it seems to me that in light of the change in patient population (overwhelmingly geriatrics) with all the physical problems they present, one should, indeed, think beyond the quadrilateral. One should also note that with the advent of total contact, the concept of ischial weight bearing needs to be re-visited and re-assessed. Designs such as CAT-CAM and work supported by the Veterans Administration at the Rusk Institute of Rehabilitation Medicine hold promise to go beyond the quadrilateral to improve patient comfort. <h3>Acknowledgments</h3> This is to acknowledge that certain concepts presented in this paper are based on, Schnur, J., DAS KUNSTBEIN- Messen und Bauen. Kothen-Anhalt: Buchdruckekel Hans Greiner. I am also grateful to Robert Wilson, M.S., research scientist, designer and medical illustrator, Orthotics & Prosthetics Research for the illustrations in this text. *Hans Richard Lehneis, Ph.D., C.P.O. Hans Richard Lehneis, Ph.D., C.P.O., is with the Rusk Institute of Rehabilitation Medicine, 400 East 34th Street, New York, New York 10016. Page Number(s) 6 - 8 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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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. <a style="text-decoration: none;">*</a></h5> 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">Fig. 1</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, Orthotics and Prosthetics, the journal of the American Orthotic and Prosthetic Association, published my article, "Allowing Normal Adduction of Femur in Above-Knee Amputations." <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg">Figure 1. X-ray of standing patient showing relative abduction of amputated femur as compared to normal side.</a> 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. 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. <h3>What Is Wrong With Our Present A/K Prostheses?</h3> 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. 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. 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. 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. 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. 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">Table I</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. <h3>Technique</h3> Thigh is measured as to length and circumference as high as possible and every two inches. 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">Fig. 2</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">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg">Figure 2. Casting garment.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg">Figure 3. Lateral view of cast ready to pour.</a> Tear the single wrap of plaster than encircles the pelvis. The cast will drop away. Immediately check depth of cast and location of ischium. 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">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg">Figure 4. Anterior view of cast.</a> Now pour the cast full of plaster and let it set. 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">Fig. 5</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Fig. 6</a>) that must be reduced in size. Practically all the reduction will take place on the lateral wall. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg">Figure 5. Posterior view of unaltered model.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Figure 6. Lateral view of unaltered model.</a> Referring to <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg">Table I</a>, the socket M-L will be 4.5" for a 19", 0 circumference level measurement of the amputee. <h3>Socket Modification</h3> <ol> <li> Lateral wall is to be shaped to give support over a wide area, and particularly the lateral posterior aspect of socket. </li> <li> 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">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg">Figure 7. Medial view of modified model.</a></li> <li> Depth of the socket will be the same as measured length of the thigh. </li> <li> The seat will be at right angle to Long's Line. </li> <li> 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">Fig. 8</a>). (Distal femur will be very close to lateral surface, probably covered only by skin.) <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 8. Posterior view of modified model.</a></li> <li> 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">Fig. 9</a>, point Y). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 9. Anterior view showing relationship of medial brim (point X) to ischium and of lateral wall (point Y) to greater trochanter.</a></li> <li> 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">Fig. 9</a>, point Y). </li> <li> 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">Fig. 10</a>). The ischium will bear on flare of socket, both medial and posterior. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg">Figure 10. Lateral view.</a></li> <li> 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">Fig. 11</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg">Table II</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg">Figure 11. Proximal view of socket and socket pattern for thigh measuring 19". Actual measurement of the pattern is 18".</a></li> <li> Many sockets require fill added distally on medial side, only because I failed to remove enough material in this area when modifying the model. </li> <li> Laminate socket using two layers of 1 oz. dacron felt plus extra felt around top. </li> <li> Remove socket from cast and trim excess plastic. </li> <li> 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">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 12. Lateral view of bench aligned prosthesis.</a></li> <li> 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">Fig. 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 13. Posterior view of bench aligned prosthesis.</a></li> <li> 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. </li> <li> 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">Fig. 12</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 13</a>) and medial wall checks out for height. </li> <li> Install valve and walk amputee. </li> </ol> DO NOT 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. DO 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. 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">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg">Figure 14. Anterior view of prosthesis following completion of shaping.</a> *Ivan A. Long, CP. Ivan Long, CP., is President of Polycadence, 6080 West 55th Place, Arvada, California 80002. 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 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/da38b7a72d5f0f1d6ac21325f1e039c0.pdf edff63be99e2d8d729cbef998b406a52 https://staging.drfop.org/files/original/d2651974fba7f87f92cd366e455eb4c5.jpg 0f355eb01031549a7c829b5af0d3f97f https://staging.drfop.org/files/original/3cfe30bd191e924a3452548f324e3ab5.jpg 47d785dd2b06ea09755b1fc2db9ef7db https://staging.drfop.org/files/original/4b1a2b96b627fa58481925790ad1945d.jpg bc16cafb9de766ae75e4542da415a35e https://staging.drfop.org/files/original/6ce24c5ca94ed61c1f0b3605e1ea6609.jpg f33c04d0c9047f47f04324fda1775b97 https://staging.drfop.org/files/original/fc25931e137ae824d29d27f46056a337.jpg 14c2a7ea1bf14353dd93b0c7e0608750 https://staging.drfop.org/files/original/1db4cd12acf584900a88521b27b26e22.jpg 23a84ca687819185cd051e2b72a42df3 https://staging.drfop.org/files/original/c3b1f79a3aaf3398396bb240f223b4de.jpg 9d5cd10084e101a37287eb8a11b4dca5 https://staging.drfop.org/files/original/469379a388c74aff071a488496e54792.jpg 17f0c07a2d134591296da907616f4734 https://staging.drfop.org/files/original/d1b3a3a68b94f6ca40969ed5ddbfc33d.jpg c6317785d951bc3b1b237c59ba182c51 https://staging.drfop.org/files/original/18fc4dd5386650d70edc02d759d56432.jpg 482a6131207eda8a57c2ad534f20a1ee https://staging.drfop.org/files/original/1d28451c642c56ef2e891b7eb76b1000.jpg 9dc47a9c6572d79510690e5ca31ff324 https://staging.drfop.org/files/original/020cd4e30afb76ef85d5f9af5a444a4b.jpg 687f1e7b639a806faa83626517e263d3 https://staging.drfop.org/files/original/f5f456fe9b7abda81bee843c15ee1a12.jpg 5d3d1d2068fe0eaa7339520b499663f8 https://staging.drfop.org/files/original/10b792b285121de0002ec3efd54edc8b.jpg 1b42f34eeda78a19f81c150ffa6edd06 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_015.pdf Text Any textual data included in the document <h2>Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles</h2> <h5>John Sabolich, C.P.O. <a style="text-decoration: none;">*</a></h5> Since 1969, it has become increasingly evident that quadrilateral sockets have serious bio-mechanical problems. Even my old-timer above-knee prosthetic patients seem to be more comfortable in their ancient plug sockets, although transverse rotational stability was not as good. Fundamental to these objections is the lack of adequate stabilization in the frontal plane, which results in the gluteus medius gait most AK amputees demonstrate. In order to stabilize the upper trunk and pelvis in normal gait, the gluteus medius and abductors on the stance side must fire vigorously when the contralateral side is in swing phase. However, we are dealing with a patho-mechanical situation when we consider the case of the above-knee amputee. No longer are bones and ligaments positively connecting the hip to the floor. There is an intervening pseudo-joint, "the patient socket interface." We now have part of the femur inside a gelatinous semifluid mass, the human thigh. When the abductors fire, what is most likely to occur in a rectangular socket with a wide M-L dimension and no bony areas for the socket to lock against medially? The answer we have discovered, is that the femur tends to abduct. In quadrilateral sockets, the ischial tuberosity is sitting on top of the ischial seat and is free to shift about (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Fig. 1</a>). As the gluteus medius pulls the femur into abduction, the pelvic slides medially on the ischial seat and makes the abduction worse. The unsupported femur has little choice than to drift into an abducted attitude within the wide M-L quadrilateral container. Pain at the distal femur and at the proximal medial area is due to this abducted position and excessive soft tissue pressure medially. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Figure 1. No bone block and no real force system to prevent femoral or ischial drift. Ischial tuberosity acts as a fulcrum. Pelvis can rotate as well as the femur abduct.</a> We now have a perfect set-up for the classical above-knee "lateral trunk leaning" gait familiar to prosthetists. The patient has to lean to the side to position his upper torso over the base of support (the abducted distal femur) during stance phase, since the prosthesis is falsely placed under him (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg">Fig. 2</a>). The patient executes this maneuver to prevent excessive pressure on the lateral distal femur and the medial proximal soft tissue. In essence, the patient must walk in a fashion similar to a person who has two sound legs with one leg out to the side in abduction. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg">Figure 2. Patient must lean lateral over distal abducted femur, use inertia, or muscular tightening to prevent pain on lateral distal femur.</a> To the best of my recollection, I began questioning the validity of the quadrilateral socket theory in 1969 when I was a student at New York University. Dr. H. Richard Lehneis, C.P.O., of that institution taught that it is not necessary to put most of the patient's weight on the ischial tuberosity and, if the truth were known, most of the weight is probably borne by the peripheral tissue and gluteal mascula-ture. Moreover, at heel strike, when the largest inertial forces are placed on the above-knee residual limb, the ischial tuberosity is not on the ischial seat due to the flexed hip.<a style="text-decoration: none;">*</a> This concept was reinforced in my mind by the idea that if the majority of the amputee's weight was borne by the ischial tuberosity on the quadrilateral socket's flat ischial seat, one would only be able to obtain a tangental force at best, which would bring to bear tremendous force on a very small part of that bony prominence, and consequently cause great discomfort. Placing extra force in the neurovascular bundle anteriorly, Scarpa's triangle, with the purpose of pushing the ischial tuberosity up onto the ischial seat, has never made much sense to me. This seems to be the worst place to apply pressure and can not have a positive effect on circulation. These thoughts confirmed my concern that the quad socket theory had serious biomechanical problems and spurred my subsequent efforts. We began to close the M-L dimension of the socket by adding material to the lateral and medial sides to try to force the femur into adduction. We also began opening up the A-P dimension, not only to reduce the pressure on the neurovascular structures of the Scarpa's triangle, but also to compensate for the reduced diameter in the M-L dimension, and thus to maintain the original circumference. (Prosthetists naturally tend to be fearful of such modifications since they have been taught to tighten the A-P to keep the ischial tuberosity on the ischial seat.) In addition, I began to slant the ischial seat in the frontal plane upward laterally at about a 30° angle, rather than leaving it horizontal, so as to increase the weight bearing of the gluteal muscles, and thus rely less on the ischial tuberosity. These are some examples of early attempts to change the quadrilateral design and may be considered as our first generation efforts. In early 1981, the Sabolich Prosthetics Center sponsored a seminar to investigate non-quadrilateral alternatives for A.K. management. Participating in this seminar, among others, was Ivan Long, CP., developer of the concept of Long's Line and an associated socket design.<a></a> The information learned from Mr. Long was of the greatest benefit in advancing our efforts. However, for reasons that will become apparent in this article, we found it essential to proceed on a different track that experience has shown was necessary to make this program work for us. After this seminar, the Sabolich Center continued research study of non-quadrilateral above-knee designs. Over 900 non-quadrilateral sockets have been fit on a documented basis in Oklahoma City to patients ranging from six months to 103 years of age. X-rays (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg">Fig. 3</a>) and Xerography have been impressive, showing the femur to be in a much improved adduction attitude. We have made major changes in shape and contour, especially in the last three years. We have coined the acronym CAT-CAM, which stands for Contoured Adducted Trochanteric-Con-trolled Alignment Method, to describe the second generation design which is covered in the remainder of this article. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg">Figure 3. Weight bearing x-rays comparing CAT-CAM and quadrilateral sockets.</a> This design includes undercutting of the trochanter and a special fossa in which the ischial tuberosity and descending ramus can rest, giving this bony prominence three-dimensional support within the socket. No more consideration is given to the transverse angle of the posterior wall relative to the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg">Fig. 4</a>). The Scarpa's triangle is virtually eliminated, as are the adductor longus and rectus channels, and the ischial seat. The ischial tuberosity still bears some measure of vertical loading since it rests on an angled surface. The old principles of the quadrilateral design simply do not function, since we are dealing with a completely different design in shape, contour, and biome-chanical principles. The socket is so different that it looks somewhat like a quadrilateral socket turned sideways with a large A-P and narrowed M-L. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg">Figure 4. Comparison of CAT-CAM and quadrilateral sockets in a transverse view. Since the femur and ischial tuberosity are fixed in position, the adductor longus tendon has to shift a small amount. Note mild O.K.C. (Oklahoma City) channel about the femur.</a> A number of prosthetists have come to our facility to learn these techniques on a one-on-one basis. We have gained much information and feedback from the other prosthetists who have participated in these informal educational efforts. However, this process is not altogether appropriate and has come to be tremendously time consuming. We feel that in the future, education should be administered to several prosthetists at once in an organized and structured course by one or another of the schools. In March, 1985, a preliminary course was taught at UCLA after two years preparation and the writing of a manual. This effort confirmed, in the minds of those involved, the necessity of such a course, and also the necessity of further efforts upon the part of the teaching staff involved to perfect techniques and teaching material. Moreover, it should be borne in mind that the acronym CAT-CAM embraces a number of varying concepts advanced by a number of prosthetists working in common directions and these differences must be reconciled into one technique to be taught. In the strongest possible terms, and in view of the problems some prosthetists have had, we can not recommend using the CAT-CAM method without a hands-on instructional course. <h3>CAT-CAM Theory</h3> The CAT-CAM holds the femur in adduction primarily by two means. First, the ischial tuberosity and part of the inferior ramus of the ischium rest inside the socket proper, and bear laterally directed forces which work in conjunction with medially directed forces borne by the femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg">Fig. 5</a>). Medially directed forces bearing on the proximal portion of the femur in the trochanteric and sub-trochanteric region act to hold the ischial tuberosity on an inclined medial-posterior surface within the socket, while forces on the mid and distal portion of the femur act to maintain the proper adduction angle. Actually, it could be described as a wedging or "locking effect." (Imagine yourself holding the ischial tuberosity of a skeleton in the cupped palm of your hand and pushing the femur into adduction with your opposing hand; thus, the "locking effect.") The lateral surface of the socket proximal to the greater trochanter is contoured intimately into the soft tissue distal of the iliac crest. It is hypothesized that medially directed forces in this area, working in conjunction with the medially directed forces on the lateral surface of the femur and laterally directed forces borne by the ischial tuberosity, create a three-point pressure system to lock the femur into adduction and reduce motion that can occur when the ischium is free to shift about. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg">Figure 5. Ischial tuberosity is locked in the socket to provide a counter force against femoral shift.</a> Second, the narrow socket means that the pressure bearing areas of the socket bear directly against the skeletal elements, thus reducing motion lost through intervening soft tissues. A wide socket M-L cannot provide this locking phenomenon since the femur can fall away from the supporting surfaces. In the transverse plane, the medially directed force of the ischial tuberosity is posterior to the laterally directed force of the trochanter and femoral shaft. One might assume, therefore, that the socket would twist or whip about its long axis. This does not happen, and apparently the adductor longus tendon and other medial proximal tissues anteriorly generate enough counter force to resist this tendency. Also, the ischial tuberosity creates a posteriorly directed force (since it is nestled in the posterior medial corner of the socket), resisting this tendency. Last, this tendency is checked by a new medial trimline (described later) which captures the medial portions, or the inferior ramus of the ischium, which are almost exactly opposite the trochanter. The exact weight bearing mechanism of the CAT-CAM socket with its wide A-P diameter and decreased emphasis on ischial tuberosity weight bearing is unclear. However, it is assumed that the femur is capable of bearing some measure of the patient's weight due to the increased adduction angle. It is also assumed that hydrostatic weight bearing plays an important role and that the ischial tuberosity still bears a measure of weight. In general, we have discovered that the prosthetic foot should be placed considerably lateral of a plumb line through the ischial tuberosity, but not always under the center of the hip joint or distal femur as with "Long's Line." This line changes position with how well the ischial tuberosity is locked in the socket and how narrow the mid and distal M-L dimensions can be molded. This alignment line also changes from patient to patient and depends on gluteal muscle strength, ischial ramus shape, femoral length, and subcutaneus tissue thickness. The prosthetist is now able to align the prosthesis in a normal physiological and anatomical fashion because the femur is no longer in abduction. The Berkeley Adjustable Shank is very useful in determining this critical relationship. By outsetting the foot more than with quadrilateral designs, the patient must adduct his femur to get his feet close together again. With the femur in abduction, as in the quadrilateral socket, a patient would be standing with his prosthesis scissored over his sound leg if he tried to stand with his femur in normal adduction angle. One cannot use a standard unchangeable line and always obtain the same adduction angle as with the contra-lateral femur, since the shorter the femur, the greater the adduction angle must be in order to place the distal femur under the center of the hip joint resulting in hyper-adduction. This was the reason I abandoned this line in favor of an adjustable line utilizing the Berkeley Adjustable Shank. This has resulted in much better alignment. One may ask, "If everything is stabilized in the M-L direction, then what about in the A-P plane?" Afer all, this is of the utmost importance at heel strike in order to stabilize the prosthetic knee and to help propel the patient over the foot. Our experience has not shown this to be a problem. In fact, if anything, an increase in A-P stability has been noted. We hypothesize two ways by which this might be explained. First, the majority of the muscle activity about the hip is in the A-P direction. The flexors and extensors are allowed to expand naturally, filling the socket quickly, and thus firmly stabilizing it (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg">Fig. 6</a>). Also, this change in contour allows the A-P muscles to function naturally, increasing their size and strength. We have noted many cases of hypertrophy of the A-P muscle groups rather than atrophy. No longer are these muscles being squeezed, stifling their motion and effectiveness. Even suction sockets seem to hold on better since the tissues are not being deformed in an unnatural fashion, causing air pockets and channels to form. Second, the ischial bone is inside the socket, creating a solid posterior stop as opposed to simple soft tissue pressure, aiding A-P control at heel strike (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg">Fig. 7</a>). Distally, CAT-CAM's become more round, again aiding A-P control. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg">Figure 6. Most muscles function in the A-P plane. The CAT-CAM socket gives these muscles room for their normal dynamics.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg">Figure 7. The ischial tuberosity is free to shift about in the A-P plane as well as the M-L plane when sitting on top of the ischial seat.</a> We have noted several interesting phenom-enons during this research effort. The first I have dubbed the "lateral pylon lean syndrome." Sometimes during dynamic alignment on the adjustable shank, the pylon has to lean laterally in order for the patient to be comfortable. The pylon can be brought vertical by increasing the socket adduction. This turns out to be a temporary solution and does not solve the real problem. This eventually results in pain in the perineum. What is actually happening is that the ischial tuberosity is slipping out of the socket proper and migrating medially on the proximal brim. As a result, the femur falls into abduction, or more realistically, the superior lateral portion of the socket drifts laterally on the patient, the medial superior brim digs in, the pylon leans laterally, and the proximal lateral brim gaps. The problem is not one of alignment at all, but of ischial containment (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg">Fig. 8</a>). This happens when the socket is too tight in the M-L plane. This happened with sockets fitted after the 1981 seminar when circumference charts were used to determine socket M-L. These resulted in the ischial tuberosity being on top of the medial brim and that is why the brims of such sockets were so wide and thick. The intention was to get the ischium in the socket, but in actual practice it invariably ended up on top. This is no longer necessary due to improved measurement techniques used to determine true M-L. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg">Figure 8. When the CAT-CAM socket is too tight, the ischial tuberosity shifts medially, the femur abducts and the lateral superior brim gaps.</a> Secondly, it seems that the shorter the femur and the greater the volume of the residual leg, the more noticeable is the "CAT-CAM effect." This is due to the favorable comparison of the CAT-CAM sockets versus quadrilateral sockets. The shorter the femur and the greater the relative amount of soft tissue in which it can move, the more obvious the problems of the quadrilateral socket become. However, even with long and lean residual legs, patients still notice the difference in comfort and adduction associated with the CAT-CAM method. A common statement is "it feels more solid," "it feels like its under me again," or "my leg goes where I want it to go." Also, the short residual limbs simply have much more peripheral tissue containment in which to bear vertical and horizontal loading, since the CAT-CAM extends much higher and contains more tissue, especially gluteal. Third, we have virtually eliminated use of hip joints even on very short sub-trochanteric above-knee patients. The adducted femur and the high lateral wall, snugly pressing into the intraillio-trochanteric region, help stabilize the M-L and tend to reduce the need for external support. Fourth, to the question of sitting: will there be a lot of gapping anteriorly? Not if the socket is dimensionally correct. Bending forward at the hip is actually enhanced due to increased room anteriorly, and with the new flexible brim described next, the problem is completely eliminated. Fifth, both the modified version of the Swedish Flexible design, with medial and lateral framing, and the new Total Flexible Brim (T.F.B.) mesh with CAT-CAM principles perfectly as both allow increased function of the A-P muscle groups (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg">Fig. 9</a>). The CAT-CAM with T.F.B., is preferred because of its superior sitting comfort, adaptability, and dynamic comfort without sacrifice of A-P muscle freedom. The T.F.B., which allows the entire upper three-fourths of the posterior wall and the entire proximal portion of the socket to be flexible and allows a flexible anterior window, is actually opposite of the Swedish Flexible design, which has its greatest measure of flexibility concentrated in the mid-thigh. The T.F.B. is possible because the ischial bone is no longer on top of the posterior or medial seat, but down in the socket, so it does not tend to collapse or push the flexible seat distally. Instead, the tuberosity forces out against the side of the socket as does the trochanter, adductor longus tendon, and peripheral tissues. This can be thought of as one trying to hold his body in place in a V-shaped vertical tunnel or shaft by pushing out on the walls of the tunnel with one's hands and feet. The residual leg pushes out in all directions at once, thus there is no collapse of the flexible posterior brim. For the first time in prosthetics, the proximal thigh is actually allowed to deform naturally during sitting and to change contour dynamically while ambulating. I feel this is important since a great deal of pain complaints are related to the proximal areas. This flexible brim has also allowed us to become much more aggressive and make a major change by extending the posterior and posterior-medial brims higher to capture the ramus and ischial tuberosity more effectively. It has also allowed us to actually slant the medial brim superiorly to better capture the ischium and ramus while relieving the pubis. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg">Figure 9. Three views of the Total Flexible Brim (T.F.B.) CAT-CAM.</a> Sixth, bilateral above-knee patients gain additional benefit from the CAT-CAM design. Our bilateral patients who rejected their quadrilateral socket accept the CAT-CAM enthusiastically. They benefit from the extra space provided in the perineal area by the narrowed M-L (especially with male patients). Even the old round plug sockets gave more room in the perineal area (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Fig. 10</a>). The shaded area in <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Fig. 10</a> demonstrates the extra area available for the genitalia from plug sockets over the quadrilateral socket represented by the rectangles. The CAT-CAM, of course, allows even more room in this area due to its opposite shape and contour. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Figure 10. Graphical representation of the amount of room afforded in the perineum by a non-quadrilateral socket.</a> Seventh, the CAT-CAM has great advantages for the geriatric patient for several reasons. We have had our worst difficulties with quadrilateral socket on people with poor muscle tone. The shortcomings of the quadrilateral design become more obvious in the older population. The sharp angles of the adductor longus channel, the posterior medial corner, the medial brim, and the Scarpa's triangle of the quadrilateral socket were almost never really comfortable. With the CAT-CAM, these patients seem to have improved vascular flow; their residual limbs feel warmer after removing the prosthesis. This seems reasonable since the neurovascular bundle is not being choked off with a large bulge in the Scarpa's triangle. The A-P is not being choked but opened up. We hope to conduct comparative temperature and later Doppler blood flow analysis of this phenomenon. For the extremely large geriatric patient population, this alone might be one of the single greatest benefits of research with CAT-CAM design. When the Total Flexible Brim is added, we have not only greater comfort, but further increase in circulation. Eighth, we have noted that a large percentage of patients who were switched to CAT-CAM comment about energy savings. They do not seem nearly as tired after walking the same distance in the CAT-CAM as with their old prosthesis. This is probably first due to less lateral displacement of the center gravity. Second, patients do not have to fight to keep the femur from hitting painfully against the socket distally by tightening their musculature. Third, with more boney contact inside the socket and thus a more solid purchase, the prosthesis moves quickly without delay from false motion. Ninth, we have found that by undercutting the greater trochanter, a much better purchase and counter force to the ramus and tuberosity can be generated with less M-L play and, I suspect, some vertical component of weight can be borne on the flare of the trochanter much like that of the medial tibial shelf in the below knee. Also, now that the femur is actually adducted, we are now probably picking up a vertical component of force on the lateral shaft of the femur. Tenth and most important, after the 1981 seminar, we used a chart that related circumference of soft peripheral tissue to the desired medial lateral dimension of the socket. We found many fallacies with this method. The reason for this is that one cannot rely on circumference measurements to indicate the proper diameters between the ischial tuberosity and sub-trochanter, or the ramus and sub-tro-chanter. In our work, we found that it was absolutely necessary to obtain both of these measurements to obtain consistent results. A patient may be very fleshy and obese, but that in no way changes the anatomical dimension of the bony structures. The reverse is true with a thin patient. This was one of the most difficult stumbling blocks to obtaining truly good results. It seemed that when using this chart, the tuberosity was usually up on top of the medial superior shelf, which acted as an ischial seat, and this explained why the medial brims at the 1981 seminar were flat and 1 1/2" to 2" wide. In effect, the medial brim became an ischial seat. The sockets fabricated at the 1981 seminar still had the ischial tuberosity out of the socket proper and superior medial lateral diameters that were too narrow, resulting in M-L socket shift. True, the ischial tuberosity was no longer on the posterior shelf, but we had simply moved the tuberosity to the top of the medial shelf. The narrow M-L did provide better adduction of the femur, but not as good as when the ischial tuberosity and ramus are totally locked in the socket, providing a medial stop. The reason for this was discovered with more research. Namely, that it is incorrect to rely on what a patient measures in circumference at the perineal or ischial level, and to expect to extrapolate the medial-lateral dimension of the socket. I had two years of severe problems in this area until we dropped the circumference chart and adopted methods to determine exact measurements through xerography, x-rays, and anatomical measurements. Only then was I able to obtain consistent results, symmetrical adduction of the femur, and stabilization of the proximal socket to prevent lateral socket shift. Eleventh, through the course of our research, we have defined three ischial tuberosity-ramus types. We call these different configurations: alpha, beta, and gamma types (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg">Fig. 11</a>). These classifications are valuable since they can be used to predict to what extent we will be able to control femoral adduction comfortably. The more purchase one can obtain by locking against the medial border of the ischial-ramus, the less the pressure that comes to bear on the soft medial proximal tissues, and the less the M-L shift of the socket. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg">Figure 11. The well defined high slope of the alpha type usually results in improved femoral adduction and M-L control. At the other extreme is the gamma type which is more difficult to grasp properly with the socket.</a> The alpha type is the most desirable, since it has a medial side which slants up at a sharp angle, making it more appropriate for good M-L purchase, and also making it easier to slip into the socket. The beta type has more sloping sides, making purchase somewhat more difficult. The gamma is the poorest type for purchase. We tend to have some pressure problems in the medial proximal area with the gamma types due to M-L socket shift. It is difficult to get this wide bone inside the socket proper. This necessitates widening the medial lateral dimensions of the socket so the wide gamma tuberosity will slip into the socket. With the gamma types, we usually have to settle for a less ad-ducted femur than the patient exhibits on the contralateral side. Another very important point that finally emerged as research continued was that, not only ischial tuberosity, but medial inferior ramus containment was very important to stabilize the socket from lateral shift. The reason for this is that, while the ischial tuberosity is more posterior, and thus helps prevent anterior shift of the socket at heel strike, the ramus is a greater asset when it comes to prevention of M-L shift of the socket and is in a much better anatomical and mechanical position to provide a true medially directed force to the socket, since it is more diametrically opposite the trochanter and sub-trochanteric regions than is the ischial tuberosity. We have had some problems in the beginning with CAT-CAM due to inexperience. However, these have fallen below the one percent range. I find this one percent figure extremely interesting since most patients, especially older people, tend to reject new designs. We found almost none of this phenomenon, however, in switching from quadrilateral to CAT-CAM. We did experience problems due to low back pain in two very old patients. This problem is probably due to the fact that the quadrilateral sockets worn for years and associated with an abducted femur, allowed the lumbar spines to drift to one side. Apparently, fitting the CAT-CAM sockets suddenly pulled the lumbar spines in the opposite directions, inducing low pack pain. During the early years, we sometimes had to fit many transparent check sockets to the same patient before we had successful outcomes. With increased experience and the formulation of rational guidelines and more exacting anatomical measurements, this necessity has been greatly reduced. However, one should expect to spend a great deal more time fitting CAT-CAM design sockets due to the intimate bony contouring. A comprehensive CAT-CAM program should include use of comparative x-rays, which aid in modification and establishment of the angle of correction, as well as transparent diagnostic sockets, video gait analysis, and biofeedback as described in the next paragraph. We also recommend that previous quadrilateral patients undergo an intensive program of abductor strengthening with a prosthetically knowledgeable physical therapist, who will also later teach them not to laterally trunk bend from habit. The full benefit of the CAT-CAM socket is not achieved if the patient has been using a quadrilateral socket long enough to weaken his gluteus medius and abductor mechanism. If the femur tends to be in abduction (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg">Fig. 12</a>), the gluteus medius is slack and not under normal tension, causing it to have a poor mechanical advantage and makes this muscle effectively weak. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg">Figure 12. The gluteus medius is not effective when the femur is in abduction.</a> We have developed a CAT-CAM program to strengthen the gluteus medius muscle through the use of myoelectric biofeedback during gait training. Pressure sensitive electrodes are mounted to the patient over the gluteus medius, and the biofeedback unit emits an audible signal proportional to the electrical activity generated by the muscle when it fires. Using this method, the patient can actually listen to the muscles fire and begin to force himself to use the abductors more. The stronger this abductor mechanism becomes and the more training the patient receives, the less the classical A.K. "lateral trunk lean" during stance phase is observed. This is an important phase of the program and a very effective way to not only strengthen the gluteus medius, but to do so dynamically while the patient is ambulating. We also explain to the patients the reason why they must trunk lean laterally in a quadrilateral socket and use a video system to provide visual feedback to enable them to see themselves walk. This works very well since people seem to react better to watching themselves walk incorrectly and correcting it voluntarily, than to have a practitioner telling them what they are doing wrong. With former quadrilateral patients, do not expect this lean to go away completely because the habit is so well entrenched; however, it can be greatly reduced if not eliminated. <h3>Future Plans</h3> In late 1985 or early 1986, we will introduce the SCAT-CAM, or Skeletal CAT-CAM, which is a highly bone and muscle contoured design. We have been working on this design for three years and it looks considerably different than CAT-CAM (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg">Fig. 13</a>). We feel this approach is the next logical step with the evolution of CAT-CAM and are very pleased with the results. SCAT-CAM is actually a third generation CAT-CAM exhibiting, among other refinements, a highly relieved lateral wall with Oklahoma City channel (O.K.C.), which is actually a trough for the entire femoral shaft along with full length of the lateral wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg">Fig. 14</a>). I feel this is a major advance, since it attempts to capture the femur in the A-P direction and to prevent A-P and transverse pseudo movement. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg">Figure 13. Evolution in shape from the quadrilateral socket (right) to the SCAT-CAM socket (left).</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg">Figure 14. Cross-sectional view of the SCAT-CAM socket.</a> The O.K.C. fossa is provided in a SCAT-CAM to place the ischial tuberosity in a hollowed out relief as opposed to the angular shelf of the second generation CAT-CAM. This fossa enhances the locking effect A-P and M-L. A transparent diagnostic socket is very helpful to properly locate this fossa placement. Also, the medial superior wall has undergone drastic changes to allow relief for the pubis, but still quickly slant superiorally posterior of the pubis to trap even more of the inferior ramus of the ischium and tuberosity. This gives a much improved medial superior locking counter force than a horizontal medial brim. It takes on the shape of a letter "V." With the SCAT-CAM, the pubis can be relieved in the vortex of the "V," while the medial border of all but the inferior apex of the ramus and all of the ischial tuberosity are caught in the arms of the "V." The use of direct anatomical measurements instead of the circumference chart has resulted in a drastic change in general contour where the superior medial-lateral dimension is wider to catch the bony areas, then quickly reduces in M-L dimension and becomes very narrow distal to the sub-trochanteric area, resulting in superior adduction control of the femur. Another important change was with the radius of the superior medial brim. We have changed from a 90° to a gentle upward sloping brim, which prevents the ramus and tuberosity from sliding or shifting out of the socket. With the SCAT-CAM, even more vertical loads are possible on the ischium than with quads sockets since the forces can be wrapped around this complex and curved ischial-ramus bone, which in essence can now be used for vertical posterior and medial loading. We are planning a research program which we hope will contain the following studies: Quantitative <ol> <li> X-ray with comparative study of femur adduction-abduction angles. </li> <li> Digitally timed video comparison of gait A-P and lateral analysis. </li> <li> Myoelectric measurements of major muscle groups, especially the abductors. </li> <li> Dynamic oxygen consumption rates to monitor energy expenditure. </li> <li> Relative Doppler blood flow in distal residual leg. </li> <li> Temperature of skin in both sockets after controlled time factor. </li> <li> Data on acceptance rates. </li> <li> Atrophy data or hypertrophy comparisons. </li> <li> Determination of the weight bearing mechanism. </li> </ol> Qualitative <ol> <li> Video comparisons. </li> <li> Patient comments. </li> </ol> <h3>Conclusion</h3> Even though the CAT-CAM and SCAT-CAM are diametrically opposite to the quadrilateral in design and precept, I believe these new principles will eventually be widely accepted and deeply penetrate the prosthetic field. I encourage practitioners to insist on weight bearing x-rays as part of a comprehensive prosthetic program, which lend credibility to our premise by exposing internal problems which result in external manifestations. My sincere hope is that the prosthetic community will not take this article to be controversial, but as a statement of what we have discovered and felt compelled to share. <h3>Acknowledgments</h3> The main source of strength in perpetuating my interest in CAT-CAM has come from the support of my father, Lester J. Sabolich, C.P.O., Thomas Guth, CP., Mike Wilson, C.P.O., and Dr. Ernest Burgess. These people have supported this project from early on and deserve much credit. I would also like to credit Ivan Long, C.P. who defined his alignment principles in 1975 and thus started us on the right track. Enough credit cannot be given this man! Also I thank my wife Lee, who has not complained about many lonely evenings during this research project. I thank the entire staff of Sabolich Prosthetics Orthotic Center. Without these people, none of this research could have been achieved. Only they understand the grit of many failures and garbled plastic in the trash. I thank all of the prosthetists who have worked with us and tried this method. Their feedback has been invaluable. Last, special credit goes to Chuck Childs, C.P.O., who could see the profound effect of this method and was in hot pursuit of it when he was taken from us. Footnote Dr. Lehneis states that the first person to indicate that the ischial tuberosity was more efficient biomechanically if it was in the socket proper was a German man by the name of Schnur in the early 1950's. *John Sabolich, C.P.O. John Sabolich, C.P.O., is Vice-President of Sabolich, Inc., 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106. References: <ol> <li>Long, I., "Allowing Normal Adduction of Femur in Above-Knee Amputations," Orthotics and Prosthetics, Vol. 29, No. 4, pp. 53-54, December, 1975.</li> </ol> Page Number(s) 15 - 26 Year 1985 Volume 9 Issue 4 Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles Creator An entity primarily responsible for making the resource John Sabolich, C.P.O. *