Atlas of Limb Prosthetics _ O&P Virtual Library

Atlas of Limb Prosthetics | O&P Virtual LibrarySearch GO O&P Library > Atlas of Limb Prosthetics Atlas of Limb Prosthetics Part I: Introduction Chapter 1: History of Amputation Surgery and Prosthetics Chapter 2: The Choice Between Limb Salvage and Amputation 2A / Overview 2B / Trauma 2C / Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options 2D / Infection 2E / Tumor Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text. Chapter 3: Planning for Optimal Function in Amputation Surgery Chapter 4: Prosthetic Management: Overview, Methods, and Materials Part II: The Upper Limb Chapter 5: Kinesiology and Functional Characteristics of the Upper Limb Chapter 6: Upper-Limb Prosthetics 6A / Body-Powered Components 6B / Harnessing and Controls for Body-Powered Devices 6C / Components for Adult Externally Powered Systems 6D / Control of Limb Prostheses Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Chapter 7: Partial-Hand Amputations 7A / Surgical Principles 7B / Prosthetic and Orthotic Management 7C / Aesthetic Restoration Chapter 8: Wrist Disarticulation and Transradial Amputation 8A / Surgical Principles http://www.oandplibrary.org/alp/[21/03/2013 21:52:35] Atlas of Limb Prosthetics | O&P Virtual Library 8B / Prosthetic Principles Chapter 9: Elbow Disarticulation and Transhumeral Amputation 9A / Surgical Principles 9B / Prosthetic Principles Chapter 10: Shoulder Disarticulation and Forequarter 10A / Surgical Principles 10B / Prosthetic Principles Chapter 11: Adult Upper Limb Prosthetic Training Chapter 12: Special Considerations 12A / Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management 12B / Fitting and Training the Bilateral Upper-Limb Amputee 12C / Upper-Limb Prosthetic Adaptations for Sports and Recreation 12D / Trends in Upper-Extremity Prosthetics Development Part III: The Lower Limb Chapter 13: Normal Gait Chapter 14: Analysis of Amputee Gait Chapter 15: The Energy Expenditure of Amputee Gait Chapter 16: Partial-Foot Amputations 16A / Surgical Procedures 16B / Prosthetic and Orthotic Management Chapter 17: The Syme Ankle Disarticulation 17A / Surgical Procedures 17B / Prosthetic Management Chapter 18: Transtibial Amputation 18A / Surgical Procedures and Immediate Postsurgical Management 18B / Prosthetic Management Chapter 19: Knee Disarticulation 19A / Surgical Procedures 19B / Prosthetic Management http://www.oandplibrary.org/alp/[21/03/2013 21:52:35] Atlas of Limb Prosthetics | O&P Virtual Library Chapter 20: Transfemoral Amputation 20A / Surgical Procedures 20B / Prosthetic Management Chapter 21: Hip Disarticulation and Transpelvic Amputation 21A / Surgical Procedures 21B / Prosthetic Management Chapter 22: Translumbar Amputation (Hemicorporectomy) 22A / Surgical Procedures 22B / Prosthetic Considerations Chapter 23: Physical Therapy Management of Adult Lower-Limb Amputees Chapter 24: Special Considerations 24A / Fitting and Training the Bilateral Lower-Limb Amputee 24B / Adaptations for Sports and Recreation 24C / Emerging Trends in Lower-Limb Prosthetics: Research and Development Part IV: Management Issues Chapter 25: Musculoskeletal Complications in Amputees: Their Prevention and Management Chapter 26: Skin Problems of the Amputee Chapter 27: Management of Pain in the Amputee Chapter 28: Psychological Adaptation to Amputation Chapter 29: Critical Choices: The Art of Prosthesis Prescription Chapter 30: Special Considerations- Rehabilitation Without Prostheses: Functional Skills Training Part V: The Child Amputee Chapter 31: Introduction to the Child Amputee Chapter 32: Acquired Amputations in Children Chapter 33: The ISO/ISPO Classification of Congenital Limb Deficiency Chapter 34: Upper-Limb Deficiencies http://www.oandplibrary.org/alp/[21/03/2013 21:52:35] Atlas of Limb Prosthetics | O&P Virtual Library 34A / Surgical Management 34B / Prosthetic and Orthotic Management 34C / Externally Powered Prostheses 34D / Developmental Approach to Pediatric Upper-Limb Prosthetic Training Chapter 35: Lower-Limb Deficiencies 35A / Surgical Management 35B / Prosthetic and Orthotic Management Chapter 36: Special Considerations 36A / The Multiple-Limb-Deficient Child 36B / Van Nes Rotation-Plasty in Tumor Surgery 36C / Juvenile Amputees: Sports and Recreation Program Development O&P Library > Atlas of Limb Prosthetics The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www.oandplibrary.org/alp/[21/03/2013 21:52:35] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 1 Chapter 1 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles History of Amputation Surgery and Prosthetics A. Bennett Wilson Jr., B.S.M.E. No doubt artificial limbs of some type, such as a forked stick, have been used since the beginning of mankind, but the earliest recorded use of a limb prosthesis is that of a Persian soldier, Hegesistratus, who was reported by Herodotus to have escaped about 484 B.C. from stocks by cutting off one of his feet and replacing it with a wooden one. The oldest known artificial limb in existence was a copper-and-wood leg unearthed at Capri, Italy, in 1858, which was supposedly made about 300 B.C. Unfortunately, it was destroyed during a bombing of London in World War II. Artificial hands made of iron were used by knights in the 15th century. The Alt-Ruppin hand, shown along with other hands from the 15th century in the Stibbert Museum, Florence, Italy, is a good example of the work of that age. With respect to surgery, Hippocrates described the use of ligatures, but this technique was a French military lost during the Dark Ages. It was reintroduced in 1529 by Ambroise Pare, surgeon. As a result, amputations came to be used more and more as a lifesaving measure since the rate of survival was much higher when ligatures were used. introduced the tourniquet in 1674, which gave another impetus to amputation Morel surgery. Pare carried out the first elbow disarticulation procedure in 1536. Sir James Syme reported his procedure for amputation at the ankle in 1843. a student and son-in-law of The introduction of antiseptic technique in 1867 by Lord Lister, Syme, contributed greatly to the overall success of amputation surgery, as did the use of chloroform and ether about the same time. The concept of kineplasty to power upper-limb prostheses directly by muscle contraction was introduced by Vanghetti in 1898 while trying to improve the function of Italian soldiers who had their hands amputated by the Abyssinians. Vanghetti's associate, Ceci, performed the first operation of this type on humans in 1900. In Germany, Sauerbruch and ten Horn (1916) developed the skin-lined muscle tunnel, and Bosch Arana in Argentina carried out clinical studies of this procedure in the 1920s. Bier, about 1900, in an effort to make the distal end of the cut bone able to bear weight, recommended an osteoplastic procedure in which the cut end was covered with a flap of cortical bone connected by a periosteal hinge. This procedure never became widespread, but in the late 1940s, Ertl went a step further and developed a procedure for forming a bone combined the bridge between the cut ends of the fibula and tibia. A few years later Mondry bone bridge technique with myodesis, or attachment of the cut muscles to each other over and others adopted and popularized the distal end of the stump. Dederich, Weiss et al., these procedures in some areas. Each major war seems to have been the stimulus not only for improvement of amputation surgical techniques but also for the development of improved prostheses. Toward the end of World War II, amputees in military hospitals in the United States began voicing their disappointment about the performance afforded by their artificial limbs. To ensure that they received the best care possible, Surgeon General of the Army Norman T. Kirk, an orthopaedic surgeon by training, turned to the National Academy of Sciences (NAS) for advice. Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library A COORDINATED PROGRAM FOR AMPUTEES A conference of surgeons, prosthetists, and scientists organized by the NAS early in 1945 revealed that little modern scientific effort had gone into the development of artificial limbs, This effort and a "crash" research program was launched later in 1945 through the NAS. was initially funded by the Office of Scientific Research and Development (OSRD). At the end of the war when the OSRD was disbanded, the Office of the Surgeon General of the Army continued support that was later assumed by the Veterans Administration, which had also inherited the responsibility for the care of military amputees after discharge from the armed services. For the first 2 years the NAS, through the Committee on Artificial Limbs (CAL), actually initiated and administered the program through subcontracts with several universities and industrial laboratories. On June 30, 1947, the CAL was discharged, and the role of the NAS became an advisory one to the Veterans Administration, which contracted directly with various research groups. In 1947, the Veterans Administration also established its own testing and development laboratory in New York City. The army and navy cooperated and contributed by supporting prosthetics research laboratories within their respective organizations. From July 1, 1947, to Dec 1, 1955, the group within the NAS was known as the Advisory Committee on Artificial Limbs. The Prosthetics Research Board was created to carry out the NAS responsibility from Dec 1, 1955, to June 30, 1959. In July 1959, the Committee on Prosthetics Research and Development (CPRD) and the Committee on Prosthetics Education and Information (later called the Committee on Prosthetics and Orthotics Education [CPOE]), both subgroups of the board, assumed this role until their dissolution by the parent NAS in 1976. The reason for the dissolution of these bodies has never been made completely clear. The Artificial Limb Program, as it came to be known, was started initially with the idea that physicians and surgeons could provide engineers with design criteria for components such as ankle and knee joints and that good engineering design based on these criteria coupled with modern materials would result in devices that could solve many of the problems of the amputee. Although some progress was made early in the program by this approach, it soon became apparent that fundamental information on how human limbs function was needed before adequate design criteria could be formulated. To provide such information on lowerlimb function, a project was established at the University of California, Berkeley, as a joint responsibility of the Engineering School in Berkeley and the Medical School in San Francisco. who had collaborated previously in a biomechanical analysis of the Eberhart et al., shoulder, directed this program, which began by using the latest technology to refine and add to the existing knowledge of human locomotion. A concurrent program was initiated under Taylor in the Engineering School at the University of California at Los Angeles on the function of the upper limbs. At the same time design and development projects were being carried out at Northrop Aviation, Inc.; Cat-ranis, Inc.; the Army Prosthetics Research Laboratory (APRL); the U.S. Naval Hospital, Mare Island (which later became the Navy Prosthetics Research Laboratory, Oakland Naval Hospital); and a U.S. Army Air Force unit at Wright Field. New York University was engaged in 1947 to evaluate the devices that resulted from the research and development program. The Veterans Administrations laboratory in New York also performed evaluations primarily by means of mechanical and chemical testing projects; later this laboratory became part of the Veterans Administration Prosthetics Center (VAPC), which contributed heavily to development and evaluation projects established within the program. Although progress was made with new devices and substitutions of materials, more significant advances were in the areas of socket design and alignment of the various types of prostheses. As a result of a visit by a commission to Europe in 1946, a study of the suction socket for transfemoral (above-knee) prostheses was made by the University of California, Berkeley. The results of this study, coupled with information derived from the locomotion studies at the University of California, Berkeley, led to a biomechanical rationale for the design and fabrication of the socket and the alignment of transfemoral prostheses. Innovative techniques for providing improved prostheses for Syme (ankle disarticulation), hip disarticulation, and transpelvic (hemipelvectomy) amputees were developed by McLaurin and his associates while working at Sunnybrook Hospital, Toronto, under the Much of this work was carried auspices of the Department of Veterans Affairs of Canada. to fruition at the University of California, Berkeley, after Foort transferred there in 1955 from http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library Toronto. Variations on the early designs of ankle disarticulation prostheses were made by VAPC prosthetists. Thus a body of knowledge of management of ankle and hip disarticulation (and transpelvic) amputees was developed and then disseminated to clinicians through a formal education program. Concurrently, on the basis of a number of innovations in transtibial (below-knee) socket designs made by practitioners in various parts of the country, Radcliffe and Foort developed the rationale and techniques of fabrication for what is now known as the "patellar tendon-bearing" (PTB) prosthesis. Education in fabrication and application was first offered through university education programs in 1960. A number of variations in technique are now used successfully in practice, but the principles set forth originally by Radcliffe and Foort have stood the test of time. In 1963, Weiss, an orthopedic surgeon in Poland, visited the United States under the auspices of the Office of Vocational Rehabilitation and the CPRD, at which time he described techniques he was using in management of lower-limb amputees. These included fitting of temporary prostheses immediately after surgery, a procedure adapted from Berlemont et al., and osteoplasty and myoplasty techniques adapted from Ertl, Mondry, and Dederich. Weiss' presentations prompted the Veterans Administration to initiate in 1964 in Seattle under a study to determine the feasibility of immediate postsurgical Burgess and colleagues fitting, osteoplasty, and myoplasty. Projects were also started at the Navy Prosthetics and the University of Miami. Just prior to this a team at Duke Research Laboratory had been studying the effects of early fitting, that is, providing the patient with University temporary prostheses with well-defined sockets within a month after the amputation. As a result of these efforts many amputees are fitted with rigid dressings immediately after surgery and with definitive prostheses much earlier than was previously considered possible. These procedures result in significantly lower hospital and training costs. Pedersen and others began, about 1958, to promote the idea that knee joints in many elderly patients with vascular disease could be saved if proper care were given postsurgically. Until then the classic instruction was to amputate transfemorally when circulation was impaired so that healing could be ensured. Weiss agreed with the view that knees could be saved and pointed out that the use of a rigid dressing should improve healing by reducing edema. Consequently, the ratio of transfemoral to transtibial amputations in the United States This continues to have between 1965 and 1975 was almost reversed from 70:30 to 30:70. a profound effect on the rehabilitation potential of dys-vascular and geriatric amputees. Although the Veterans Administration had no direct responsibility for children, it did provide indirect support to the Children's Bureau in adapting some of the devices and techniques and the Michigan Crippled Children's developed for adults. Frantz and Aitken Commission initiated a project to develop methods of management for child amputees in Grand Rapids in 1952. A similar project was launched at the University of California, Los Angeles, in 1955, and New York University was funded to further evaluate the devices and techniques emanating from these projects. The Children's Bureau also provided the NAS with some funds for coordination of activities in child prosthetics. From this emerged the Child Amputee Clinic Chiefs Program, which has held meetings nearly every year since 1958, and the Inter-Clinic Information Bulletin (ICIB), a small monthly publication that has proved to be useful for the dissemination of results of research and development. After the dissolution of the CPRD (Committee on Prosthetics Research and Development) in 1976, the Child Amputee Clinic Chiefs formed the Association of Children's Prosthetic and Orthotic Clinics to continue the educational activities of the Chiefs' group. AMPUTEE PROGRAMS IN OTHER COUNTRIES In Great Britain, the Limb Fitting Centre at Queen Mary's Hospital, Roehampton, expanded its research effort shortly after the end of World War II and became known as the Biomechanical Research and Development Unit. The Scottish Department of Home and Health Services has sponsored research and development at the Limb Fitting Centre, Dundee; University of Strath-clyde; and Princess Margaret Rose Hospital, Edinburgh. The work in Edinburgh was devoted mainly to children. At the University of Strathclyde there is a 4-year Bachelor of Science program in prosthetics and orthotics. http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library Work concerning children's problems is also being carried out in other places in Great Britain, namely, at Chailey Heritage and the Nuffield Clinic, Oxford. Suppliers of artificial limbs in Great Britain also support research and development within their own organizations. Support of research in prosthetics in Canada has been sporadic, but some of the results have and Sauter at the been important. The work of Scott at the University of New Brunswick Hugh MacMillan Medical Centre (formerly Ontario Crippled Children's Centre) has made significant contributions to externally powered artificial arms, and Foort's team at the University of British Columbia have been the leaders in the development of computer-aided design and computer-aided manufacturing (CAD/CAM) techniques in lower-limb prosthetics. A number of research and development efforts were started in Germany after World War II, but there appears to have been little coordination of these efforts. The work at the University of Münster in body-powered upper-limb prosthetics has influenced practice elsewhere, as has the work at the University of Heidelberg with severely involved child amputees. Since the early 1970s research in Germany seems to have moved from the universities to the private manufacturers. The manufacturers have had a significant influence on prosthetics and orthotics practice throughout much of the world by providing innovative hardware. A formal education program for prosthetists has been in operation in Germany for many years. The thalidomide tragedy prompted the Swedish government to expand its research and development work in technical aids for the handicapped to include artificial limbs in 1962. This program continues today. During the 1960s and early 1970s, the French government expanded its support of artificial limb research mainly through the Ministre des Anciens Combattants et Victimes de Guerre. Research and development in artificial limbs in Italy have a long history. A research unit has been in operation at the University of Bologna for many years, and a group at the Prosthetic Centre in Budrio is very active in the development of externally powered upper-limb prostheses. Not a great deal is known about activities in Russia, but research units are located in Leningrad and Moscow. Their contribution has been the first clinically useful myoelectrically controlled hand. The U.S. government, through the Surplus Agricultural Commodity Act (P.L. 480), supported work in Poland, Yugoslavia, Israel, Egypt, India, and Pakistan from the early 1960s until funds were depleted in the early 1980s. Some prosthetic research has been carried out in Japan but as yet has had little effect on practices in the United States. RELATED ORGANIZATIONS The American Orthotics and Prosthetics Association (AOPA) is an organization primarily of privately operated prosthetics and orthotics facilities in the United States and Canada to assist its members in providing the best possible services. The parent group was organized in 1917 as the Artificial Limb Manufacturers' Association. The name was changed in 1946 to the Orthopedic Appliance and Limb Manufacturers' Association when orthotists were invited to join, and the present name was adopted in 1958. The American Board for Certification in Prosthetics and Orthotics was established in 1948 as an accreditation body to certify the professional competence of practitioners and facilities in these disciplines. In addition to its accreditation activities, the board also seeks to advance the highest levels of competency and ethics in the prosthetic/orthotic profession. In 1952, the International Society for the Rehabilitation of the Disabled (now called Rehabilitation International) appointed an International Committee on Prosthetics and Orthotics (ICPO) to promote the dissemination of knowledge of prosthetics and orthotics throughout the world. The chairman was Knud Jansen, and headquarters for the committee was established in Copenhagen, where a number of very successful international seminars were conducted in the late 1950s and 1960s. The committee also sponsored courses and http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library conferences at other locations during this period, and in 1971, with the concurrence of Rehabilitation International, the members of the committee and others formed the International Society for Prosthetics and Orthotics (ISPO) "to promote high quality prosthetics and orthotics care to all people with neuromuscular and skeletal disabilities." ISPO, an organization of all professionals associated with prosthetics and orthotics, conducts an international congress at 3-year intervals to bring together clinicians, educators, research personnel, and administrators to exchange information and ideas and to make plans for cooperative programs. The American Academy of Orthotists and Prosthe-tists (AAOP) was founded in 1970 by practicing prosthe-tists and orthotists as a professional society to promote the advancement of knowledge in the field of prosthetics and orthotics. Its goals and organization relate primarily to education. Through the years amputees have formed clubs for the purpose of exchanging experiences and views. Their initiation was accompanied by a good deal of enthusiasm, but few seem to have survived for any appreciable time. However, in recent years there has been a proliferation of well-organized amputee support groups across the country that have the potential for influencing amputee rehabilitation. By working closely with rehabilitation personnel, especially clinicians, the amputee groups, in addition to providing psychological and other support to individual amputees, can provide clinicians, researchers, and administrators with information that will eventually improve the delivery system as well as prosthesis design and methods of therapy. This new amputee movement is probably the result of a public that is more informed about medical problems in general and eager to acquire a better understanding of medical problems. ENGLISH-LANGUAGE PERIODICALS Although several periodicals were devoted to artificial limbs prior to 1946, they were directed toward amputees. The first English-language periodical written for practicing prosthetists was the Orthopedic and Prosthetic Appliance Journal. This journal began publication in 1946 when the Artificial Limb Manufacturers' Association became the Orthopedic Appliance and Limb Manufacturers' Association, the immediate predecessor of the American Orthotic and Prosthetic Association (AOPA). The journal's name was changed in June 1967 to Orthotics and Prosthetics. The next prosthetics publication to appear was Artificial Limbs- A Review of Current Developments in 1954, published two or three times each year by the Advisory Committee on Artificial Limbs-later called the CPRD (Committee on Prosthetics Research and Development)-of the NAS, to provide recent results of the U.S. program to clinical personnel. In 1972, the CPRD staff felt that Orthotics and Prosthetics had matured to the point that it was appropriate for it to be responsible for publishing clinically useful results of research, and publication of Artificial Limbs was terminated. In 1964, the Prosthetics and Sensory Aids Service of the Veterans Administration (now the Department of Veterans Affairs) began semiannual publication of the Bulletin of Prosthetics Research, with emphasis on reports of research activities and results. In 1983, the name was changed to the Journal of Rehabilitation Research and Development. In addition to three issues per year devoted to technical reports, a separate issue is dedicated to progress reports from the majority of the research projects in prosthetics, orthotics, and sensory aids in the English-speaking world. From time to time the Department of Veterans Affairs also publishes "clinical supplements" to the journal to provide clinicians with current practice in selected areas such as "recreation for the handicapped" or "wheelchairs." During the late 1950s, the CPRD organized a network of Child Amputee Clinics throughout the United States as a means of improving prosthetics services for children. To encourage rapid interchange of information among the clinics, publication of the ICIB (Inter-Clinic Information Bulletin) was begun in 1961. Primary responsibility for putting the bulletin together was initially assigned to New York University, then was transferred to CPRD, and is now published under the auspices of the Association of Children's Prosthetic and Orthotic Clinics. The ICIB was received with such enthusiasm that in 1969 the CPOE (Committee on Prosthetics and Orthotics Education) applied the same concept to adult prosthetics and http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library orthotics with the publication of Newsletter - Amputee Clinics. This bulletin continued until the dissolution of CPRD and CPOE in 1976. Because Newsletter - Amputee Clinics was sorely missed, the AAOP (American Academy of Orthotists and Prosthe-tists) initiated publication in 1976 of Newsletter - Prosthetic and Orthotic Clinics. In 1982, the title was changed to Clinical Prosthetics and Orthotics. In 1988, the AOPA and AAOP combined Orthotics and Prosthetics and Clinical Prosthetics and Orthotics to create a new quarterly entitled Journal of Prosthetics and Orthotics. In the late 1950s, the ICPO (International Committee on Prosthetics and Orthotics) of the International Society for the Rehabilitation of the Disabled began publication of a technical journal that was published sporadically until 1970. At that time the ICPO was reformed into the ISPO (International Society for Prosthetics and Orthotics) and became a separate entity. After volume 1, the ICPO publication was renamed Prosthetics International. Volume 2, number 1 is dated simply "1964." From 1972 through 1976, the ISPO published the ISPO Bulletin four times a year, primarily to keep the membership informed of administrative and technical developments. As the ISPO grew, it was able in 1977 to replace the Bulletin with Prosthetics and Orthotics International, a scientific journal published three times a year that contains research reports and results of clinical evaluation of new devices and techniques. DEVELOPMENTS IN LOWER-LIMB PROSTHETICS Sockets and Suspension Prior to the U.S. research program, the most common approach to the design of the transfemoral socket was the carved "plug fit" wooden socket with a conical interior shape. The weight of the amputee during the stance phase of walking and during standing was transferred to the skeletal system through the muscles about the thigh. The transfemoral socket design introduced by the University of California, Berkeley, about 1950 was shaped to permit use of the remaining musculature. It contained well-defined walls and became known as the "quadrilateral socket." The posterior wall was shaped to provide ischial-gluteal weight bearing. Following the German practice, an air space was left between the distal end of the stump and the bottom of the socket, and an air valve was installed in the medial wall in this area. Most of the patients used this system successfully, but a sufficient number experienced edema and dermatologic problems to warrant further study. The University of California, Berkeley and San Francisco, undertook studies of the problems of transtibial amputees as well as those of transfemoral amputees. The result was the PTB (patellar tendon-bearing) prosthesis, which involved total contact between stump and socket. Further analysis of problems with transfemoral amputation and experience with the PTB prosthesis resulted in the total-contact quadrilateral transfemoral socket, which minimized the problems of terminal edema. Because it was felt that the education programs strayed from the fundamental principles of the quadrilateral design or for other reasons, some prosthetists began to feel by 1980 that a second generation of transfemoral sockets was needed. In the early 1980s Long, Sabolich, and others introduced designs known variously as NS/NA (normal shape-normal alignment), CAT-CAM (contoured, adducted trochanter/controlled alignment method), and narrow ML (medial-lateral). These widely publicized designs caused confusion in the field because not only was it difficult to explain their rationale and thus difficult to teach but their advocates also produced many variations. However, the one common feature was that the support of the amputees body relied less on the ischial "seat" than the original quadrilateral design specified. Two conferences sponsored by the ISPO in 1987 helped to clear up most of the confusion. The "ischial containment" sockets, as they are now called, are used in many areas with a better understanding of the underlying principles, but more study is needed if they are to be prescribed properly. Fabrication Materials and Methods Immediately after World War II the vast majority of lower-limb prostheses were constructed of a combination of wood and leather. These materials, alone and together, have many properties desirable for the construction of artificial limbs, but they also possess properties that make them a good deal less than perfect. Wood requires the skill of carving and shaping, and leather absorbs perspiration and is difficult to keep clean. http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library To overcome some of the deficiencies of wood and leather, Northrop Aviation, Inc., introduced the use of thermosetting resins for laminating tubular stockinette-over-plastic replicas of the stump to form sockets and structural components of upper-limb prostheses. The Veterans Administration Prosthetics Center conducted extensive demonstrations to encourage prosthetists to use plastic laminates over wood, thereby furthering the trend toward the use of plastics. and his coworkers in Toronto coupled the plastic laminating technique with a McLaurin good engineering analysis of the problem to produce the "Canadian Syme prosthesis," which was a significant improvement over former practices. This design and variations developed by the Veterans Administration Prosthetics Center were adopted worldwide as prosthetists learned to use plastic laminates. (Experience with the foot of this prosthesis led to the development of the solid ankle, cushion heel [SACH] foot.) The same group also conceived and developed the plastic socket "Canadian hip disarticulation prosthesis" about 1955, which was also soon adopted worldwide. Plastic laminating techniques made total-contact sockets practical; most of the prostheses used throughout the world now are total-contact sockets made essentially of either a plastic laminate or thermoformed plastic. The search for a practical method of making transparent sockets was highlighted in 1972 when Mooney and Snelson developed a method for vacuum-forming a polycarbonate sheet over a positive model of the stump to provide the first practical transparent test sockets. Polycarbonate has been replaced by several cheaper materials, and today use of transparent check sockets is the rule rather than the exception. Vacuum-forming polypropylene, the properties of which seemed to make it appropriate for definitive use, was introduced in 1975 by the Moss Rehabilitation Hospital in Philadelphia, and today polypropylene sockets used with endoskele-tal systems are considered to be the norm. The introduction of socket designs based on sound biomechanical analyses to take full advantage of the functions and properties of the stump in conjunction with a rationale for alignment undoubtedly represents the greatest achievement in prosthetics since World War II. Suspension of the Prosthesis Prior to the development of socket designs based on biomechanical principles, suspension of most lower-limb prostheses presented formidable problems. Until the introduction of the pelvic band about the time of World War I, over-the-shoulder suspenders were used almost universally for keeping transfemoral prostheses in place. Until the development of the PTB prosthesis, the side bars of the thigh lacers, or corset, of the trans-tibial prosthesis were bent to conform to the medial and lateral surfaces of the thigh to provide suspension. This arrangement was often supplemented by a waist belt. The quadrilateral design not only permits the use of suction for suspension but makes the suspension problem easier because the muscle action of the stump within the intimately fitting socket also helps to hold the prosthesis in place. Until the past few years suction was seldom used to suspend the transtibial prosthesis. The intimate fit of the transtibial socket makes it possible in most cases to achieve quite adequate suspension by a supracondylar strap. Variations of the original PTB prosthesis design (supracondylar or supracondylar-suprapatellar) employ more proximal brims that are contoured to make the supracondylar straps unnecessary. Nevertheless, retention of the transtibial prosthesis by suction is considered desirable, and the efforts by Kristinsson and Durr-Fillauer have resulted in the so-called 3-S transtibial which uses a closely fitting elastomeric sleeve as an inner socket to provide the socket, adherence needed for adequate suspension. It has been recognized for many years that if the flexibility of socket walls could be varied to match the properties of the underlying tissues of an amputation stump, the result would be a more comfortable and functional socket. The most successful approach to this problem was initiated by Kristinsson in the early 1980s, who used a semiflexible liner in a rigid outer or frame, shaped so as to provide rigidity where it is required. The concept was structure, and Durr-Fillauer. Each adopted by a group in Sweden and then by New York University added slight variations. These sockets have been well received but not widely used because the materials currently http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] 1: History of Amputation Surgery and Prosthetics | O&P Virtual Library available are not sufficiently durable when made thin enough to provide the desired flexibility. The ultimate arrangement for achieving suspension would seem to be attaching the prosthesis directly to the bone. The first recorded efforts in what is often called "skeletal attachment" seem to have been made in Germany in the 1940s. Some work was considered at the University of California, but the first experimental work in the United States was probably that in Birmingham, Michigan, during the 1960s, which was undertaken on a small of Es-slinger scale with support from the Veterans Administration. Results with dogs were encouraging. Hall et al. of Southwest Research Institute continued this work for several years as a result carried out some investigations at of some experiences he had with horses, and Mooney Rancho Los Amigos Hospital, Downey, California, in the early 1970s. In spite of encouraging results, interest in "skeletal attachment" seems to have waned. Computer-Aided Design/Computer-Aided Manufacturing To accelerate the process of fitting and fabrication of artificial limbs, in the 1960s James Foort of the University of British Columbia proposed the use of numerically controlled milling machines with data supplied by stereophotography to produce a positive model of the stump ready for the molding of a socket. Progress was slow until the introduction of computer-aided design procedures and personal computers. The University College London in the late 1970s developed an automated process for molding polypropylene sockets, called Rapidform, and it seemed logical to develop a system that would include computer-aided design, numerically controlled production of a positive model of the stump, and automated production of the socket. Workers there also envisioned automated fabrication of the entire artificial limb if alignment data could be fed into the system. In the early 1980s University College London introduced a system that requires taking a loose cast of the transtibial amputation stump, transferring the inside contours to a personal computer by means of a digitizer to produce an image of a positive model, modifying on the screen the shape of the positive model, and feeding this information into a numerically controlled milling machine that carves a positive model from a blank of plaster of paris or wax. At this point the positive model is ready for use in fabrication of a socket by any method desired, but vacuum-forming of polypropylene or similar sheet plastic is the rule. In the mid-1980s the Veterans Administration began funding several projects in the United States to further the application of the CAD/CAM process in the fabrication of artificial limbs. Not a great deal of progress is apparent, although the interest generated by these projects and the availability of hardware and software for two systems from England based on the University College London work has induced several U.S. prosthetics facilities to experiment with the introduction of CAD/CAM on a routine basis in spite of the fact that in its current state of development the advantages do not seem to outweigh the disadvantages. Undoubtedly, further development will make CAD/CAM a useful tool in providing improved service to amputees. Prosthetic Knees Locomotion studies at the University of California showed that swing-phase control of the shank is as important as stance-phase control in lower-limb prosthetics. Until that time, control of the shank during swing phase in most transfemoral prostheses was provided by introducing friction about the knee bolt, the so-called constant-friction knee, an arrangement that provides a smooth gait at only one cadence for a given amount of friction. was designed to overcome the shortcoming of the The Navy Variable Cadence Knee Unit constant-friction unit to some degree by increasing the friction toward the end of the swing phase. The Navy design, introduced about 1950, did indeed permit improvement in the gait pattern, but the materials available at that time soon failed as a result of wear, and maintenance became a problem. The same principle is employed in the Northwestern University variable-cadence knee, which was available commercially for some years. In 1949 the Vickers Corporation in Detroit requested assistance from the government through the NAS in perfecting the Stewart-Vickers Hydraulic Above-Knee Leg, a design by Jack Stewart, who had had an amputation through the thigh. This system used hydraulic principles to lock the knee on heel contact and to provide coordinated motion between the knee and Laboratory and clinical trials at New York University with a ankle during the swing phase. dozen units showed that the prosthesis was well accepted by a significant proportion of amputees, apparently because of the swing-phase control resulting from the hydraulic system http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44] especially the Carbon Copy II. To eliminate the bulk usually associated with knee disarticulation prostheses. excessive maintenance prevented it from being a commercial success. Many hydraulic swing-phase units are now available as a result of the research program. The Greissinger foot. John Campbell developed and introduced in the late 1970s the SAFE (stationary attachment-flexible en-doskeletal) foot. Results of the New York University evaluation program and other efforts prompted the United States Manufacturing Company to make a version of the Stewart-Vickers design available commercially.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library that had been provided primarily for stance-phase control and not because of the stancephase control itself. It was learned later that the degree of resistance to plantar flexion of the ankle during the early stages of stance phase was beneficial in providing stability during the stance phase of walking. The Prosthetic Research Study at the University of Washington. The swing-phase phase. but because of the high cost. which uses a fourbar linkage within the shank to provide an effective knee axis that approximately matches the normal knee axis. feature was later incorporated into the stance-phase system (model A) and called the Mauch S 'n' S System. who along with Henschke had been developing a hydraulically actuated stance-phase control unit under the auspices of the U.oandplibrary. is now available and known as the UC-BL Pneumatic Swing Control. Endoskeletal Prostheses http://www.org/alp/chap01-01. and several competitive designs are now available and used widely. This ankle contained a block of rubber with variable stiffness to control motions in all three planes. cushion heel) foot with the PTB prosthesis represented the ultimate in simplicity while providing acceptable function for most The SACH foot has had outstanding success in the marketplace primarily patients. because of its simplicity." Meanwhile the introduction of the SACH (solid ankle. this unit retained the swing phase and hydraulic ankle features. and knee units similar to the OHC are used in many transfemoral prostheses as well as knee disarticulation limbs. which is the unit available today. Other stance-phase controls have been developed by commercial organizations. The Flex-Foot employs the same concept but is a radical departure from artificial foot design in that the endoskeletal shank and keel of the foot are one piece of carbon graphite flat stock. which proved to be well accepted in spite of a slight increase in weight over the SACH foot. Mauch. California.S. However. was persuaded in 1951 to concentrate his efforts on the use of hydraulic principles for control of the shank during swing The result was the model "B" Hen-schke-Mauch Knee Unit. Copenhagen) knee unit. Berkeley. The OHC unit. This principle has been adopted by several manufacturers. These are essentially mechanical systems with an incremental resistance added upon weight bearing. An outstanding achievement of the early years was the "Navy ankle" developed by the Naval Prosthetic Research Laboratory in Oakland. In this system energy is stored in an elastic keel as the foot rolls over during stance phase to be released just prior to toe-off. This feature was appreciated by less active users as well. To retain most of the simplicity of the SACH foot while providing some of the function of three-way feet. by virtue of the four-bar linkage. To overcome the high costs involved in manufacturing hydraulic units and yet retain the advantages. Lyquist in 1973 designed the OHC (Orthopaedic Hospital. pioneered the concept of energy-storing feet with the introduction of the "Seattle" foot in the early 1980s. developed in Germany to offer the kind of function provided by the Navy unit. a pneumatically controlled system designed at the University of California. and it is available with a hydraulically controlled swing-phase system. the stance-phase control feature was not included. Air Force since 1946. has commonly been used to provide "three-way action. is quite stable during stance phase.asp[21/03/2013 21:52:44] . in an effort to provide the athletic lower-limb amputee with more function. Known as the Hydra-Cadence. Considerable effort in the early years of the program was given to the design of articulated feet with the expectation that such designs would enhance the amputee's ability to walk. Prosthetic Feet Throughout the years great attention was devoted to the design of artificial feet to provide better function than allowed by the standard single-axis wood foot. usually referred to as modular en-doskeletal limbs. which appeared about 1949. the development of devices was discontinued at that time. and harness designs produced by Northrop. Northrop also initiated a study in harness design that was later taken over by the University of California at Los Angeles. the "pylon" being covered with a resilient foam shaped to match the contralateral leg. These designs. primarily because the sensory feedback so necessary for automatic or semiautomatic operation was not adequate.S. These devices were well received by a significant proportion of the amputee population. it was Alderson who. The primary assignment to the APRL (Army Prosthetic Research Laboratory) was the development of artificial arms with emphasis on artificial hands. http://www. Pylons. but it was difficult for the manufacturer to produce quality devices at a competitive price because of the close mechanical tolerances required. with adjustment features began to appear about 1960. it soon replaced other available units.asp[21/03/2013 21:52:44] . Their use was then accelerated by immediate postsurgical fitting studies. The hardware. but the high costs preclude widespread use. Inc. and others between 1946 and 1950 made it practical and desirable for the surgeon to save all length Unfortunately. harness for transhumeral amputees was first developed by Northrop in 1947. socket designs. produced many ingenious designs for artificial arms in addition to The alternating-lock elbow unit operated from the introducing plastic laminating techniques.. For this reason. DEVELOPMENTS IN UPPER-LIMB PROSTHETICS Early in the Artificial Limb Program it was decided that the best approach to take at that time for upper-limb replacement was to develop a variety of components. Northrop Aviation. the idea of temporary prostheses was revived. Refinements of these basic socket and harness designs are still the standard for body-powered upper-limb prosthetics. After becoming available commercially.oandplibrary. These devices are still available today. External Power Although some work was done in Germany earlier. and harnessing methods that could be assembled to best meet the needs of individual patients rather than trying to develop special systems for each level of amputation. Although the APRL hand and hook are not used widely. the ultimate concept being an adjustable endoskeletal structure that could be carried over into the definitive prosthesis. The manufacture of nearly all of the cosmetic gloves provided for artificial hands is based on techniques developed at the APRL. systems. have gradually had more and more success despite the difficulty in shaping and maintaining their foam covers. all of which required use of the contralateral hand or motion against a fixed object to activate the lock. developed the first working model of an electrically powered artificial arm. socket. Out of this effort came the voluntary-closing APRL hand and the APRL hook. poorly fitting sockets mounted on peg legs. and some effort was put into a study of sensory feedback. but evaluations at New York University and UCLA in 1953 revealed that amputees could not operate any of the designs without conscious thought. after the rationale for socket configuration was fully developed and plastics had proved to require less time but resulted in a better fit than earlier methods of fabrication. with support from the United States government and International Business Machines. They have become the norm rather than an alternative. or endoskeletal prostheses. and various designs began to appear on both sides of the North Atlantic. Staros established the criteria for their use as temporary limbs. APRL. no major advances that have found widespread use have been made in upper-limb prosthetics since the early 1960s. Demonstrations were impressive. the basic research required led to the development of the sizes and configurations that are now standard for most artificial hands produced today. However.org/alp/chap01-01. UCLA.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library During the first decade of the U. UCLA also developed socket designs for all levels of upper-limb amputation that were based on anatomic and physiologic principles. This basic design is in use throughout the world. except for externally powered possible in amputation through the upper limb. research program the use of temporary prostheses was discouraged because it was believed that more harm than good would result from the use of crudely made. especially for blind amputees because of the sensory feedback provided. One positive result of the kineplasty program was that it provided for the first time the opportunity to study the biomechanical characteristics of an intact human muscle. Otto Bock Orthopaedic Industry. Simpson in Edinburgh used pneumatic prostheses of his own design quite successfully for severely disabled children. the Liberty Mutual electric elbow. was originated in Germany and is used there today. Canada. and Canada. and pectoral muscles in transhumeral and shoulder disarticulation cases. The thalidomide tragedy Sweden. Kessler and Kiessling complementary development work. created a great deal of interest in externally powered prostheses. the technique has been abandoned largely because of the extra surgery involved and the considerable care that must be used in keeping the tunnel clean if complications are to be avoided. EDUCATION AND TRAINING Pilot courses sponsored by the University of California. thus eliminating the need for any wiring or harness above the elbow. are electric elbows for children and youths from Variety Village in Toronto. An interesting design was proposed in Yugoslavia but was never carried to fruition. and such prostheses are no longer novelties. kine-plasty procedures were performed. England. artificial hands from Otto Bock. New socket designs for transradial amputees that provide self-suspension were developed.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library In 1958 Russian workers announced that a "thought-controlled" artificial arm had been perfected. Results on some severely disabled adults and children were impressive. the only practical system that could be Although many devised was one involving the biceps tunnel for the transradial amputee. Although a number of prosthetists and surgeons had advocated through the years that http://www. which proved to be an electric hand controlled by myoelectric signals from the flexors and extensors of the wrist and was suitable only for transradial amputees. orthopedic surgeons and pros-thetists received instructions together as teams. and alignment of the suction socket transfemoral prosthesis were followed by local courses presented in key areas of the country by the Veterans Administration Prosthetics and Sensory Aids Service (PSAS) and the Orthopaedic Appliance and Limb Manufacturers In these courses Association (now AOPA [American Orthotic and Prosthetic Association]). Berkeley. Rights to manufacture these devices were purchased by groups in Canada and Great Britain. and other devices that can be assembled in prostheses to meet the particular needs of individual patients.asp[21/03/2013 21:52:44] . fabrication. but these units were never widely accepted. After extensive investigation of use of muscle tunnels through the wrist flexors and extensors in transradial amputees. in Germany centered around pneumatically operated prostheses. but a lack of funds curtailed this effort in 1968. and Bosch Arana in Argentina) appealed to a Sauerbruch and ten Horn number of investigators in the United States immediately after World War II. Canada. However. Initial efforts especially in Germany. in 1949 in prescription. Because of its somewhat grotesque appearance. The Krukenberg procedure. Special Procedures The idea of harnessing a muscle directly to power an arm prosthesis (Vanghetti in Italy. in addition to the Utah arm for transhumeral amputees. in Germany. in Germany and Viennatone in Austria made versions of the Russian design available that they marketed with some success. but the design did not get beyond the United Kingdom. Inc. Mason of the Veterans Administration Prosthetics Center and Childress and Billock at Northwestern University provided refined designs in which the batteries were located within the hand or wrist unit. biceps and triceps in transradial and transhumeral amputees. adequate feedback signals were lacking. Now available. During the 1980s the application of externally powered upper-limb prostheses gradually increased. the Krukenberg procedure is seldom used in the United States despite the success reported by Swanson.. the education of a prosthetist consisted of an informal apprenticeship program in which very little formal instruction was available. and by arrangement with in the United States undertook the University of Heidelberg. controls developed at the University of New Brunswick.org/alp/chap01-01. Again.oandplibrary. Prior to this. beginning about 1960. in which the forearm stump is split between the ulna and radius and the forearm muscles are attached to them in such a way as to provide a functional pincer grasp. To provide a similar facility in the Midwest the Office of Vocational Rehabilitation (now Rehabilitation Services Administration) of the Department of Health. It then became practical for surgeons to save all length possible in upper-limb amputations and thus preserve more function than had been the case previously. the results of the training program reached the nonveteran population as well. Government-sponsored research program begun toward the end of World War II was responsible not only for delineating the basic principles of fitting and alignment but also for initiating a preparatory education program that has had a very strong influence on improving the practice of prosthetics throughout most of the world. and private clinics were established throughout the United States and Canada. The U. The material presented in the original series of suction socket courses was refined and supplemented with new material on alignment by the University of California. Twelve of these courses were offered to clinicians in the United States on a regional basis during 1953 and 1954 with tremendous success. little was done until 1949 when the Veterans Administration PSAS organized 30 amputee clinic teams consisting of a surgeon. Private as well as Veterans Administration teams attended. At the present time (1991) a comprehensive study of the educational needs of prosthetists and orthotists and how to meet these needs have been initiated by the AAOP (American Academy of Orthotists and Prosthetists). However. Over the years. Aitken GT: Hazards to health.asp[21/03/2013 21:52:44] . Wilson PD: Human Limbs and Their Substitutes. has been made throughout the world since World War II. 1960. Because the Veterans Administration teams. References: 1. Biomechanics Laboratory. A rationale for socket and harness design was developed for every level of amputation in the upper limb. Components that could be selected and assembled to meet the individual needs of upper-limb amputees were designed and tested. in Klopsteg PE. and most were available through regular commercial channels. The nationwide program reached a peak in the late 1980s when 12 universities offered preparatory education programs in prosthetics and orthotics. http://www. almost without exception. With financial assistance from the Veterans Administration. 265:133-134. Approximately 140 Veterans Administration and private teams were trained. consisted of surgeons and prosthetists in private practice. Reprinted by Hafner Press. these three universities were joined by others to provide preparatory education programs in all aspects of prosthetics. led for some years by the United States. a body of knowledge in upper-limb prosthetics was being accumulated at UCLA. New York. Alderson SW: The electric arm. stimulated mostly by the aftermath of war. 2. although World War I did arouse a small flurry of interest that had little effect on clinical practice. Education.S. considerable progress. prosthetist. While this experimental teaching program on the suction socket was being carried out and the clinic teams were being formed. and 7 offered One baccalaureate and 1 certificate program were discontinued certificates of completion. N Engl J Med 1961. etiology of traumatic amputations in children. including shoulder disarticulation and the forequarter amputation. physical therapist. the Veterans Administration sponsored the establishment of a Prosthetics Education Program at New York University in the Post-Graduate Medical School in 1956. surgeons. in 1991 owing to a lack of fiscal support from the federal government.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library teamwork between the two disciplines would result in improved service. Five were at the baccalaureate level. New York. McGraw-Hill International Book Co. Because UCLA could not meet the needs of the country with respect to the number of teams that desired training. SUMMARY The development of artificial limbs and amputation surgery has had a long history. A pilot school based on this material and presented to leading prosthetists. There seems to have been little progress made between the American Civil War and World II. occupational therapist. and Welfare sponsored the establishment of the Prosthetic Education Program at Northwestern University in 1959. and therapists in Berkeley in 1955 led the way to establishing formal courses in 1956 at UCLA in transfemoral prosthetics for practicing clinic teams.oandplibrary. UCLA initiated a series of formal 6-week courses in upper-limb prosthetics for the amputee clinic teams in 1952. 1954. Berkeley. and prosthetics representative.org/alp/chap01-01. New York. 1954. Berlin. 2.May 1987 and Workshop on Teaching Material for Above-Knee Socket Variants. 1954. Miami. Inc. 29. Reprinted by Hafner Press. 3:8-18. Committee on Artificial Limbs. Orthopedic Division. 1:32-36. Mich.asp[21/03/2013 21:52:44] . Bull Prosthet Res 1970. Prosthet Orthot Int 1969. 63:101. 30. 10:4-21. Orthop Prosthet Appliance J 1955. Walter Reed Army Medical Center.org/alp/chap01-01. International Society for Prosthetics and Orthotics. Arbogast R. Bier A: Uber amputationen und exarticulation. Pritham C. Berlemont M. 1986. National Research Council. a Report to the National Research Council. Anderson MH. Veterans Administration. Golbranson FL. Bull Prosthet Res 1970. Eberhart HD. 1947. 2710 Amnicola Highway. 1987. 46:5976.Report of a Workshop. 1919. 10:35-39. Ertl J: Uber amputationsstumpfe. 1987. Traub JE. Ann Arbor. Asbelle C. 1963. 20:218-224.May 1987. DC. Wilson PD: Human Limbs and Their Substitutes. Bosch Arana G: Kineplastic amputations: Arm bimotor and a prosthesis. 9. Clin Orthop 1968. Willot JP: Ten years of experience with the immediate application of prosthetic devices to amputees of the lower extremities on the operating table. McKennon JC: Suction-socket suspension of the above-knee prosthesis. Committee on Prosthetic Research and Development: Immediate Postsurgical Fitting of Prostheses . 24. J Bone Joint Surg [Am] 1957. Washington. Strand D: Immediate postsurgical fitting and early ambulation. Billock JN: Self-containment and self-suspension of externally powered prostheses for the forearm. Inman VT. National Academy of Sciences. Orthop Prosthet Appliance J 1956. vol 2. DeFries MG. 11. Presse Med 1906. 14. 2:57-65. Ill. Washington. Childress D. Borchardt M. Philadelphia. 4. Artif Limbs 1966. National Research Council: Terminal Research Reports on Artificial Limbs (Covering the Period From April 1. Miami. 8. Springfield. et al: Prosthetic Principles. Dec JB. http://www. Garrison FH: An introduction to the History of Medicine. Aitken GT: Cineplasty.oandplibrary. 27.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library 3. 6. DC. 1947). WB Saunders Co. Leonard J: Color realism in the cosmetic glove. American Academy of Orthotists and Prosthesists. Donovan RG. 1947. 7. McGraw-Hill International Book Co. Burgess E. Berger N: The ISNY (Icelandic-Swedish-New York) flexible above-knee socket. 22. Artif Limbs 1955. an end-result study. Chirurgie 1900.S. Mschr Unfallheilk 1960. 12. in Klopsteg PE. Weber R. 15. Bechtol CO. Dederich R: Amputationsstumpf Krankheiten und ihre chirurgische Behandlung. 1967. 1960. Chirurgie 1949. International Society for Prosthetics and Orthotics. New York. Through June 30. 16. Arbogast CJ: The Carbon Copy II-from concept to application. 10. DeFries MG: Sizing of Cosmetic Hands to Fit the Child and Adult Population. 10:219-225. Calif. DC. DC.American Orthotic and Prosthetic Association: Orthotics/ prosthetics education issue. 28. 20. Committee on Artificial Limbs. 13. 25. 1960. Springer-Verlag. Wilson AB Jr (eds): International Workshop on Above-Knee Fitting and Alignment. 5441. et al: Fundamental Studies of Human Locomotion and Other InformationRelating to the Design of Artificial Limbs. Wilson AB Jr: Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees. Chattanooga. 1960. 1945. Charles C Thomas Publishers. J Prosthet Orthot 1988. et al (eds): Ersatzglieder und Arbeitshilfen. Above-Knee Amputations. Army Medical Biomechanical Research Laboratory. 5. 42:416-420. Frantz CH: An evolution in the care of the child amputee. 18. 21. 78:1439-1474. et al: Cineplasty. TN 37406. 26. Bell CA: Canadian hip disarticulation prosthesis. in Donovan RG. Surg Gynecol Obstet 1926. Esslinger JO: A basic study in semiburied implants and osseous attachments for application in amputation prostheses. Eberhart HD. 23. 9:59-68. 56:119-131. 10:1-4. 19. Washington. Technical Report No. U. J Prosthet Orthot 1990. Ceci A: Amputations cineplastiques des membres su-perieurs (Cineplastic amputations of the upper extremity). Brav EA. et al (eds): International Workshop on Above-Knee Fitting and Alignment. in American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas. Carnelli WA. Fletcher MJ: Problems in designing of artificial hands. Edwards Brothers. Washington. 31. University of California. 17.October 1987. Durr-Fillauer Medical. Berkeley. 14:745-747. 56. NC. Calif.org/alp/chap01-01. 34. New York. Calif. 47. Kiessling EA: Pneumatic arm prosthesis. vol 1. 1987. pp 616-621. Durham. Artif Limbs 1954. Aug 27-31. 1965. Ralston HJ: The mechanics of voluntary muscle. Murdoch G (ed): Amputation Surgery and Lower Limb Prosthetics. Ann Arbor. Clin Prosthet Orthot 1986. 1967. 45. Sauerbruch F. 58. Mallow WA: Skeletal extension development: Criteria for future designs. 41. 53. in Donovan RG. Thomas A: Status of the above-knee suction socket in the United States. in American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas. Final Report of Project No. London. Mooney V. 59. et al (eds): International Workshop on Above-Knee Fitting and Alignment. 10:69-96. Inman VT. 12:1-3. the Histories. Berkeley. Snelson R: Fabrication and application of transparent sockets. Final Report to the National Research Council. Pederson HE: The problem of the geriatric amputee. Orthot Prosthet 1975. 46. 1960. Radcliffe CW. Blackwell Scientific Publications Inc. Miami. Miami. 50. Newman JD: Relative incidences of new amputations. in Donovan RG. New York. 48. 29:3-16. Penguin Books. 65:114-117.oandplibrary. J Bone Joint Surg [Br] 1956. J Bone Joint Surg [Am] 1963. 26:1-13. Presented at the Sixth International Conference on Medical Electronics and Biological Engineering. Hawthorne. Kay HW. International Society for Prosthetics and Orthotics. Boston. 1960. Selincourt A (ed): Herodotus. 1988. Advisory Committee on Artificial Limbs.) Vocational Rehabilitation Administration by Duke University Medical Center. McLaurin CA: The evolution of the Canadian-type hip-disarticulation prosthesis. 1951. 62. 1978. Clippinger FW Jr. Edition Mal-gaigne. Voskoboinikova LM. 1954.asp[21/03/2013 21:52:44] . Belgrade. Haddan CC. 51. Murphy EM: Lower-extremity components. 52. 55. in Proceedings of the First International Congress of the International Federation of Automatic Control. Motis GM: Final Report on Artificial Arm and Leg Research and Development. 23:517. 40. Mooney V: Personal communication. et al: The CANFIT system: Shape management technology for prosthetic and orthotic applications. 6:86-99.1: History of Amputation Surgery and Prosthetics | O&P Virtual Library 32. Titus BR: Use of Temporary Plaster or Plastic Pylons Preparatory to Fitting a Permanent Above Knee or Below Knee Prosthesis. Hall CB. 45:1717-1722. Foort J: Patellar-Tendon-Bearing Below-Knee Prosthesis. Tokyo. Bull Prosthet Res 1976. Mondry F. 10:66-74. Yugoslavia. Hall CW. vol 2. 33. 1960. Pare A: Oeuvres Completes. Goldner JL. Clin Prosthet Orthot 1987. Loon HE: Below-knee amputation surgery. Bolhovitin SV. Kessler HH. 54. Wilson PD (eds): Human Limbs and Their Substitutes. Orthot Prosthet 1972. Reprinted by Hafner Press. ten Horn C: Die willkurlich bewegbare kunstliche Hand (artificial hand capable of voluntary movement). Rakic M: Practical design of a hand prosthesis with sensory elements. 1954. Orthot Prosthet 1976. et al: Problems of bioelectric control in automatic and remote control.May 1987. Michael JW: Upper limb powered components-current concepts. Chirurgie 1952. 37:611-612. Bechtol CO: Modern amputation technique in the upper extremity. in Klopsteg PE. 44. Michael JW: Energy storing feet: A clinical comparison. vol 2. University of California Press. 1960.S. J Prosthet Orthot 1989. Springer-Verlag. Kristinsson O: Flexible sockets and more. et al (eds): International Workshop on Above-Knee Fitting and Alignment May 1987. Artif Limbs 1968. 49. 47:425-434. 1923. http://www. 1987. New York. International Society for Prosthetics and Orthotics. Moscow. Bioengineering Laboratory. 4:29-39. Saunders C. 4:22-28. 30:27-28. Kobrinski AE. Northrop Aircraft Inc. pp 335-336. Cox PH. 57. 1:122-130. Berlin. 42. Pritham CH: Above-knee flexible sockets-the perspective from Durr-Fullauer. 11:154-172. Butterworth. 1961. McGraw-Hill International Book Co. Der muskelkraftige ober. 1363 to (U. J Bone Joint Surg [Br] 1965. 1840.und underschenkel-stumpf. Artif Limbs 1957. 1962. 37. 38. 36. Marquardt E: Heidelberg pneumatic arm prosthesis. 43. Mich. 60. Simpson DC: Powered upper arm prostheses for young children (digest). 39. Edwards Brothers. Lyquist E: The OHC knee-disarticulation prosthesis. 61. 35. Presented at the International Symposium of the Application of Automatic Control in Prosthetics Design. Artif Limbs 1962. Am J Nurs 1965. Paris. Mercer W: Syme's amputation. Germany. TR-4. 1961. 73. 1989. New York. 1963. 1964. Artif Limbs 1968. New York. 30:43-47. New York. Arch Ortop 1899. National Academy of Sciences. Orthot Prosthet 1975. 65. Surgeon General's Office. 39:230232. 46:1540-1548.Atlas of Limb Prosthetics: Surgical. 71. Prosthetic. 77. 75. J Bone Joint Surg [Am] 1964. Wilson AB Jr: Recent advances in above-knee prosthetics. 12:1-27. Veterans Administration. Contact Us | Contribute http://www. International Society for Rehabilitation of the Disabled (Reprint of paper presented at the sessions of the World Commission on Research in Rehabilitation. in The Geriatric Amputee. 69. DC. TR-2. Wiesbaden. Washington. Publication 919. Veterans Administration. Wirski J: Myoplasty Immediate Fitting Ambulation. Artif Limbs 1965. Tenth World Congress of the International Society for Rehabilitation of the Disabled. DC. 385.oandplibrary. Washington. Wilson AB Jr: Prostheses for Syme's amputation. 74. Swanson AB: The Krukenberg procedure in the juvenile amputee. 66. Staros A. 41:305. Vanghetti G: Plastica dei monconi a scopo di protesi cine-matica (plastic surgery of stumps for cinematic prostheses). Wilson AB Jr. Prosthetic and Sensory Aids Service: Clinical Application Study of the Henschke-Mauch "Hydraulik" Swing Control System. Prosthetic and Sensory Aids Service: Clinical Application Study of the Dupaco "Hermes" hydraulic Control Unit. 68. 1965. J Bone Joint Surg [Br] 1957. Weiss M. Wilson AB Jr: Lower-limb modular prostheses: A status report. TR-3.org/alp/chap01-01. 29:23-32. 64. 9:45-52. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 1 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .1: History of Amputation Surgery and Prosthetics | O&P Virtual Library 63. United States Army. 70. Orthot Prosthet 1976. New York. 1946. New York. 72. Chapter 1 . 6:52-75. Wilson AB Jr: Limb Prosthetics. Gielzynski A. September 1966). 76. ed 6. Staros A: The temporary prosthesis for the above-knee amputee. Peizer E: Northwestern University intermittent mechanical friction system (disk-type).asp[21/03/2013 21:52:44] . Demos Publications. Veterans Administration. 67. Commission on Amputations and Prostheses: Report on European Observations. Zanoli R: Krukenberg-Putti amputation-plasty. Stills M: Ultra-light prostheses for below-knee amputees. Prosthetic and Sensory Aids Service: Clinical Application Study of the Hydra-Cadence Above-Knee Prosthesis. Artif Limbs 1961. if not a surgeon. it seems appropriate to present. thus sparing the patient considerable morbidity. 1992. endoprosthesis. often combined with radiation and selective excision of solitary metastatic deposits. tumors of the limbs were routinely treated with early amputation as the best hope for cure. improved methods of fracture fixation and vessel and nerve repair. American Academy of Orthopedic Surgeons. In trauma cases. along with the selective use of vascularized distant muscle and skin flaps. IL. While in years past there were often no alternatives to amputation other than palliation. Since most cases of major foot infection occur in diabetics.2A : Overview | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 2A Chapter 2A . the first inevitable question is "Can it be saved?" The initial physician. if immediate surgery is not required. often followed by prolonged rehabilitation. Infected feet. By using the method of Kritter. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. a diabetologist as well as an infectious disease specialist has much to offer in helping to manage the patient preoperatively and postoperatively. A thorough evaluation of each situation will include appropriate consultation with other specialists to assure the patient and the family as well as the amputation surgeon that all reasonable avenues have been explored. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. In peripheral vascular occlusive disease. reprinted 2002. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). edition 2. in a book on amputations and prosthetics. Bowker. To ensure cost-effectiveness. The current limb salvage approach combines ablation of the tumor with reconstruction using an allograft. trauma rating scales based on the probability of a good functional outcome should be applied.oandplibrary. http://www. Advantage should be taken of the major advances that have been made in recanalization and reconstruction of vessels. or a combination. Whenever a patient presents to a physician regarding a serious injury or disease of a limb. Consultations may be sought from a vascular surgeon both in peripheral vascular disease and in limb trauma involving major vessels. The tremendous increase in a patient's Reproduced with permission from Bowker HK. In cases of infection. is suggested. have provided many opportunities for limb salvage in cases destined for amputation prior to development of these techniques. this is no longer true in many instances. In the past. will be asked by the patient and family for a referral to a surgeon whom the primary doctor feels will give every consideration to saving the limb. as in dry gangrene limited to the forefoot. have made tumor control possible in many instances. prior to procedures based on abscess drainage with or without limited distal amputation.org/alp/chap02-01. Many of these advances in treatment concepts and procedures have occurred in the decade since the first edition of this book was conceived. Restoration of flow to the foot by in situ and reverse vein grafting may result in salvage of most or all of the foot. Prosthetic. Prosthetic. consultation with a surgical oncologist. Prosthetic.asp[21/03/2013 21:52:50] . ©American Academy or Orthopedic Surgeons. M. limb blood flow should be evaluated to give the surgeon and patient reasonable assurance that the resulting wound will heal. Because of the finality of amputation.Atlas of Limb Prosthetics: Surgical. current thought and available options regarding limb salvage as an alternative to amputation. mostly related to diabetes mellitus. Powerful new chemotherapeutic agents. Rosemont. both in a physical and psychological sense. This approach to limb salvage involves the skills of several specialists during multiple surgical procedures. and Rehabilitation Principles. The patient and certainly the surgeon should be constantly looking for such options to ensure that the best result in terms of function and disease eradication is achieved.D. a vascular surgeon should be consulted if limb blood flow to that area is critically diminished. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Overview John H. most feet with low-grade infection can be loosely closed following thorough debridement. can often be drained adequately with resultant salvage of most or all of the foot. In tumor cases. Click for more information about this text. preferably prior to biopsy. provided that the salvaged limb is functionally better than its prosthetic counterpart. Prosthetic. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 2A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . While this dichotomy cannot be ignored. Contact Us | Contribute http://www.Atlas of Limb Prosthetics: Surgical. the fact remains that prosthetic replacement following amputation falls far short in restoration of motor and sensory function. Chapter 2A . limb salvage rather than amputation should be the goal.oandplibrary.asp[21/03/2013 21:52:50] . Until this situation changes.2A : Overview | O&P Virtual Library expectation of a good outcome based on technological advances is offset by the cost of many of the more advanced procedures.org/alp/chap02-01. and although amputation was recommended. In World War II. and Rehabilitation Principles. Wounds were packed with dressings made of old bedsheets and rags. The mortality rate for open fractures in the Franco-Prussian War In the (1870-1871) was 50% for transtibial and 66% for transfemoral amputations. M.2B: Trauma | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 2B Chapter 2B . Prosthetic. and amputations were done with strong men holding the patient down. War was even worse. the mortality rate for transtibial amputations was 33% and for transfemoral amputations 54%. Casual onlookers put their hands in the wound. His mortality and amputation rate. Trueta. was able to obtain a 0. most patients died. All surgery before 1846 was performed without anesthesia. Malgaigne reported that the mortality rate for amputations performed in the hospital was 52% for major This is not surprising when amputations overall and 62% for thigh amputations specifically. Winnett Orr in World War I treated open wounds by using a protocol of wound extension. and improved nursing caused mortality rates from open fractures to virtually disappear. stabilization. cleaning. American Civil War.D. 1992.D. and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Trauma Roy Sanders. was extremely low. an open fracture was a sentence of death. Reproduced with permission from Bowker HK. Rosemont. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Instruments were simply wiped clean. and open packing of open fractures. IL. Postoperatively.org/alp/chap02-02. Click for more information about this text. David Helfet. Prosthetic.oandplibrary. Advances in all fields of medicine have made salvage of the massively injured lower limb a http://www. The next important advance was vascular reconstruction.069 open fractures in the Spanish Civil War. hands were not washed between pro-section and amputation. who in 1540 advocated irrigation. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). proper sanitation. DeBakey and Simeone still reported an amputation rate of 75% for popliteal artery injuries associated with fractures. hand washing. often on the surgeon's shirt. and by the Vietnam conflict. HISTORIC PERSPECTIVE: AMPUTATION AS THE STANDARD OF CARE The choice between limb salvage and amputation of the severely traumatized lower limb is a rather modern concept. debridement. M. stable reduction of the fracture. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. using this technique.Atlas of Limb Prosthetics: Surgical. reprinted 2002. usually within 3 minutes. American Academy of Orthopedic Surgeons. Prosthetic. Operations were conducted on the unwashed patient in his bed with the rest of the ward looking on. the overall amputation rate for open fractures with vascular injury was negligible. the methods employed are scrutinized. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. a pus bucket was used to wash wounds on the ward. For thousands of years. as a result. edition 2. and application of plaster with the wound left open. THE MODERN ERA: LIMB SALVAGE As death from wound sepsis disappeared and safe and effective elective surgery became possible. In 1832. It is interesting to note that these two men simply used the principles of Ambroise Pare. by the end of the day this bucket contained the blood and pus of all patients on the ward. H.6% septic mortality rate in 1. salvage of the mangled limb became a reasonable consideration.asp[21/03/2013 21:52:54] . In 1874 von Nussbaum recorded a 100% mortality rate for 34 consecutive knee disarticulations! The development of the germ theory. ©American Academy or Orthopedic Surgeons. Because surgeons also performed autopsies. but the Korean War experience paved the way for successful arterial repair. Speed was of the essence. 00 in hospital costs. surgeons began to view amputation of a mangled lower limb as an admission of defeat. This included the following: type IIIA. In their review of 62 type III open tibial fractures. did not clearly define the nature and severity of the skeletal injury. Fourteen patients had a fractures.oandplibrary. shoe modifications. They isolated the type III open fracture as having the worst prognosis. They also felt that soft- http://www. and $53. Similarly. 6. "triumph of technique over reason. early amputation would improve function. to date no predictive scale exists that can be used with confidence in amputation decision making.00 in hospital costs. adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps.9 operative procedures. Recently. and secondary amputation. Additionally. extensive soft-tissue injury with periosteal stripping and bony exposure. reported on the financial cost of limb salvage in open MB and MC tibia Of 263 patients. This classification was used by Caudle and Stern and again found to be prognostic. controlled multicenter studies with large patient populations are needed to obtain these data. Gustilo and Anderson reported on a prognostic classification scheme for open fractures that was based on wound size.6 operative procedures. in rational decision making in these difficult injuries.4 days in the hospital. type IIIB. and (4) the age of the patient. Hansen and others have noted that when post-traumatic limb salvage patients were candid. and little was written about long-term results. type IIIB open fractures had significant complications. The authors suggested that with appropriate criteria. 43 ultimately underwent amputation. reported on a subclassification of type III open fractures. a predictive scale with objective criteria is required. salvage were considered unnecessary. however. nonunion. and type IIIC open tibial fractures had disastrous rates with 100% major complications and a 78% secondary amputation rate ( Table 2B-1.asp[21/03/2013 21:52:54] . Furthermore. These authors began to question the wisdom of salvage in type IIIB and IIIC tibial injuries. As orthopedic traumatology developed into a subspecialty. Lange et al. neurologic impairment. usually associated with massive contamination. The authors suggested that a realistic appraisal of functional outcome be made when deciding in favor of salvage for limbs with type IIIC injuries inasmuch as the overall amputation rate for these injuries in the more recent literature approached 60% ( Table 2B-2. NEWER CONCEPTS: DECISION MAKING In 1976. complications or functional disability at the 1-year follow-up visit.2B: Trauma | O&P Virtual Library reality. prospective. THE TYPE IIIC TIBIAL FRACTURE-CAN SALVAGE BE PREDICTED? To determine when amputation is not only justified but beneficial. with a high rate of infection. decision-making alogorithms for amputation vs. type IIIA injuries had a low complication rate. and none had vascular compromise. Published reports of these heroic procedures.) Bondurant et al.462. Daines evaluated 26 lower-limb fractures with vascular injuries on the basis of four variables. 1. long-term functional outcome studies on patients with salvage procedures are needed as well. which again was prognostic. These authors defined a score that was predictive of amputation and had no Overlap in data. analyzed 23 cases of open tibial fractures with limb-threatening Fourteen cases (61%) underwent amputation. and prolonged rehabilitation times justify salvage.org/alp/chap02-02. an open fracture with an arterial injury requiring repair. Gustilo et al. Salvage of even the most complex injury became technically possible. It is uncertain whether donor site morbidity.).3 days in the hospital." Several authors now suggest that early amputation and prosthetic fitting are perhaps the preferred alternative to salvage of a questionably functional It is the goal of this chapter to offer the orthopedist information that will assist lower limb. they frequently stated that although their limbs were saved. their lives were ruined by Hansen has termed this approach the the prolonged and costly attempts at reconstruction. Although several studies have attempted to develop objective criteria. those patients who underwent limb salvage required several operations and had persistent wound or tibia healing problems at 1 year. (3) the presence of shock. shorten hospitalization. and lessen the financial burden placed on both the patient and the institution. joint stiffness.964. Those who had attempts at limb salvage averaged 53. (2) the duration and severity of ischemia. These included (1) the extent of soft-tissue damage. In 1984. and $28. primary amputation and averaged 22. In contrast. and type IIIC. Well-designed. 2B: Trauma | O&P Virtual Library tissue grading was the most important variable. Gregory et al. proposed a mangled extremity severity index (MESI). A point system was developed for the severity of injury to four major organ systems of the limb (integument, nerve, vessel, and bone). This injury severity scale (ISS) considered lag time, age, preexisting disease, and shock. They found a dividing line at 20, below which limb salvage was predictable and above which amputation was 100%. This initial series was limited to only 12 cases, the fracture type was not identified, and an unspecified number of primary amputations was included. Lange et al. proposed a protocol based on absolute and relative indications for amputation ( Table 2B-3.). The occurrence of one absolute indication or two relative indications was felt to warrant amputation. Unfortunately, only a minority of cases fit these criteria, and the relative indications listed were extremely subjective and required considerable experience. Recently, Helfet et al. have combined most of the abovementioned studies into a modified version of the MESI to predict amputation rates ( Table 2B-4.). This scoring system was used only in documented type IIIC open tibial fractures, first retrospectively in 26 cases and then prospectively in an equal number of cases. The scoring was performed after the salvage-vs.-amputation decision had been made. In both groups there was a significant difference in the mean MESI scores between those limbs that were amputated and those that were salvaged. In both, a score of 7 or greater was 100% predictive of amputation. Although the preliminary data base is small, this scoring system holds promise as the first objective scoring system that can predict poor outcome and thereby justify amputation. Given the above discussion, when should the surgeon amputate, and when should he consider salvage in a type IIIC tibial injury? At the present time, the basis upon which to make a sound, defensible, and reasonable decision for primary amputation is still insufficient. Lange has recently identified certain variables that are important ( Table 2B-5.), but feasibility variables (technically salvageable) combined with advisability variables (best interest of the patient) result in a complex prognostic-treatment interplay. A crush injury in a young laborer is very different from the same injury in a 60-year-old diabetic. Similarly, a tibial injury may need a different approach if severe ipsilateral foot trauma exists. It should therefore be obvious that the majority of cases will fall into a gray zone of indeterminate prognosis. In these cases a decision-making team and a tertiary-care facility are almost mandatory. Lange has stated that inexperience in evaluating these injuries and the lack of multidisciplinary consultation may render it ethically impossible for a surgeon to recommend a primary amputation and, as well, may make successful limb salvage unrealistic. In summary, the MESI and Lange's absolute and relative indications should be used to determine possible need. Several surgeons should be consulted. Patient and family conferences (perhaps with an amputee present) are required, and a frank discussion should ensue; then a joint decision can be made with, it is hoped, better patient satisfaction. TYPE IIIB INJURIES-THE CASE FOR SALVAGE In type IIIB open fractures, limb salvage has a greater likelihood of success because by definition a vascular injury requiring repair is not present. The preponderant problem in this group of patients is infection from massive contamination and muscle necrosis. Should attempts at salvage be undertaken, standard protocols should be used. The patient should be examined in the emergency room, and the wound should be identified and then sterilely covered. It is not uncovered until the operating room. Antibiotic treatment is started, and the patient is brought to the operating room as soon as possible. Angiography, if needed, is performed in the operating room and not in the angiography suite. In no other injury is meticulous debridement so important. Damaged and contused skin and all obviously necrotic muscle, tendon, and bone must be initially removed. Thereafter, irrigation with saline is necessary to remove all particulate matter. At this point deep cultures, which will represent true bacterial flora, are taken. After initial debridement of soft tissue and bone, bony stability is obtained, usually with an external fixator, to prevent further soft-tissue compromise. Osseous defects can be filled with antibiotic-impregnated methyl-methacrylate beads (made by mixing 1.2 g of tobramycin and one package of methylmethacrylate) over braided 26-gauge wire. These beads provide a local depot of antibiotic and a space for the later bone graft. Temporary open wound coverage (not closure!) is obtained by the use of dressing sponges or http://www.oandplibrary.org/alp/chap02-02.asp[21/03/2013 21:52:54] 2B: Trauma | O&P Virtual Library Epigard (Syn-thes USA, Paoli, Penn), a synthetic biological dressing. Once stable, the limb will need repeat debridements at 24 and 48 hours to assess muscle viability. All dead tissue must be removed. Although the patient receives intravenous antibiotics during this period, debridement is without doubt the most important treatment to prevent infection. Once clean, closure of the soft-tissue wound within 5 to 7 days is ideal. This can be accomplished with either split-thickness skin grafting, local flaps, or vascularized free-tissue transfer, most commonly with the latissimus dorsi or serratus anterior muscles. If this treatment is successful, the surgeon has transformed a massively contaminated open fracture into a clean, closed fracture that requires only bony reconstruction. Usually this can be accomplished with a variety of internal fixation devices and/or bone grafting, including vascularized fibula transplantation and the Ilizarov technique. Because an injury is classified IIIB, however, does not mean that a vascular component is not present; it only means that an arterial repair was not needed. Many limbs therefore again fall into a gray zone. If the posterior tibial artery is severed and the leg is perfused through the anterior tibial artery, partial necrosis of the posterior musculature can occur. Similarly, prolonged arterial kinking that is corrected with realignment of the limb may cause significant myonecrosis. These problems will essentially result in a loss of a large amount of muscle mass during debridement and may in fact result in a loss of foot and ankle function. This, coupled with bony injuries involving the ankle or subtalar joint, may make salvage totally unrealistic. Recently, Sanders et al. evaluated the results of a salvage protocol in 11 grade IIIB ankle and talus injuries. All patients required anterior plating, multiple-level fusions, free flaps, and bone grafting. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2 per patient (range, 5 to 12). The total in-patient hospital stay averaged 61.6 days (20 to 107 days), and inpatient costs averaged $62,174.43 per patient (range, $33,535.06 to $143,847.45). Overall hospital cost averaged $1,009.32 per day. All injuries healed; the fusion rate and muscle flap success were 100%, no patients developed osteomyelitis, there were no nonunions, and none required subsequent amputations. When asked about their functional outcome in detail however, all patients stated that the injury had significantly altered their life-style. Five patients returned to an altered job, while the other six became permanently disabled. All stated that their interpersonal relationships with spouses or immediate family members had become strained. Those patients with children or grandchildren stated they could no longer play with them, even on an occasional basis, because this required too much activity. Shopping at the mall or going out at night was equally difficult, with most patients participating in these activities only if absolutely necessary. All stated that they were unhappy with the appearance of their limb, their gait, and their shoes. All patients were offered an amputation as a definitive procedure at the time of final interview; all refused. Before a decision regarding limb salvage can be made, prognosis for the injury must be known. While the outcome for some injuries is fairly predictable, for most it is not. Prospective grading scales infrequently exist, and outcome studies are few. Again, should salvage be undertaken in a type IIIB open tibia, certain guidelines exist. Posterior tibial nerve disruption in an adult coupled with severe foot and ankle trauma will lead to an extremely poor result. In an adult with underlying vascular disease, this is probably an indication for amputation. In injuries that involve much muscle damage, debridement leaves the patient with little if any functional capabilities, and when associated with significant bony loss in excess of 6 cm, amputation will probably best serve the patient. Finally, a large segmental defect involving the knee joint and extensor mechanism, coupled with a peroneal nerve injury, will, if salvaged, result in a knee fusion and the use of an ankle-foot orthosis. The lack of mobility (especially in older patients) coupled with the large energy expenditure required makes amputation in this situation equally desirable. CONCLUSIONS When massive trauma to the lower limb occurs, difficult decisions must be made by the orthopaedic surgeon. Although treatment has changed significantly over the last 200 years, many of the same dilemmas exist. It is the obligation of the physician to treat the entire patient and not the limb in isolation. What is technically feasible may not be in the best interests of the patient. Amputation should not be considered a failure, but rather another therapeutic modality. To return an individual to preinjury function while limiting pain and http://www.oandplibrary.org/alp/chap02-02.asp[21/03/2013 21:52:54] 2B: Trauma | O&P Virtual Library suffering is the goal of treatment. If this cannot be accomplished by limb salvage, then serious consideration must be given to amputation. It is hoped that future multicenter prospective studies will clearly delineate the necessary guidelines. References: 1. Bondurant FJ, Cotler HB, Buckle R, et al: The medical and economic impact of severely injured lower extremities. J Trauma 1988; 28:1270-1272. 2. Border J, Allgower M, Hansen ST, et al: Blunt Multiple Trauma: Comprehensive and Pathophysiology and Care, New York, Marcel Dekker Inc, 1990. 3. Caudle RJ, Stern PJ: Severe open fractures of the tibia. J Bone Joint Surg [Am] 1987; 69:801-807. 4. Christian EP, Bosse MJ, Robb G: Reconstruction of large diaphyseal defects, without free fibular transfer, in grade-IIIB tibial fractures. J Bone Joint Surg [Am] 1989; 71:9941004. 5. Daines M: Severe lower extremity trauma: Can objective criteria predict ultimate amputation? Unpublished data. 6. DeBakey ME, and Simeone FA: Battle injuries of the arteries in World War II: An analysis of 2471 cases. Ann Surg 1946; 123:534-579. 7. Gregory RT, Gould RJ, Peclet M, et al: The mangled extremity syndrome (M.E.S.): A severity grading system for multi-system injury of the extremity. J Trauma 1985; 25:1147-1150. 8. Gustilo RB: Management of Open Fractures and Their Complications. Philadelphia, WB Saunders Co, 1982. 9. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: A retrospective and prospective analysis. J Bone Joint Surg [Am] 1976; 58:453-458. 10. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24:742-746. 11. Hansen ST: Overview of the severely traumatized lower limb. Clin Orthop 1989; 143:17-19. 12. Hansen ST: The type IIIC tibial fracture. J Bone Joint Surg [Am] 1987; 69:799-780. 13. Helfet DL, Howey T, Sanders R, et al: Limb salvage versus amputation: Preliminary results of the mangled extremity severity score. Clin Orthop 1990; 256:80-86. 14. Hicks JH: Amputation in fractures of the tibia. J Bone Joint Surg [Br] 1964; 46:388392. 15. Lange RH: Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop 1989; 243:92-99. 16. Lange RH, Bach AW, Hansen ST, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985; 25:203-208. 17. Rich NB, Baugh JH, Hughes CW: Popliteal artery injuries in Vietnam. Am J Surg 1969; 118:531-534. 18. Sanders R, Helfet DL, Pappas J, et al: The salvage of grade IIIB open ankle and talus fractures. Orthop Trans 19. Wangensteen O, Wangensteen S: The Rise of Surgery from Empiric Craft to Scientific Discipline. Minneapolis, University of Minnesota Press, 1978. Chapter 2B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 2B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www.oandplibrary.org/alp/chap02-02.asp[21/03/2013 21:52:54] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 2C Chapter 2C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options Peter T. McCollum, B.A., M.B., B.Ch. Michael A. Walker, M.B., Ch.B., M.D.,M.Ch., F.R.C.S.I. F.R.C.S.Ed. Major amputations of the limbs are essentially disfiguring operations that carry a fairly high perioperative mortality and morbidity in elderly, debilitated patients suffering from critical limb ischemia (CLI). Estimated incidence rates of major amputations ( Table 2C-1.) suggest that in the United Kingdom, as in other parts of Europe, the amputation rate is likely to be between 10 to 15 per 100,000 per year, up to half of whom may be considered unfit for referral to a These figures, taken in limb-fitting service because of widespread chronic arterial disease. conjunction with recent advances in both limb prosthetics and surgical techniques, highlight the need for further critical appraisal of available options open to all involved in the care of patients with a limb that may require amputation. Although trauma, tumor, and infection are significant disease entities that can require primary or secondary amputation, over 90% of all limb amputations in the Western world occur as a direct or indirect consequence of peripheral vascular disease (PVD) and/or diabetes. This chapter seeks to explore the moral and ethical dilemmas faced by both the patient and medical team presented with such a problem and describes investigation and treatment options open to those faced with a decision whether to amputate a limb or to attempt some form of limb salvage procedure. Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text. LIMB SALVAGE OR PRIMARY AMPUTATION-GENERAL CONSIDERATIONS The presence of a chapter on alternative options to amputation in a book on amputation and prosthetics highlights the difficulties and importance of decisions confronting physicians when presented with end-stage PVD. As a consequence of newer techniques and a more aggressive and enlightened approach to treatment, many patients who in the past would have undergone an amputation may now be offered the chance of a limb salvage procedure. However, it is also clear that advances in prosthetics and the concurrent development of limbfitting services have meant that a functioning prosthesis is now the likely outcome of major limb amputation rather than a wheelchair existence. Nevertheless, this assumes that access to such facilities is available and that the patient is fit enough to manage an artificial limb. Furthermore, despite these advances, the prognosis of those undergoing an amputation for CLI secondary to end-stage PVD or diabetes is very poor. In many published studies amputation itself carries a significant mortality. Although this has been reported as up to 30% in some series, the use of spinal and regional anesthesia combined with improved perioperative management has been responsible for a greatly improved perioperative mortality. In addition to perioperative deaths, up to 40% will have died within 2 years of amputation, and a further 30% may develop CLI in the remaining limb that will require either a second amputation or limb salvage surgery. While there can be little doubt that saving a limb and retaining its function should always be the primary goal of the physician, there are many situations in which limb salvage is neither feasible nor indeed desirable. Although a high perioperative morbidity attends an unsuccessful revascularization procedure, primary amputation should only be offered when revascularization is deemed inappropriate. Specific examples of this include a functionally Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library useless limb, necrosis of a major part of the limb, life-threatening toxemia, absolute absence of distal vessels (rare), or instances in which revascularization is inadvisable due to severe coexistent medical disease. The overall desire for limb salvage should not therefore overshadow the primary aim of all those dealing with end-stage vascular disease; the aim should be to decrease mortality and morbidity and improve the quality of life in both the short and medium term. It is evident that in approaching this problem consideration must be given to the possible morbidity and mortality of the revascularization or amputation procedure itself. Whatever the primary disease, each individual case must be reviewed and investigated thoroughly and then dealt with on its own merits. Therefore a multidisci-plinary team approach be is crucial to provide the best results. Several basic considerations and principles must followed in each case where findings suggest that either limb salvage or amputation is deemed appropriate. Clearly, the single most important factor in this process is the projected quality of life following the particular action taken. QUALITY OF LIFE AND PATIENT EXPECTATIONS Quality of life is very much dependent on the individual expectations of the patient and the sometimes more realistic expectations of the attending staff. In a patient with a poor prognosis, perhaps because of a stroke, it may be felt that the morbidity of a salvage procedure is too great to achieve salvage of an already functionless limb. Conversely, in a unilateral amputee, extra effort may be necessary to ensure that the remaining limb is salvaged in order to keep the patient mobile. Professional judgement must also be exercised as to whether the patient's expectations are realistic. This can be a difficult and emotional issue. There is also no doubt that the expectations of relatives and paramedical and nursing staff can also influence the situation. This may prove especially important and useful if the patient has an unrealistic expectation of his future, whether it be overly optimistic or otherwise. It is essential not to overestimate the long-term prognosis in patients with end-stage PVD requiring limb salvage or amputation. Life expectancy clearly depends on the natural history of any diseases afflicting the patient. With mortality rates of at least 30%, 50%, and 70% after 5, 10, and 15 years in those with CLI, a 20% mortality rate for those undergoing amputation, and a 2-year survival rate of 60% in those surviving initial amputation, it is clear that the long-term outcome in the group with CLI is poor, despite an advanced age group, whatever action is taken. Further important factors affecting the decision to amputate or reconstruct include not only the availability of medical facilities but also the standard of medical and paramedical care. Plainly, the expertise and experience of a physician are vital, but equally important is the availability of quality facilities. These include resources that are readily accessible for ancillary care, diagnostic investigations, operative backup, postoperative support, and other treatment options such as prosthetic and rehabilitation infrastructures. Crucial among these is the availability of a good vascular service. In well-developed countries, it is likely that an expert vascular opinion can be obtained within 12 hours of being sought, even if this means transfer of the patient. ETHICS Quality of life is quite closely linked with the medical ethics surrounding a patient faced with end-stage vascular disease. An important consideration in decision making relates to the practical aspects of intervention in end-stage PVD. Is it always justifiable to subject a patient to prolonged hospitalization and perhaps suffering in order that limb salvage can be attempted? If so, what is the real return for the misery that can occasionally be caused in some patients due to multiple reconstructive procedures when eventual limb salvage is not guaranteed? Moral considerations are thus very important, and each case must be examined on its own individual merits. There can be no standard doctrine in these difficult situations, although, in general, a reduction in a patient's morbidity should remain the prime objective when considering the options in a particular case. FINANCIAL CONSIDERATIONS No discussion on the dilemma would be complete without some mention of the financial http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library implications of treatment in these patients, although whether it is ethically important is a different and debatable issue. While the immediate cost of lower-limb bypass surgery and postoperative treatment is considerable, it does not compare with the cost to a patient or health system of major amputation, especially where there is no family backup and the patient is dependent upon outside support. Indeed, any treatment that can limit this situation and retain quality of life is potentially cost-effective, although it must be remembered that some patients undergoing reconstructive surgery will inevitably come to major amputation later and therefore incur double expenses. INFORMED CONSENT It is clear that patients in this difficult position must be made fully aware of the available options and the consequences of a particular course of action. Limb salvage procedures can be fraught with many problems and a prolonged hospital stay without any guarantee of eventual success. Patients should therefore be fully informed as to the regimen they are proposing to embark upon. Whereas it might well be considered a failure of medical technique and practice if an amputation is ultimately required, this feeling should not be conveyed to the patient, who must be persuaded to feel that all possible limb salvage options have been explored and, if these have not been possible or vascular surgery has been unsuccessful, the next stage of amputation and fitting of a functional prosthesis is a logical and necessary progression. Thus, patients must never feel that proceeding to an amputation is an admission of failure in management. A positive attitude to prosthetics is similarly vital if the patient is to later come to terms with his amputation. The major etiologies that may lead to possible amputation can be grouped as follows: 1. 2. 3. 4. Peripheral vascular disease (PVD) and diabetes mellitus (DM) Trauma Infection Tumor Each of the above can lead to possible early or late amputation during the natural history of the disease. Trauma, infection, and tumor are specific entities that are covered meticulously elsewhere in this chapter and therefore will not be discussed in more detail here. PERIPHERAL VASCULAR DISEASE Of those patients requiring amputation, over 90% are a direct or indirect consequence of CLI. With an increasingly elderly population and a significant increase in life expectancy (males, 73 years; females, 78 years in the United Kingdom) over the past 10 years, it is clear that the number of patients presenting with critically ischemic limbs is likely to increase substantially into the 21st century. This large group is therefore likely to continue to provide all but a few of the patients who require major limb amputation. Most patients presenting with CLI present with severe and debilitating pain, often at rest, that prevents them from sleeping in a bed at night. Indeed, many patients will sit up all night rather than suffer the pain that results from lying prone in bed. The prevalence of intermittent claudication increases from 0.2% in men aged 45 to 55 to 0.5% in men 55 to 65 years of age. However, there is a large group of patients with significant hemodynamic distal arterial disease who remain asymptomatic-perhaps up to 30% show no symptoms or do not present to a physician. Work done within the United Kingdom suggests that anywhere between 10% and 50% of those suffering from claudication will present to physicians, with a greater percentage of men, but with only a few deemed serious enough to merit referral to hospital practice. Fortunately, up to 75% of those with claudication will stabilize spontaneously over a few months, which leaves 25% of individuals with increasing trouble from deteriorating symptoms. Of this group, fewer than 5% will eventually come to some form of limb salvage revascularization procedure. Thus, fewer than 2% of all patients who present with intermittent claudication ever come to amputation. Much of the concern over management of patients with severe PVD relates to the fact that arteriosclerosis is a generalized disease and consequently these patients have significant cardiac and cerebrovascular disease. Evidence suggests that approximately 15% will develop a myocardial infarction and at least 5% a cerebrovascular accident (CVA) over a 5-year http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library period. The mortality rate is actually at least threefold greater than that observed in an age-matched population. It has been further noted that 50% of deaths are cardiac related, 15% related to a CVA, and 10% from other vascular causes. The most important coexisting risk factors in this group are smoking, diabetes, and hypertension. Figure 2C-1 highlights the outcome of those suffering from claudication and clearly shows that the prognosis in this group is poor. The actual life expectancy is summarized in Figure 2C-2. Work by Szilagyi et al., who examined the long-term outcome following lower-limb arterial bypasses, suggests that after the fifth postoperative year the annual mortality rate of patients is greater than the graft occlusion rate. The natural history of the generalized atherosclerosis that coexists in sufferers of claudication and CLI shows that these groups, especially those with CLI, must be considered to represent a population with a poorer-than-average prognosis, even in the short to medium term. Thus, the likely length of hospitalization for the treatment option selected should be gauged against the likely life expectancy for the patient. Most would agree that it is not in patients' best interests to spend the majority of their remaining months in a hospital environment, although occasionally this is an inevitable consequence of whatever course of action is taken. MANAGEMENT OPTIONS The decision to perform either a major amputation or major reconstructive surgery is based largely upon clinical parameters that are undoubtedly influenced by past experience and current prejudice. It is therefore important to be aware of the developments in other specialties that may, it is hoped, modify these decisions. It is clear that vascular surgery, in particular, has evolved as a fully fledged specialty in many countries and has made enormous strides in several specific areas. Nowhere is this more apparent than in the management of the patient with CLI. While aortofemoral bypass grafting has become well established over the past 40 years as a reliable method of providing adequate femoral inflow, distal arterial bypass has now also become a routine procedure in specialist vascular centers. Bypass grafting to the tibial or pedal arteries can now be expected to salvage the limb, even in patients with tissue necrosis and ulceration. Vein graft patency to the tibial vessels is about 80% at 1 year, with limb salvage rates somewhat higher. Indeed, the current situation is such that few if any patients should undergo a major amputation for CLI without first having been seen by a specialist vascular surgeon with experience in distal bypass grafting. This is not unreasonable because most physicians in Western countries can obtain access to such services within 12 hours of patient referral. This allows more than sufficient time for CLI investigations and intervention to be instigated without significant deterioration in the patient's condition. Nonsurgical Management of Critical Limb Ischemia There has been much interest in the use of pharmacologic agents that could be used in the management of CLI. This is because many patients are high-risk surgical candidates and any method that might reduce the number of patients requiring surgery, either revascularization or amputation, would be welcome. The mainstay of medical management is to postpone amputation either by relieving pain or by sufficiently improving the local blood flow in the limb to render it viable until further collateral circulation develops. A broad range of thrombolytics agents has been studied, including anticoagulants (heparin and warfarin), (streptokinase, urokinase, tissue plasminogen activator [t-PA]), antiplatelet agents (aspirin, Of these, the dipyridamole), and various vasoactive agents (naftidrofuryl, pentoxifylline). use of intravenous prostacyclines and their synthetic analogues (e.g., prostaglandin I2 [PGI 2 ] analogues such as iloprost) appears to offer the most hope for the future. Recent work with these prostacycline analogues suggests that a small number of limbs (generally Fontaine stage III, i.e., with rest pain) may be salvaged by prolonged intravenous infusion. Unfortunately, many limbs in these studies would not fall under the definition of true CLI because Doppler pressure measurements are too high in most instances. However, it is clear that some critically ischemic limbs (perhaps 10%) are salvaged by such infusions and further work in this area is urgently needed. In particular, the use of PGI 2 analogues appears to convey some definite benefits. Interventional Radiology A further, small number of patients may be suitable for percutaneous angioplasty (PTA), http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library although it is our experience that angioplasty alone rarely "salvages legs." PTA was first described by Dotter and Judkins in 1964 and later developed by Gruntzig and Hopffin 1974. In essence, it involves placing a sausage-shaped balloon catheter across a stenosis or occlusion (over a guide wire) and inflating this to restore continuity by ablating the underlying lesion. Used extensively for patients with claudication, it has obvious advantages for the patient with CLI, who is often unfit and usually has coexistent cardiac and other diseases ( Fig 2C-3.). In particular, because it is performed under local anesthetic and without long incisions, it carries a lower morbidity and mortality than vascular surgery does. It is quite possible to negotiate short arterial occlusions (5 to 6 cm) with good expectation of success, and as in surgery, the best results are obtained in the larger vessels (iliac and femoral). In fact, the role of PTA in tibial vessel disease is controversial and as yet unproved. However, because the majority of limbs with true CLI have widespread, mul-tisegment arterial occlusions, it is usually not possible to apply this technique to this group of patients. Disappointingly, further new developments in balloon angioplasty have not been accompanied by improved results. In particular, the present vogue for laser-assisted balloon angioplasty does not yet offer any advantage over simple PTA, although it is very much more expensive. Similarly, atherectomy devices have yet to really demonstrate that they confer a significant advantage over PTA or (simple) femoropopliteal bypass grafting in terms of outcome. The one present area of definite interest is the use of local thrombolysis in association with PTA. This technique relies upon the fact that many "acute-on-chronic" ischemic legs have had a recent fresh thrombosis that has precipitated their symptoms. By lysing this thrombus with streptokinase or t-PA and performing an angioplasty upon the underlying stenosis, the vessel may once again be rendered patent. Although several studies have reported a greater than 75% "limb salvage" rate in CLI the patients concerned in most studies have not all had patients suitable for angioplasty, CLI as currently defined. Data from Sheffield suggest that the clinical success rate from PTA in patients with CLI (and whose disease pattern is potentially treatable with PTA) is only about 50%, which therefore represents fewer than 10% of all patients presenting with CLI. Sympathectomy Lumbar sympathectomy was often used to try to improve the blood flow of the lower portion of the leg in CLI. Unfortunately, although a perception of increased flow is achieved in some patients by an apparently warmer foot, this warmth is primarily secondary to opening of nonnutritional arteriovenous shunts and does nothing for the flow in the nutritional capillary bed unless the perfusion pressure is already reasonably good. In a small number of patients with isolated rest pain, chemical or operative lumbar sympathectomy may help to relieve this pain by a direct inhibitory effect on pain perception pathways. This effect has also been achieved with direct spinal cord stimulation, an area of interest that may offer more in the future because there is some evidence of an increased total limb perfusion in addition. Vascular Reconstruction The optimal type of reconstructive vascular procedure varies according to the level of the disease process. There is no doubt that PTA is appropriate to short occlusions (<6 cm) and to stenoses in the iliac and superficial femoral arteries. On occasion, correction of such a lesion is sufficient to relieve rest pain in some patients. In the case of longer occlusions that are unsuitable for PTA, bypass surgery can confidently be expected to do likewise. This type of surgery may involve an aortoiliac or aortofemoral bypass using Dacron or polytetrafluoroethylene (PTFE) grafts. If the patient is grossly unfit, an axillofemoral or femorofemoral bypass may be easily accomplished. These "extra-anatomic" bypasses are invaluable in the management of such cases, and although they do not carry the same excellent graft patency rates as aortic procedures, they carry less risk to the patient and are easy to perform in high-risk cases. The absence of a patent common femoral artery is no bar to these approaches because excellent results can be achieved by bypassing directly to the profunda femoris artery, with or without an extended profunda endarterectomy and patch angioplasty. The aim of all of these procedures is to provide an adequate "inflow" to the leg with a good resultant femoral pulse. While such procedures may be sufficient for Fontaine stage III patients (rest pain), they rarely suffice alone where there is tissue necrosis. In these stage IV patients, there is usually superficial femoral occlusion and/or tibial vessel disease, although in the case of diabetics, there may be only tibial vessel occlusions. Such patients nearly always require a femoropopliteal, femo-rotibial, or even femoropedal bypass to achieve healing of the foot in patients with limited outflow tracts ( Fig 2C-4.). In diabetics, a http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library popliteal-tibial or popliteal-pedal bypass will often be required. Critical ischemia of the limb is rarely if ever seen with isolated superficial femoral occlusion. More often, there is multilevel disease. Where there is a reasonable femoral pulse, there will invariably be superficial femoral occlusion with tibial vessel disease also. This usually necessitates a distal bypass with in situ vein or re-versed-vein graft techniques ( Fig 2C-5A and Fig 2C-5B ). In such patients, good results (>70% rate of 1-year patency) can be expected where the optimal conduit (autologous vein) is available. However, if prosthetic grafts are used to the tibial vessels, this falls dramatically to perhaps only 25% at 1 year, although there is some evidence that the technique of an interposition vein cuff will improve these results. In general, provided that there is autologous vein present and there is at least one tibial artery present (this may often be the peroneal), good limb salvage rates can be expected from vascular surgeons well versed in these techniques. Unfortunately, this is a specialized area, and consistently good results tend to occur only in dedicated vascular units. In planning surgical outcome, it should be remembered that a patient with digital gangrene and rest pain will often require a prolonged admission with initial distal revascularization, later digital amputation, and subsequent rehabilitation. Trauma and Acute Vascular Insufficiency In dealing with any serious limb insult in which vascular compromise is evident, it must be realized that even urgent treatment is barely soon enough! Rapid but careful assessment by the primary-care team and assessment of the order of treatment priorities, first of the patient as a whole and then in relation to the injured limb, are paramount. The level of priority with respect to the limb in trauma cases is generally vessels, nerves, bones, and then soft tissues, although at the time of surgery it is often necessary to splint the bones first prior to attempting vascular reconstruction in the interests of stability. Any limb that is regarded as showing signs of acute CLI should, if possible, be rapidly referred to a specialist in this field. Time in such cases is vital. Full and careful evaluation by an experienced vascular surgeon followed by appropriate investigation and subsequent treatment will provide the greatest chance of limb salvage. There is little place for treatment of these patients by the occasional vascular surgeon if acceptable results are to be obtained, although this may be necessary on occasion in the absence of immediate specialist resources. Of all those admitted with acute CLI, those with an otherwise normal vascular tree are most at risk because there will be little if any collateral circulation present, unlike those with previous underlying PVD. Of all those admitted with evidence of acute CLI of the legs, about 60% to Of those surviving, up to 15% will require 70% will leave the hospital with an intact limb. amputation. Operative treatment depends upon circumstance, but general principles include the use of autologous vein as a bypass medium if at all possible and generous decompression fasciotomies to reduce the risk of reperfusion injury. Amputation level selection, where necessary in this group of patients, is defined by the available viable tissue present and depends entirely upon clinical assessment with the emphasis on preserving limb length. Brief mention may be given to one specific problem that, although fortunately rare, can cause considerable difficulties with management. The increasing growth in the number of drug abusers is inevitably leading to an increasing number of addicts presenting with arterial injury following intra-arterial puncture and consequent microembolization following injection of a variety of substances. Although at first sight these injuries may not seem serious, after a few hours the injected limb can show severe signs of ischemia that is not always reversible. In this situation, opening the diseased artery will often show massive intraluminal reaction and edema causing a significant hemodynamic stenosis in the artery. In general, the treatment of choice is decompression fasciotomies, intravenous anticoagulation, and prostacycline infusions, with a "wait-and-see" policy usually justified. Vascular surgical exploration has a very limited role, although major amputation is often the final outcome. In any dealings with these patients, it should be remembered that a large percentage are human immunodeficiency virus (HIV)-positive and some will have full-blown acquired immunodeficiency syndrome (AIDS). Infection In patients with PVD, "dry" gangrene is a result of reduced arterial inflow or stasis in the http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library circulation of the limb or digit. Demarcation develops early and is usually clear-cut, with resultant mummification showing few signs of infection. Patients with dry gangrene will sometimes autoamputate the affected limb or digit with few if any systemic effects, especially if the blood flow is improved to the limb by vascular reconstruction. In contrast, "wet" gangrene may be a consequence of both arterial and venous obstruction and is also seen in diabetics. There is always infection and putrefaction present in this process. Early revascularization may help to reduce the volume of tissue lost in wet gangrene, although there is a risk of graft infection in bypass cases. The decision to amputate primarily or to attempt limb preservation can be extremely difficult, but in the case of life-threatening sepsis, primary amputation will usually be indicated. AMPUTATION LEVEL SELECTION For the minority of patients with CLI in whom revascularization has failed or in whom there is some other reason why it cannot be attempted, the alternative is major limb amputation. For most practical purposes, there are three common "levels" of amputation to examine in relation to PVD in the lower limb; these are transfemoral, transtibial, and digital or partial foot. With the conspicuous exception of diabetics, digital and partial-foot amputation for end-stage vascular disease is generally disappointing in the absence of prior successful revascularization. When consideration is being given to one of these distal amputations, the question of a distal bypass must always be recognized because it is almost certain that a successful bypass will result in foot healing. Similarly, if a leg amputated at the Syme or Chopart level shows signs of healing, it is virtually certain that there were patent tibial arteries at the ankle to which a distal bypass could have been placed. The foot therefore might have been salvaged with perhaps only a minor digital amputation. The only exception to this rule is the diabetic patient without serious PVD who may sometimes heal a partial-foot amputation without revascularization. Therefore, the main deliberation in amputation patients is whether they will heal a transtib-ial amputation or not. Most diabetic and vasculitic patients will require a more detailed assessment of foot viability. This is because local excision of dead tissue can often be effected successfully if accompanied by vigorous antibiotic therapy and careful debridement and protection of neurotrophic ulcers and skin with appropriate plaster slippers and splintage. Clinical Assessment It is not adequate to merely perform angiography in patients with CLI who are being considered for amputation and/or limb salvage revascularization. This is simply because the absence of visible vessels does not necessarily portend failure for surgery. In many instances, it is simply a failure of radiologic technique where contrast is not seen at the foot level. In such cases, exploration of the ankle or pedal vessels will generally reveal an adequate recipient artery. This quite common failure of angiography to show distal vessels is well recognized and has led to the development of other methods to demonstrate patent ankle and foot vessels. If, despite all this, amputation is felt to be required, further investigations may be needed to aid in selection of the optimum level of amputation. While it is generally agreed that there are certain clinical factors (such as a severe flexion contracture of the knee) that precipitate an amputation at a particular level, the physician's ability to select the optimum level of amputation based upon clinical appreciation of tissue viability is poor. Criteria such as poor skin edge bleeding at the time of surgery and absence of pulses do not correlate well with failure to heal despite the fact that they are still commonly used standards. Although clinical judgement alone will produce reasonable results when it is carried out by an experienced amputation surgeon, it is clear that this form of assessment is not very objective and is probably ineffective in the majority of patients. This is particularly so where attempts are being made to save the knee joint in cases of marginal viability. Angiography As already stated, arteriography ought to have been performed already in almost all preamputation patients as a preliminary to possible arterial reconstruction. It has, however, been shown to be of little value in deciding the optimum level of amputation. Robbs and Ray found no difference between healing and failure to heal in terms of the number of major patent vessels present in a study of 84 amputees. Other workers have also found arteriography to be of little value, although Roon et al. maintained that a patent profunda http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library femoris was of major importance in the presence of a superficial femoral occlusion and should be ensured before attempting a transtibial amputation. Certainly, occlusion of both profunda and superficial femoral vessels would seem to indicate a poor prognosis for healing in transtibial amputations. Segmental Systolic Pressure Measurements Although they are necessarily an indirect assessment of tissue perfusion and not reliable in situations where arteries are calcified, Doppler-derived segmental pressure measurements have been utilized in the assessment of CLI for many years. Indeed, the working party of the International Vascular Symposium set out a definition of CLI based upon segmental pressure criteria in 1983, although this definition has now undergone further refinement in a consensus conference. While these are useful moves aimed at identifying patients with CLI and allowing reasonable comparison of patient groups between different studies, the criteria are of little help in deciding upon the level at which to amputate. There was considerable initial enthusiasm for ankle Doppler pressure measurements, but this was tempered by the In particular, ankle pressure failure of later studies to substantiate initial reports. measurements appear to be of little or no value in partial-foot amputations and also in diabetics. This is probably largely because of arteriovenous shunting in the foot giving rise to nonnutritional blood flow and also because of the difficulty in compressing calcified vessels with consequent artificially high "systolic pressures" in diabetics. In contrast, thigh pressure measurements appear to be predictive of success in transtibial amputation surgery. Several workers have demonstrated that transtibial amputation healing is likely to occur at thigh The pressures greater than 70 mm Hg and possibly between 50 and 70 mm Hg. widespread adoption of this baseline standard alone would certainly reduce the number of transfemoral amputations currently being performed, with very little, if any, consequent increase in morbidity. Infrared Thermography Infrared thermography has been used to delineate areas of nonviability and to try to identify specific skin flaps for lower-limb amputations over the past two decades. Although there is a good relationship between skin blood flow and thermography, recent work suggests that much of the "heat" seen on the thermogram derives from two main sources: convective heat where the transfer is primarily from arterioles >50 µm in diameter and conducted heat where there is a temperature gradient from the deeper structures to the skin. Good results have been obtained from specialized units using this technique, but the cost and difficulty of interpretation of such images combined with a difficulty in accurately quantitating the image other than by additional skin blood flow measurements render it useful mainly as a development tool in specialist centers. It is, however, one of the few tests that provides an indication of specific skin flap viability. Skin Fluorescence As with thermography, the principle of being able to outline nonviability of specific skin flaps has been used by several workers. The absence of uptake of fluorescein when injected intravenously has been used to examine healing in amputations, and more recently, a technique of quantitative fluorometry has been developed in an effort to provide more objective criteria for the method. Since it is both fairly cheap and reasonably easy to perform, there is some promise in this methodology, and it is to be hoped that other units will validate the data found by Silverman and his colleagues. Despite the technique being available for many years, however, it has not found widespread popularity, and there is still some difficulty in interpretation of results, especially where there is associated inflammation. Skin Blood Flow Measurements The application of "point source" measurements to assess tissue viability is epitomized by the use of skin blood flow measurements. The principle of skin blood flow techniques is to measure the washout of an intra-dermally injected radioisotope tracer and from this to derive a result that is a function of capillary skin blood flow. By using an original principle devised by Kety, the precise skin blood flow can be calculated. The advantages of this technique are that it appears to measure nutritional blood flow and it provides an absolute measurement for blood flow. The problems with the technique principally relate to both its invasive methodology and the need for a radioactive tracer. Testing is also relatively slow to perform and requires http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] 2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library multiple measurements in order to avoid the pitfall of finding and relying upon an isolated high or low result. In addition, it is not easy to perform repeated measurements because the isotope dosage is cumulative. A number of different tracers have been used, including 133 Xe, 131 I, and 125 I-iodoantipyrine. Xenon is more difficult to use because of its biphasic clearance and affinity for adipose tissue; nevertheless, excellent results have been achieved, principally by Moore's group in San Francisco. These results have been reproduced by using 125 I-iodoantipyrine more recently and a good correlation between healing and mean skin blood flow levels greater than 2.5 mL/100 g/min was achieved. While providing good and reproducible data, especially in the skin blood flow measurements in the foot are very variable, and a high skin lower limb, blood flow value does not necessarily predict a successful outcome to amputation. The logical explanation for this is that a local point measurement of skin blood flow is not representative In any event, the healing of of the region as a whole, and this is particularly so in the foot. an amputation depends upon the skin blood flow after the amputation, not upon that measured prior to the procedure. Despite these drawbacks, the skin blood flow technique is probably the single most accurate measurement to assess skin viability that is currently available, particularly around the knee joint level. A development of the skin blood flow technique is the measurement of skin perfusion The principle of the method is to note the blood pressure pressure, pioneered in Denmark. at which the capillary return to the skin is abolished. The detection technique may be the The method has the clearance of a radioisotope or the use of a photo-spectrometer. advantage of ignoring specific values for skin blood flow but has the disadvantage that there can be great difficulty in deriving absolute pressure values at the very low clearance rates found in critically ischemic skin. There is some debate as to what absolute skin perfusion pressure should be used to predict healing, and this may reflect the methodology involved. Transcutaneous Oxygen Measurements Since transcutaneous oxygen pressure (TcPO 2 ) measurements were first used to aid in the assessment of tissue viability, there has been an explosion of published data discussing its Although the transcutaneous value in PVD, especially in relation to amputation level. electrode was originally designed to reflect arterial po 2 in the newborn, since then its application has been widened to include the evaluation of ischemic tissue. Unfortunately, electrode design has not been modified to allow for the skin characteristics of the adult, and there is a great variation in results between different workers using different machines. Variables affecting TcPO 2 measurements in normal skin such as Pao 2 , skin thickness, electrode response, skin blood flow, local oxygen availability, and others are overshadowed by a maximal vasodilatory response to the integral heater. Fortunately, ischemic skin does not respond in the same way and is much more affected by other variables, particularly by the underlying perfusion pressure. The great attraction of the method is its simplicity and ease of use. However, the difficulties of calibration and interpretation are usually greatly underestimated or not considered and result in data that at best are insensitive. In early reports of the method, there were wide variations in conclusions as to what TcPO 2 value reliably predicted amputation healing at the transtibial level. This was highlighted by several reports that healing took place in a number of amputations where the TcPO 2 was zero. The addition of 100% oxygen inhalation undoubtedly improved the sensitivity of the technique immeasurably but may be inconvenient and timeconsuming. It therefore appears that TcPO 2 levels greater than 35 mm Hg at the calf reliably predict transtibial amputation healing but that values below this give an unpredictable outcome. If oxygen inhalation is added to the test, then discrimination between healers and nonheal-ers is improved dramatically. TcPO 2 values in the foot are of little predictive value. SUMMARY Several other techniques have also been tried in an attempt to aid in amputation level selection. These include laser Doppler studies, 99m Tc pertechnetate scanning, muscle pH studies, and others. Of these, the laser Doppler has the most potential because it offers the ability to interrogate the microcirculation in a noninvasive mode. http://www.oandplibrary.org/alp/chap02-03.asp[21/03/2013 21:52:59] although skin perfusion pressure techniques appear to be most predictive. Where there is a partiality for trans-femoral amputations in a unit. Therefore. Specifically. For general purposes. Although skin blood flow is a local measurement and therefore not necessarily representative of the blood flow in an entire region. and therefore adjunctive preoperative laboratory testing has become a crucial part of any amputation service that is committed to preserving limb length. with fluorom-etry perhaps being much cheaper although more difficult to perform and interpret. with few transtibial failures as a consequence. obvious to the clinician and require only good nursing and analgesia to keep them comfortable.2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library There are several major problems that can be identified when attempting to analyze data relating to amputation level selection. Is there any test that the present-day amputation surgeon can apply to help in selecting the optimum amputation level? Most of the available techniques are expensive and difficult to perform correctly. Although this prejudice can be unreasonable at times. then the optimum conditions under which that amputation is to be performed must be provided. It is probably worth corroborating these data with some other regional methodology to look for specific well-vascular-ized flaps.org/alp/chap02-03. in general. It is only when surgery is being performed at the edge of tissue viability that sophisticated evaluation techniques have a valuable role to play. These patients are. and results are difficult to reproduce. This is a particularly important area because transfemoral/transtibial amputation ratios vary enormously from region to region and country to country. many transfemoral amputations could probably be avoided. all published amputation data for CLI should include some reference to the number of distal vascular reconstructions (and failures) currently being performed in the unit. The main difficulty lies in the group of patients in whom it is not clear whether a primary amputation or revascularization should be attempted. There may be a good case to be made for nonintervention in a small minority of elderly patients whose CLI is merely a manifestation of total-body failure and whose inevitable conclusion will be early death. In these instances. Fluorescein angiography or thermography offers the best methods for this approach. With this reference. there is considerable evidence to support the use of a cutoff range of 50 to 70 mm Hg at the lower part of the thigh for transtibial amputations in the absence of arterial wall stiffening. if there is a predilection for primary amputation rather than attempted reconstructive surgery. One obvious example of this issue is the problem of who performed the amputation. http://www. a better amputation healing rate may be attained because many of these patients would not have strictly "end-stage" PVD. Principal among these is the enormous variation in approach on the part of physicians. be regarded as likely to result in flap failure. Much more work needs to be carried out on the critically ischemic foot to ascertain why current techniques are insensitive as predictors of foot healing. multiple skin blood flow measurements appear to be more dependable and A mean skin blood flow of less than 2. the methods often prove quite difficult to duplicate effectively elsewhere. successful surgical revascularization of a critically ischemic limb is the optimum management in the vast majority of such patients.oandplibrary. This is because we live in an age of increasing life expectancy coupled with the ever-present patient and relatives' notion that something can and ought to be done for the leg. the value of ancillary methods to predict amputation outcome is considerably diminished because it is likely that those amputations that would be considered most "at risk" would automatically have transfemoral resections. It is clear that clinical assessment alone is inadequate for the majority of surgeons in decision making for amputation surgery.5 mL/100 mg/min may correlate well with outcome. The second major area concerns clinician prejudices.asp[21/03/2013 21:52:59] . CONCLUSIONS The dilemma facing the present-day physician regarding critically ischemic limbs is increasing rather than disappearing. Therefore. Although relatively insensitive. no one method has proved completely reliable for the purposes of partial-foot amputations. In particular. any attempt to perform noninvasive vascular tests is largely irrelevant because most amputations in such patients will heal. Of these. It is probably only in those limbs with marginal skin flap viability that other techniques of evaluation have a major role to play. skin blood flow measurements would seem to offer the most precise objective criteria. some would undoubtedly be technically reconstructable with one or more patent tibial vessels. while they may provide useful data for a particular specialist unit. it is undoubtedly not the most experienced surgeon available. Again. which renders much of the accumulated data of dubious value. In many cases. if the benefits of a certain test to predict healing in transtibial amputations are to be examined. In other words. the single most readily available (and cheapest) test is undoubtedly Doppler-de-rived systolic pressure measurement. This is certainly not the case in many of the published series. with each member realizing the limits of his own expertise. amputation. Cronenwett JL. The approach to these patients must of necessity involve a multidisciplinary team. J Vase Surg 1988. Karmody AM. Gaines PA. Scott DJ. J Bone Joint Surg [Am] 1981. 3. the lowest level that should ever be contemplated for primary amputation is the transtibial level. 63:1493. 64:378. Stock G: Definition and epidemiology of chronic critical limb ischaemia. 1990. Ascady G. It is important for us all to be aware of the wide variety of options that are at our disposal before deciding upon a particular strategy. Bounameaux H. This is simply because if a more distal level is to heal. Mamir M. et al: Prostacycline treatment of ischaemic ulcers and rest pain in unreconstructable peripheral arterial occlusive disease. Wales and Northern Ireland (1986). J Vase Surg 1984. 100:369. it is obvious that there are still many legs being lost to major amputation without sufficient thought being given to revascularization. 8. Description of a new technique and a preliminary report of its application. Patient expectations and improvements in therapeutic options have changed our approach to the patient with end-stage lower-limb vascular disease today. Beard JD: Radiological management of acute limb ischaemia. et al: Measurement of transcutaneous oxygen pressure in normal and ischaemic skin. Stock G (eds): Critical Leg Ischaemia. Evans JM. Department of Health and Social Security: Amputation Statistics for England. Megerman J. 1:362. J Am Coll Cardiol 1986. 4. Sham DM. Cooper JC. Burgess EM. 10. in Dormandy JA. 8:98. it is likely that unless partial-foot amputation can be confined to the digital or transmetatarsal level after revascularization. 15. Where tissue necrosis has impinged upon the midtarsal area or hindfoot. Beard J. Dotter CT. Zelenock GB. J Bone Joint Surg [Br] 1983. Berlin. and prolonged reconstruction. 12. Verstraete M. et al: Pulse generated run off: A new method of determining calf vessel patency. Occasionally. 314. Surgery 1984. Verhaeghe R. Corson JD. J Bone Joint Surg [Am] 1982. Dormandy JA.asp[21/03/2013 21:52:59] . there must be at least one reasonable tibial or pedal vessel patent and therefore distal revascularization should be possible. Whitehouse WM Jr. 30:654. the patient can only benefit from such a team approach. et al: Segmental transcutaneous measurements of po 2 in patients requiring below-the-knee amputation for peripheral vascular insufficiency. Br J Hosp http://www. it may be justified to revascularize a limb with the object of attaining healing at the transtibial or Syme level in order to cater for a specific circumstance.org/alp/chap02-03. References: 1. Cina C. Judkins MP: Transluminal treatment of arteriosclerotic obstruction. primary transtibial amputation should be undertaken. 5. Bell PRF: Are distal vascular procedures worthwhile? Br J Surg 1985.oandplibrary. Linge K. In the absence of prior vascular reconstruction or pure diabetic microangiopathy. Dormandy J. 13. Katsamouris A. 72:355. Little JM. et al: Fate of the patient with critical leg ischaemia. Its Pathophysiology and Management. 7. 30:50. J Cardiovasc Surg 1989. Dowd GSE. et al: In situ vein bypasses to distal tibial and limited outflow tracts for limb salvage. 9. Br J Surg 1988. Inevitably. Matsen FA. 65:79. Dormandy J: Natural history of intermittent claudication. Hosp Update 1991. Springer-Verlag. 96:756. 6. 4:449. et al: The role of percutaneous transluminal angioplasty and femoro-popli-teal bypass in patients with threatened limb. These patients have a very limited life span. however. Circulation 1964. Bentley G. 11. Eur J Vase Surg 1990. a good transtibial amputation will provide a much better chance of early rehabilitation and a shorter inpatient care than will distal vascular surgery followed by a midtarsal amputation or Syme ankle disarticulation. 1990. Fletcher JP. 75:361. 14. et al: Utility of transcutaneous oxygen tension measurements in peripheral arterial occlusive disease. Conversely. Wyss CR. but these cases are very few. and rehabilitation should be avoided if they are not to spend most of the rest of their lives in hospital. 17. Fortunately. 2. Fermanis GG. the vast majority of limbs with CLI may be salvaged with no amputation or else "minor" partial-foot amputation. 8:226. et al: Thromboembolism and antithrombotic therapy in peripheral arterial disease. Welch CL: The role of transluminal angioplasty in the treatment of critical limb ischaemia.2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library There are several rules of thumb that may be used in this difficult group. Matsen FA: Determining amputation levels in peripheral vascular disease. 16. Burgess EM. Surgery 1986. London HMSO. Indeed. 45:343. McCollum PT. et al: Prospective use of xenon Xe-133 clearance for amputation level selection. Prosthet Orthot Int 1983. Jamil Z. Ketty SS: Measurement of regional circulation by the local clearance of radioactive Sodium. 21. Lusby RJ. Isoniemi H. 43. Henry RE. Volny J. Badiology 1987. Ann Vase Surg 1989. 26. Br J Surg 1974. J Surg Res 1980. in Spence VA. 99:2502. Br J Surg 1985. Larsen B. 28. et al: Amputation for peripheral vascular disease: The case for level selection. World J Surg 1983. et al: Arterial blood pressure in the skin measured by a photoelectric probe and external counterpressure. et al: Early assessment of amputation level in frostbite by 99m Tc pertechne-tate scan. 18. McFarland DC. Hess H. J Am Geriatr Soc 1985. a method to predict amputation site healing. Harris P. et al: Oxygen induced changes in the skin as measured by transcutaneous oxymetry. Moore WS. Vorne M. Aust N Z J Surg 1984. Sheldon CD (eds): Practical Aspects of Skin Blood Flow Measurement. Harris P. Dtsch Med Wochenschr 1974. Walker WF. 33. et al: Drug induced inhibition of platelet function delays progression in peripheral occlusive arterial disease. Ferguson L. 36. Eardley A. 19. Acute lower limb ischaemia: Pathogens and management. McGee DI: Update on some epidemiological features of intermittent claudication. Spence VA. Lund P. Griintzig A. Spence VA. 1985. 42. Romano RL. et al: Antipyrine clearance from the skin of the foot and the lower leg in critical ischaemia: Clinical implications. Walker WF. 76:119. A prospective double blind arteriographically controlled trial. 48:335. Vasa 1973. 163:753. 45. Ristkari SKK. 20:305. Walker WF. 1990. Berlin. et al: Oxygen inhalation-induced transcutaneous po 2 changes as a predictor of amputation level. Its Pathophysiology and Management. Malone JM. Acta Chir Scand 1988. Br J Surg 1986. Prosthet Orthot Int 1985. 54:283. 2:65. 35.2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library Med 1991. 61:665. S Afr J Surg 1982. Neilsen PE. 1:415. 116:86. 3:220. J Surg Res 1982. Lawrence PF: Skin fluorescence. Foreman RK. Scand J Clin Lab Invest 1973. Kyllonen L. O'Driscoll K. 23. 73:882. Burgess EM: Level selection in lower extremity amputations. Mietaschk A. 41. Modification der Dotter-Technik. 7:340. Golbranson F. Lepantalo M. 44. Mokka REM. McCollum PT. Spence VA. McCollum PT. 39. Poulsen HL. 31:245. 40. London. McCollum PT. Kannel WB. Ratcliff DA. 75:1193. 38. Holloway GA. Stock G (eds): Critical Leg Ischaemia. Robbs JV. Harward TRS.asp[21/03/2013 21:52:59] . McCollum PT. Hopff H: Perkutane Rekanalisation chron-isher arterieller Verschliisse mit einem neuen Dilatation-skatheter. 33:13. Clyne CAC. J Vasc Surg 1985. Gyntelberg F. 2:220. 31. et al: Can the failure of a below knee amputation be predicted? Ann Chir Gynaecol 1987. Walker WF. Walker WF. 154:403.org/alp/chap02-03. 29. Scand J Clin Lab Invest 1977. 27. Arch Surg 1981. Burgess EM: Preliminary experience with laser Doppler velocimetry for the determination of amputation levels. McCollum PT. 4:449. et al: Circumferential skin blood flow measurements in the ischaemic lower limb. Spence VA. et al: Peripheral arterial occlusions: A 6-year experience with local low-dose thrombolytic therapy. Mehta K. Miller JH. Eur J Vase Surg 1990. Deischel G. Baadsgaard K: Healing of below knee amputations in relation to perfusion pressure of skin. 32. Hobson RW. 9:100. Biologic Engineering Society. Mietaschk A. Br J Surg 1988. 22. 7:63. et al: Skin perfusion pressure measured as the external pressure required to stop isotope washout. et al: Interposition vein cuff technique for anastomosis of prosthesis to small artery. Wylie EJ:. Clin Orthop http://www. Hess H. Moody P: Amputations. Holstein P: Distal blood pressure as guidance in choice of amputation level. 32:410.oandplibrary. Lancet 1985. 37:649. et al: Intravenous oxpentifylline in the treatment of rest pain. Hammersgaard E. Chant ADB. 34. et al: Fallibility of Doppler ankle pressure in predicting healing of transmetatar-sal amputation. et al: A rationale for skew flaps in amputation surgery. Acta Orthop Scand 1977. 37. Read F. 47. 71:219. Springer-Verlag. et al: Prediction of amputation wound healing: The role of transcutaneous po 2 assessment. 30. in Dormandy JA. 46. 25. et al: The fate of the elderly amputee. Kent P. Ray R: Clinical predictors of below knee stump healing following amputation for ischaemia. Br J Surg 1984. Norgen L: Non-surgical treatment of critical limb ischaemia. 28:466. 24. Spence VA. Am Heart J 1949. 38:321. 20. 72:310. Brucki R. Holstein P. Szilagyi DE. Mageman JH. Contact Us | Contribute http://www.Atlas of Limb Prosthetics: Surgical. McCollum PT. 65. Bergensz SE. 6:437. et al: Treatment of limb-threatening ischaemia despite a palpable popliteal pulse. Am J Surg 1977. Cox MI. 60. et al: The healing of through-knee amputations in relation to skin perfusion pressure. Silverman DG. et al: Factors affecting the patency of infrainguinal bypass. Smith RF. 52. 56. et al: The effect of the transcutaneous electrode on the variability of dermal oxygen skin tensions. 134:153.asp[21/03/2013 21:52:59] . Steen Jensen J.org/alp/chap02-03. Rutherford RB. 146:533. Pearce WH. Prosthet Orthot Int 1983. 57. Samson RH. Holstein P. 51. 74:177. 53. 63. J Vase Surg 1988. 86:836. Br] Surg 1988. Widmer LK. Kanwel WB. Surg Gynecol Obstet 1982. Circulation 1964. 32:535. Nolan L. 27:496. Spence VA. 69(suppl):2.oandplibrary. Wilson SB. 61. Roberts A.2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library 1971. 59. et al: Occlusion of peripheral arteries-a study of 6400 working subjects. 58. Clin Phys Physiol Meas 1985. et al: Predictive value of distal perfusion pressure in the healing of amputation of the digits and the forefoot. J Vase Surg 1987. Welch GH. Roon AJ.Verstraete M. et al: An investigation into the patency of PTFE grafts. Chapter 2C . et al: The effect of streptokinase infusion on chronic arterial occlusions and stenoses. J Cardio-vasc Surg 1971. Donati MB. et al: Autogenous vein grafting in femoropopliteal atherosclerosis: The limits of its effectiveness. Leiberman DP. Prosthetic. Jones DN. Br J Surg 1982. J Surg Res 1982. Reilly CA. 48. et al: Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension. 6:139. et al: Below knee amputation: A modern approach. Harley D. Eur J Vasc Surg 1987. Goldstone J. Moore WS. McFarland RJ. Rutherford RB. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 2C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Gupta SK. Surgery 1987. Vermylen J. Surg Obstet Gynecol 1978. 72:888. Taylor RS. Schuler JJ. et al: Extra-anatomical bypass: A closer view. Couch NP: Muscle perfusion and the healing of below knee amputations. Scher LA. 50. 74:377. 101:335. Greensher A. 54. Spence VA: Dynamic thermographic imaging method for quantifying dermal perfusion: Potential and limitations. Ann Intern Med. 8:236. Working party of the International Vascular Symposium: The definition of critical ischaemia of a limb. O'Connor RJA. Surgery 1979. Windsor T: Vascular aspects of thermography. 30:836. 1:335. Med Biol Eng Comput 1989. 55. 12:379. 49. Thyregod HC. White RA. 58. et al: Fluorometric quantification of low-dose fluorescein delivery to predict amputation site healing. Pollock JG. 154:865. et al: Failure of Doppler ankle pressure to predict healing of conservative forefoot amputations. Patt A. Young AE. 7:61. 64. McGregor IW. 1971. 144:68. Schwartz JA. 62. Am J Surg 1982. thus leaving the skin under the metatarsal heads with little protective fat padding.D. A preoperative sinogram will determine the origin and full extent of the sinus. other than dry gangrenous changes related to proximal arterial occlusion. The most widely recognized risk factor. In addition. A number of risk factors for infection exist in this group. They can also become quite depressed. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. In the absence of normal pain sensation. it is quite common for diabetics to exhibit marked denial even in regard to open sores. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. edition 2. All of these basically psychological difficulties may lead to poor compliance with a preventive foot care regimen. Prosthetic. American Academy of Orthopedic Surgeons. which leads to shifting of the metatarsal fat pad distally as the toes go into a clawed position. MANAGEMENT OF ACUTE PROBLEMS Diagnosis The approach to management of foot lesions in the diabetic patient is greatly simplified by use of the Meg-gitt-Wagner foot lesion grading system ( FIG 2D-1. A displaced locus of control is manifested by an inability to take responsibility for the care of their feet and/or diabetic state in general. while an intraoperative injection of methylene blue mixed with a small proportion of hydrogen peroxide will assist in complete removal of the sinus by staining all passages and loculations.2D: Infection | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 2D Chapter 2D . autonomic neuropathy results in extremely dry skin. While many are naturally quite fearful of amputation as an outcome. Motor neuropathy may affect the foot and toe dorsiflexors and allow a rapid uncontrolled descent of the forefoot following heel strike. Rosemont. they are not overtly infected and may be readily treated by various non-weight-bearing devices including total-contact casts for http://www. which then develops fissures that provide sites of entry for bacteria. ©American Academy or Orthopedic Surgeons. Prosthetic. M. and thereby expose themselves to penetrating wounds from various objects left on the floor.asp[21/03/2013 21:53:05] . at least in the house. Click for more information about this text. This slapping gait can result in damage to the skin under the metatarsal head area. The vast majority of limb-threatening infections occur in the foot. especially if they have experienced chronic problems with their feet. because of denial they may fail to come in during the early stages of an infection. appears to be directly related to the duration of the diabetic condition. reprinted 2002. Neuropathic patients are unsure that properly sized footwear really fit their feet and will tend to wear shoes that are too tight. This is based on the presumption that most of these problems. usually seen in immunosup-pressed patients. Chronic osteomyelitis secondary to open tibial fracture usually presents with a long-standing draining sinus. Grade 1 and 2 lesions are ulcers that have not involved bone and joint. Prosthetic.Atlas of Limb Prosthetics: Surgical. especially in hyperglycemic states. mostly in patients with longstanding diabetes mellitus. Other infections in the lower limb may also lead to amputation.org/alp/chap02-04. are secondary to a penetrating lesion. All sinus tissue should be carefully examined microscopically for evidence of carcinomatous change. 1992. thus inducing ulcer formation. and Rehabilitation Principles.oandplibrary. Reproduced with permission from Bowker HK. Calf abscess. should be treated aggressively by wide incision and debridement if the foot is viable. sensory neuropathy leading to ulceration. Infection in diabetic patients is further complicated by decreased chemotaxis and phagocytosis by leukocytes.). This effect will be aggravated by paralysis of the foot intrinsics. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Bowker. IL. They also may see no harm in walking without shoes. Although frequently colonized with bacteria. and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Infection John H. This may be followed by later split-thickness skin grafting. either beginning in an ulcer or by direct puncture of the foot. When accurate Doppler data are unobtainable due to severe vessel calcification. and immunocompetence. we are primarily concerned with grade 3 lesions. SURGICAL MANAGEMENT The goal of any surgical procedure in the infected foot is the removal of all necrotic and infected tissue while preserving as much of the foot as possible. however. Rather than delay the opening of an obvious abscess if operating room time is not immediately available. If the ischemic index (foot systolic pressure divided by the brachial systolic pressure) is 0. including gram-positive. osteomyelitis with or without septic arthritis is usually present. There are a number of methods available that will give an indication of blood flow to the distal part of the foot. no anesthesia at all due to the patient's sensory neuropathy. In many chronic. On occasion. i. During both temporizing emergency room and formal operating room procedures. nutritional status. Normal weightbearing surfaces such as the heel pad. The extent of penetration and involvement of bone beneath an ulcer is easily determined by probing the wound.5 and the problem is one of low-grade infection or distal dry gangrene. This can be done very simply by first applying the cuff just above the malleoli and determining systolic pressure over the dorsalis pedis and posterior tibial arteries and then moving the cuff to the midfoot and determining pressures at the level of the metatarsal necks ( FIG 2D-3. the use of crutches or a walker is much less effective in insensate patients. while a total lymphocyte count of at least 1. Magnetic resonance imaging (MRI) rather than bone scans is best able to make the distinction. Due to a lack of compliance. the patient's potential for healing a wound should be evaluated. neuroarthropathy (Charcot joint) and an ulcer may coexist and lead to an erroneous diagnosis of osteomyelitis. transcutaneous oxygen measurements will give reliable information regarding local tissue perfusion. ulcers penetrating bone and joint. All wounds should be lightly packed with gauze to allow free wicking of the infective fluids to the surface. Definitive antibiotics will be determined by culture sensitivities. Charcot changes in the foot are commonly mistaken for acute osteomyelitis. joint capsule. the surgeon should use longitudinal incisions to preserve as many neural and vascular structures as possible. and anaerobic bacteria. The wound should be cultured and the patient initially given intravenous antibiotics that cover a wide range of organisms. as well as poorly vascularized tissues exposed in the area of infection such as tendon. and volar plates of the metatarsophalangeal joints..). lateral portion of the sole. Nutritional status is considered adequate with a serum albumin level of 3. If the ischemic index is below 0.asp[21/03/2013 21:53:05] . and metatarsal head areas should be respected. It may be necessary to do multiple dorsal and plantar incisions to gain full open drainage of all abscess pockets.500/mm is considered evidence of immunocompetence. especially when tested during inhalation of 100% oxygen. If bone is exposed in the depths of the wound.5 or more. by extending a midsole incision into the heel pad or a dorsal incision proximal to the ankle joint. In this discussion. which are not necessary in the usual penetrating lesion. Plain radiographs are useful in determining the extent of bony involvement as opposed to bone scans.2D: Infection | O&P Virtual Library ulcers in any plantar location or a hindfoot shoe for forefoot lesions ( FIG 2D-2. Prior to embarking on a definitive surgical solution. In doubtful cases. foot salvage is attempted.org/alp/chap02-04. Gentle probing will also give a good idea of the extent of any abscess that has developed in the forefoot. This may be accomplished by using ankle block anesthesia or. following removal of necrotic tissue the possibility of loosely closing the wound primarily should be considered ( FIG 2D- http://www. The surgeon should not unnecessarily compromise a later ablation.e. nonpurulent cases of chronic osteomyelitis. the abscess should be widely opened to reduce its internal pressure while the patient is still in the emergency room. however.5 g/dL or above. Tissues to be removed include grossly infected bone and soft tissue. gram-negative. but the simplest reliable bedside test remains the Doppler ultrasonic evaluation. Infection can be excluded in most cases on clinical examination by noting that patients with neuropathic arthropathy are not systemically ill and exhibit only moderate local skin warmth relative to the bony destruction seen on plain radiographs.oandplibrary.). This includes evaluation of blood flow to the foot. the patient should be referred to a vascular surgeon regarding the possibility of vascular reconstruction prior to limited distal amputation (see Chapter 2C). MRI has been shown to be the most definitive test available to date. such as a Syme ankle disarticulation. in many cases. This process may go on for 3 to 6 months or more. The patient should probably be non-weight bearing for a minimum of 5 to 6 weeks. the first toe may go into a valgus position due to loss of the lateral support provided by that toe ( FIG 2D6. The fluid passes from the wound between the sutures and is absorbed by the dressing ( FIG 2D-5. including nail and callus trimming. The alternative is the prolonged morbidity associated with several months of healing by secondary intention when the wound is packed and left open.org/alp/chap02-04. This program. depression. the patient should be actively engaged in a program devoted to prevention of further lesions by the use of proper footwear. Following disarticulation of the second toe alone. They will be seen promptly and appropriately treatedand referred to avoid the long emergency department waits common to many large public hospitals. REHABILITATION OF THE INFECTED FOOT As noted above. changes in footwear may be limited to simple fillers attached to an insole. and other problems affecting compliance. a transmetatarsal amputation may give a better functional and cosmetic result. control of infection and hyperglycemia by a combination of early and complete debridement and appropriate antibiotics and insulin. At the end of that time.asp[21/03/2013 21:53:05] . ). Amputation of only the distal phalanx of the great toe will also give a good result. A great deal of attention is also paid to psychological reorientation to overcome denial. with the exception of the entire great toe. If pus formation occurs after discontinuation of the irrigation. tight control of diabetes. and protection of the foot from external trauma. The advantage is that primary healing of the wound will usually occur in a 3. and a situation in which debridement results in a grossly clean wound. The criteria for this method include a wound presenting with minimal or no pus. One liter of irrigation fluid is run through the wound each 24 hours for a period of 3 days. It features a hotline so that patients can call in at any time regarding early treatment of incipient foot problems. combined when necessary with a fairly rigid rocker sole on an in-depth shoe. as much metatarsal length as possible should be left to allow for effective orthotic restoration of the medial arch. A small polyethylene The methodology originally described by Kritter is quite simple. In our facility. Resection of the second ray (toe and metatarsal) will allow the foot to narrow and thus avoid secondary hallux valgus ( FIG 2D-7. open management for each case of this type. it may still be necessary to skin-graft the wound to obtain adequate durable coverage. the wound can be simply reopened and packed at the bedside. In this situation. a vascular surgeon should be consulted regarding the feasibility of vessel recanalization or reconstruction.2D: Infection | O&P Virtual Library 4A. In this case. ). Success in this endeavor depends on timely presentation of the patient. Any single-ray amputation can result in an excellent functional result except for loss of the first ray. Amputations of a single toe. result in little loss of foot function. The outermost wrap is changed every 4 to 5 hours. proper padding of bony prominences. The removal of two or more central rays is less desirable. The surgeon should individually assess the feasibility of closed vs. following the healing process the patient is referred to the Patient Family Education Clinic. SUMMARY The prevention of major lower-limb amputation by the salvage of all or most of the foot in patients with diabetic foot infections has become a reality in recent years.). Better cosmesis is also generally achieved by eliminating the need for skin grafting of residual defects. provides longterm follow-up care. http://www. Skin sutures are placed only at wide intervals ( FIG 2D-4B. referral for proper shoe fitting.oandplibrary. If minimal removal of forefoot bony structure has been possible. Once healing is achieved. If it has been possible to close the wound loosely over an irrigation system. the sutures may be removed at 3 weeks. and counseling regarding self-care of the feet. The Kritter irrigation system can be used to assist in the closure of minor foot-salvaging procedures such as toe and ray amputations. the inability to loosely close the wound primarily over a wash-through system results in prolonged morbidity as the wound slowly granulates and shrinks. operated by master's level nurse-educators. Properly designed shoewear should provide the partial-foot amputee with a stable platform. and education in foot care with emphasis on assumption of responsibility for selfcare.). irrigation tube is placed in the depths of the wound and sutured to the skin.).to 5-week period. When gangrene or poor healing is related to vascular occlusion alone. remaining tissues that are not inflamed or necrotic. Kubrusly DB.asp[21/03/2013 21:53:05] . Orthop Clin North Am 1978.org/alp/chap02-04. 6. Prosthetic. Tally FP. Surg Gynecol Obstet 1979. et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. 85:461-463. 4. Boulton AJM. 66:305318. Root R. References: 1. et al: Impaired vibratory perception and diabetic foot ulceration. Louie TJ. 2:220-227. Hunt TK: Wound healing and the diabetic patient.2D: Infection | O&P Virtual Library BIBLIOGRAPHY Goodson WH III. Volay R. Weinstein D. Kwasnik EM: Limb salvage in diabetics: Challenges and solutions. Wagner FW Jr: Orthopaedic rehabilitation of the dysvas-cular limb.oandplibrary. et al: MRI and diabetic foot infections. 3. 7. Bartlett JG. Orthop Clin North Am 1973. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 2D The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Page CR: Nutritional studies: Importance in predicting woundhealing after amputation. Bagdade JD. 66:71-75. Golbranson F. 4:21-30. Bowker JH. 149:600-608. 8. DeLee JC. Bone Joint Surg [Am] 1984. Chapter 2D . Kritter AE: A technique for salvage of the infected diabetic gangrenous foot. Magn Reson Imaging 1990. Contact Us | Contribute http://www. 19:364. Dickhaut SC. Wang A. 5. et al: Oxygen inhalation-induced transcutaneous Po2 changes as a predictor of amputation level. Ann Intern Med 1976. Diabetes 1970. Greenfield L. et al: Host defense in diabetes mellitus: The feckless phagocyte during poor control and ketoacidosis. 3:335-337.Atlas of Limb Prosthetics: Surgical. 9:325-350. Diabetic Med 1986. Vasc Surg 1986. Vasc Surg 1985. 8:805-809. Nielsen K. Harward TRS. 2. Reproduced with permission from Bowker HK. American Academy of Orthopedic Surgeons. Limb salvage surgery is any procedure that effectively removes a bone or soft-tissue tumor while preserving the limb with a satisfactory functional and cosmetic result. reported an almost 20% incidence of significant problems in patient management caused by inappropriate biopsy technique. it is recommended that patients be transferred to a specialty center before rather than after the biopsy. and Rehabilitation Principles. The surgical stage of the tumor is based on its histogenic type (as determined by biopsy) as well as on its local extent and any existing metastasis 8-11 (as determined by radiologic studies including radiographs. bone scan. and social workers. IL. limb-saving procedures have proved to be as effective as amputation in terms of local tumor control without compromising survival. and stage 3 (aggressive). M. A frozen-section tissue preparation for immediate appraisal of the adequacy of the specimen for diagnosis is recommended. The biopsy is done after completion of the radiologic staging studies and should be carried out by the surgeon who will perform the definitive surgery. and magnetic resonance imaging [MRI]). In a multicenter study. The treatment plan for malignant tumors is a mul-tidisciplinary one utilizing surgery. since the midseven-ties and as a result of advances in adjuvant chemotherapy and radiotherapy newer staging studies of tumors. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). It categorizes benign tumors into three stages designated by Arabic numerals: stage 1 (latent). A poor biopsy technique may have a profound adverse effect on the subsequent definitive surgical treatment and in fact may preclude the execution of an otherwise feasible limb-saving procedure. Prosthetic. Click for more information about this text.oandplibrary. edition 2. http://www. prosthetists. Both stage I and stage II are subdivided into A (intracompartmental) and B (extracompartmental). However. Moreover. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. physical therapists.Atlas of Limb Prosthetics: Surgical. The biopsy incision should be longitudinal rather than transverse and should be correctly placed in line with the planned incision of the subsequent surgery so that in case a limb-saving procedure is done. The new staging system that has been adopted by the Musculoskeletal Tumor Society8-11 and that is currently utilized by most orthopaedic oncologic surgeons applies to bone as well as soft-tissue tumors. and Stage III (any malignant grade with regional or distant metastasis). Mankin et al.org/alp/chap02-05.2E: Tumor | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 2E Chapter 2E . Plugging the intraosseous biopsy site with methylmethacrylate cement may be done to prevent soft-tissue spread of the tumor hematoma. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and improved surgical techniques of skeletal and soft-tissue reconstruction.D. Prosthetic. errors in diagnosis occurred twice as commonly when the biopsy was done in a community hospital as opposed to when it was done in an oncologic center. Prosthetic.5% of the patients who might have had a limb-saving procedure required an amputation as a result of an ill-planned biopsy. Intraosseous biopsy material is obtained through a round or oval cortical window. computed tomography [CT]. It was found that 8% of the biopsy procedures produced significant adverse effect on prognosis and that 4. stage II (high-grade malignancy without metastasis). Rosemont. ©American Academy or Orthopedic Surgeons. chemotherapy. the biopsy tract can be excised in continuity with the resected tumor.asp[21/03/2013 21:53:09] . Deeper dissection should avoid intermuscular planes and should stay clear of the major neurovascular structures. and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Tumor Walid Mnaymneh. 1992. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Malignant tumors are categorized into three stages designated by Roman numerals: stage I (low-grade malignancy without metastasis). Hence. there has been an upsurge of interest in limb-saving procedures in lieu of amputation. For many years amputation was the conventional surgical treatment of malignant bone and soft-tissue tumors. Moreover. and radiotherapy as well as the supportive services of psychologists. reprinted 2002. It is based mainly on the surgical stage of the tumor as well as its size and anatomic location. stage 2 (active). An additional advantage of preoperative chemotherapy is the possible reduction of tumor size. Amputations are discussed in another chapter. INDICATIONS FOR LIMB-SAVING PROCEDURES Conceptually. radiotherapy. SURGICAL TREATMENT In the decision-making process of choosing between amputation or limb salvage procedure. the ultimate goal of treatment should be to maximize the patient's survival and minimize the risks of metastasis and local recurrence.org/alp/chap02-05. amputation becomes the preferred option. in terms of survival and local recurrence. A study specifically targeting tumors about the knee showed no significant difference in psychological showed that patients whose limbs were and physical function. if one or more of these criteria are considered unattainable. limb-saving procedures are indicated if all the following criteria are deemed attainable: 1. needs. and demands. The author strongly believes that such procedures are superior to high amputations around the hip and shoulder where not only body image and function are severely affected but also because a normal limb distal to the tumor site is unnecessarily sacrificed.oandplibrary. Postoperatively. Moreover. Interestingly. chemotherapy. This chapter describes the limb-saving procedures only. http://www. Recently.2E: Tumor | O&P Virtual Library Treatment strategy following the staging of the tumor is dependent on the tumor characteristics: in the case of high-grade. A similar strategy is followed in soft-tissue tumors: high-grade soft-tissue or radiotherapy. Histologic assessment of the extent of necrosis in the resected primary tumor allows an evaluation of and hence will help in selecting the the efficacy of the preoperative chemotherapy appropriate adjuvant postoperative chemotherapy. no such therapy is given in low-grade bone tumors including chondrosarcoma. thus making limb saving less feasible. whereas another study salvaged by knee arthroplasty walked at a higher velocity and with a lower net energy cost than did patients who had above-knee (transfemoral) amputation. 4. chemotherapy-sensitive bone tumors such as osteosarcoma and Ewing's sarcoma. or both are usually administered. An oncologically sound wide or radical resection of the tumor can be achieved. The ultimate goal is not merely "salvaging" the limb but reconstructing a functional and cosmetically appealing limb. The cosmetic and functional results are superior to those of an amputation. 2. early diagnosis is important for successful limb saving inasmuch as a delay in diagnosis allows the tumor to increase in size. Definitive surgical treatment is then performed and consists of resection with limb saving. Obviously. Sometimes there is sufficient reduction in tumor size to change an equivocal limb-saving situation into a definitely feasible one. the chemotherapy-induced necrosis could conceivably reduce the potential escape of viable tumor cells during the operation. Obviously. The prognosis. Limb reconstruction is technically feasible. treatment is initiated with neoadjuvant preoperative chemotherapy . By and large. or amputation. a few studies have actually shown no significant difference in the psychological and quality-oflife parameters between patients with limb-saving and amputation procedures. further similar comparative studies that are stratified by the level of amputation and that utilize more sensitive tests are needed to reach a rational scientific answer to the important question of whether patients and their treating physicians prefer limb-saving procedures because of preconceived notions of the resultant body image and quality of life or because of conclusive measurable subjective and objective advantages of limb-saving procedures. or both. is not compromised. Other important factors to be considered include the psychological impact of the surgical treatment in terms of the resultant body image and quality of life as well as the function of the operated limb. depending on the type of tumor and the surgical procedure performed. if feasible. there have been serious efforts to examine the true merits of limb-saving procedures over amputations. with due consideration given to the patient's life-style. 3. Tumors that lend themselves to limb-saving procedures include malignant tumors (stage I and II) and some recurrent aggressive benign tumors (stage 3). sarcomas are treated preoperatively with either chemotherapy whereas low-grade soft-tissue sarcomas are not.asp[21/03/2013 21:53:09] . In bone. In bone tumors. more frequently. metallic prostheses. resection of invaded major nerves may be performed. There are three major methods of skeletal reconstruction: (1) intercalary (segmental) reconstruction. However. Displacement or even involvement of adjacent neurovascular structures are not absolute contraindications to resection. wide resection of the tumor. rib. metacarpal. and it utilizes allografts. phalanx. shoulder.asp[21/03/2013 21:53:09] . The need and the type of reconstruction are determined preoperatively. it comprises two procedures: tumor resection and skeletal reconstruction. or allograft-prosthesis composites.2E: Tumor | O&P Virtual Library In general. At the present time. metallic prostheses. the patient's lifestyle. By and large. elbow. clavicle. The recommended procedure for malignant tumors is either radical or. Intercalary reconstruction is needed after diaphyseal resection. Autografts are the best bone substitutes. TUMOR RESECTION In both bone and soft-tissue tumors. allografts. It utilizes allografts. these are not commonly used because they cannot replace large bone segments and articular joint surfaces cannot be provided.A-C ). radical resection indicates removing the entire muscle compartment from origin to insertion. In softtissue tumors. Arthroplasty is used to replace a resected hemijoint or whole joint with an articulating joint such as the knee. whereas wide resection indicates removing the tumor with a wide surrounding cuff of normal soft tissues in all dimensions ( Fig 2E-1. limb salvage procedures are technically more complex than amputations. If necessary. in nondispensable or "essential" bones. In soft tissue.e. In cases where dispensable or so called "nonessential" bones are resected. and metatarsal bone can be resected with compensable disturbance of function. distal end of the ulna. an intra-articular resection including the articular surface is performed. radical resection indicates removing the entire bone from joint to joint.org/alp/chap02-05. and the surgeon's preference and expertise. For epiphyseal or metaphyseal tumors. Previous biopsy scars and tracts are excised in continuity with the tumor. Arthrodesis is used to reconstruct the limb after extra-articular resection of a joint such as the knee. Under proper circumstances. or rarely. especially MRI and CT studies. ischium. The adequacy of the resection cannot be overemphasized inasmuch as inadequate resection is the main cause of local recurrence. (2) arthrodesis. the size of the resected bone. SKELETAL RECONSTRUCTION Postresection skeletal reconstruction constitutes the second stage of the operative procedure. proximal part of the radius. and (3) arthroplasty. i. shoulder. whereas wide resection indicates removing the tumor with a wide margin of normal bone around it. a careful subadventitial dissection is performed to preserve the vessel. soft-tissue reconstruction is rarely needed.oandplibrary. and metallic prostheses. or wrist. If a major indispensable vessel is displaced but not directly involved by the tumor. hip. which in turn implies a worse prognosis. customized metallic prostheses. Resultant functional deficit is rectified by means of external orthoses or by reconstructive surgery. no reconstruction is needed to preserve function. pubis. If there is evidence of tumor extension into the joint. An adequate surrounding cuff of soft tissues around the bone is also resected. an extra-articular resection including the whole joint is indicated. It also utilizes allografts. fibula (except the distal end). most orthopaedic oncologists perform wide resection of the tumor combined with chemotherapy and radiotherapy. The scapula (except the glenoid portion). a vessel directly involved by tumor or circumferentially surrounded by tumor can be sacrificed and replaced by a vein graft or a synthetic graft. is preoperatively determined by radiologic staging studies. http://www. resection should be performed according to strict surgical oncologic principles. patella. or wrist. Optimal resection should not be compromised for the sake of subsequent reconstruction. autografts. The level of bone resection should include a margin of normal bone ranging from 3 to 5 cm beyond the tumor limit. based on its intraosseous and extraosseous extent. However. Adequacy of margins of excision is documented by frozen-section microscopic examination of sampled tissues intraoperatively. indications for amputation. The choice of the reconstructive procedure is contingent on the location of the tumor.. skeletal reconstruction is indicated to preserve the limb and its function. autografts. the commonly used skeletal substitutes in these reconstructive methods include autografts. or rarely. The resectability of the tumor. whereas a joint prosthesis necessitates the sacrifice of the normal uninvolved half of the joint in order to accommodate the prosthesis. One is resection-arthrodesis of the knee. Following wide resection of the proximal third of the tibia or distal part of the femur. arthrodesis of the knee is achieved by inserting a long intramedullary nail and bridging the resection defect with a combined construct made up of the ipsilateral fibula and a half of the proximal end of the tibia (to replace a resected distal femur) or half of the distal part of the femur (to replace a resected proximal tibia). When successful. allograft-prosthesis composites.oandplibrary. quicker recovery.A-D ). Intercalary allografts are either frozen or freeze-dried and are used to reconstruct diaphyseal defects. and easier rehabilitation. These are related to the biological nature of the allograft. on a dual fixation concept. which allows healing at the grafthost junction by a process of creeping substitution. especially in younger patients with high physical activity levels. Osteoarticular allografts are glycerol-treated frozen allografts and are the most commonly used.2E: Tumor | O&P Virtual Library Nevertheless. metallic prostheses have the potential late complications of loosening or fatigue fracture of the prosthesis. the advantages of prostheses include a simple operative procedure. ALLOGRAFT PROCEDURES We have used four types of allografting procedures to reconstruct large skeletal defects in bone tumors. The bone bridging around the prosthesis is accomplished by applying autogenous iliac grafts over the porous segment. with initial fixation of the solid intramedullary stem by methylmethacrylate bone cement and long-term fixation by extracortical bone bridging and ingrowth over the porous shoulder region of the segmental prosthesis. being similar to fracture healing.org/alp/chap02-05. an osteoarticular allograft replaces only the involved half (or quarter) of the joint. both allografts and prostheses can replace large segments of bones and provide movable joints. Conversely. in contrast to the long rehabilitation following allografting procedures. this technique produces a long-lasting and durable reconstruction. most patients prefer to have a movable rather than a fused knee. Prostheses are also recommended in patients with metastatic tumors. These expandable prostheses allow periodic lengthening of the devices to gradually keep up with the growth of the contralateral limb ( Fig 2E-2. Previously. shoulder. and elbow joints. thus sparing the uninvolved normal portions of the joint. improved. to achieve arthrodesis following knee or shoulder joint resection. the healing potential is greatly diaphyseal defect. allografts have certain advantages over prostheses. Wholejoint allografts have proved unsatisfactory because of articular cartilage degeneration and bone fragmentation reminiscent of Charcot (neuropathic) joints. http://www. Moreover. thus restoring motor function and joint stabilization. However. in our experience. These are massive osteoarticular allografts. They are usually utilized as hemijoints to reconstruct the knee. On the other hand. In contrast to autografts. and high cost. and the presence of allograft stubs of tendons and ligaments. fracture. improper size. need for customized implants. and intercalary allograft-arthrodesis. Initial clinical results seem to be quite promising. The indication for each of these procedures is dictated by the skeletal location and extent of tumor resection.asp[21/03/2013 21:53:09] . Useful new "expandable" metallic prostheses have been successfully used in children with malignant tumors of long bones of the limbs. which serve as anchors to which host tendons and ligaments can be reattached. there has been an unacceptably high incidence of fragmentation and collapse of the allograft femoral and humeral head. or as allograft-prosthesis composites to reconstruct the hip or shoulder joints. we prefer to use metal prostheses in conjunction with intercalary allografts (allograft-prosthesis composite) in lieu of os-teoarticular allografts to replace the proximal part of the femur and the proximal end of the humerus because. Although we generally favor allografts. loosening. new modular segmental defect replacement prostheses have recently been developed for the proximal and This system depends distal ends of the femur and proximal parts of the tibia and humerus. The graft is more readily incorporated and frequently hypertrophies with time. in terms of To help solve some of the problems encountered with customized prostheses. wrist. intercalary allografts. The other surgical technique is the use of a vascularized free fibular autograft as an intercalary graft to reconstruct a Unlike an avascular fibular allograft. Conceptually. limb saving in young children was not recommended when epiphyseal growth plates of long bones had to be sacrificed with the resected tumor because of the expected significant shortening of the limb. two useful surgical techniques utilizing large autografts can be used in selected cases. congruent joint fit. and joint capsule. When evaluation necessitates resection of the whole glenohumeral joint or resection of the deltoid muscle and rotator cuff. Femur In the proximal end of the femur. The following are examples of allograft reconstruction of the limbs: Scapula The whole scapula or the functionally important glenoid and neck portion can be replaced by a scapular allograft. then we recommend an allograft-arthrodesis utilizing a proximal humerus allograft with fusion to the scapula ( Fig 2E-4. the normally long dorsal lip of the articular surface of the radius becomes volar. function. we favor the use of a proximal femoral allograft combined with a long-stem femoral prosthesis instead of an osteoarticular allograft ( Fig 2E-7. We favor the use of a massive pelvic osteoarticular allograft to replace the resected hemipelvis.2E: Tumor | O&P Virtual Library An allografting procedure is often complex and lengthy.org/alp/chap02-05. a partial or complete internal hemipelvectomy can be as effective as a conventional transpelvic amputation. thus acting as a blocking strut against volar subluxation of the carpus. To prevent this complication we now recommend the use of the donor's contralateral radius with a 180-degree rotation on its longitudinal axis. However. stability. A-C ).asp[21/03/2013 21:53:09] . tendons. local muscle transfer. The stubs of the allograft collateral and cruciate ligaments are sutured to the corresponding stubs of the patient.A-C ) or one femoral condyle can be replaced. These include size matching of the graft to the resected segment. http://www. Diaphyseal defects are reconstructed by an intercalary allograft ( Fig 2E-8. When ( Fig 2Esuccessful. particularly in the osteoarticular allograft.oandplibrary. certain technical aspects have to be heeded.A and B ). Theoretically. 6. if necessary. the pelvis allograft restores anatomy. We have observed a late complication of volar subluxation of the carpus on the allograft radius with progressive degenerative changes in the radiocarpal articulation.A and B ). However. then a bipolar femoral prosthesis is used rather than a proximal femoral allograft. Pelvis In selected patients with tumors of the bony pelvis. this procedure produces significant disability in terms of loss of hip function and stability.A and B ).A-C ). we have observed a relatively high incidence of late fracture or fragmentation of the humeral head ( Fig 2E-3. or free flaps. To achieve optimal results. rigid fixation of the graft-host junction. The whole distal part of the femur ( Fig 2E-9. In the distal third of the femur. we have reconstructed the ligaments by utilizing a hemi-Achilles tendon allograft. and adequate skin and soft-tissue coverage by utilizing. skin grafts. Humerus The proximal or distal thirds of the humerus can be successfully replaced by an osteoarticular allograft. either by directly suturing the tendons to the allograft trochanter or by fixing the patient's greater trochanter to the allograft. size matching of the allograft and joint fit as well as ligamentous repair are critical. This has not been a problem with distal humeral allografts. particularly the hip abductors. we now recommend using an allograft-prosthesis composite to replace the proximal end of the humerus by utilizing a long-stem Neer endoprosthesis combined with an intercalary humerus allograft. by rotating the allograft. This allograft-prosthesis composite provides a strong construct as well as a good osseous bed for reattaching tendons.A-B ). Accordingly. and leg length. To restore joint stability and function. being a two-in-one procedure combining resection and reconstruction. If such stubs are absent. osteoarticular allografts have been successful in our hands. reconstruction of ligaments. Radius The distal end of the radius can be replaced by a size-matched osteoarticular allograft that is fixed to the host radius by a dorsally placed compression plate ( Fig 2E-5. In case the femoral head and neck have to be included in the resection. we have successfully used distal femur and proximal tibia allograft-prosthesis composites and incorporated a rotating hinged-knee prosthesis. According to Mankin's grading system. Clin Orthop 1985. Orthopedics 1985. or replacing a resorbed humeral head with a Neer shoulder endoprosthesis. has shown the following results. Mnaymneh W: Massive allograft implantation following radical resection of high grade tumors requiring adjuvant chemotherapy treatment. Eckardt JJ. This is followed by protection of the limb in a kneeankle-foot orthosis and gradual mobilization of the knee joint. In proximal femur allograft-prosthesis composites. over half of these complications were salvaged by subsequent surgery such as autografting a fractured or nonunited allograft. 6.asp[21/03/2013 21:53:09] . It is our firm impression that the learning experience with these allografting surgical techniques has enabled us to reduce the incidence of our earlier complications.org/alp/chap02-05. which technically are the most complex and challenging. in Enneking WF (ed): Limb Salvage in Musculoskeletal Oncology. the patient uses crutches to avoid weight bearing on the affected leg until union occurs. 7% nonunion of the graft-host junction. 2. 5. J Bone Joint Surg [Br] 1987. Bradish CF. and 5% resorption of a portion of the allograft (such as the humeral head). 13% fair. The allograft-related complications consisted of 10% infection. CLINICAL RESULTS These limb-saving resection-reconstructive procedures utilizing massive allografts are often complex and long procedures with relatively high rates of complications. In proximal humerus allografts. Of course. New York. 69:276-284. Chao EYS: A composite fixation principle for modular segmental defect replacement (SDR) prostheses. Churchill Livingstone Inc. 197:88-95. Scales JT. At the University of Miami. 192:431. the use of these allografts (either alone or in combination with metal prostheses) provides a useful reconstructive method in limb salvage procedures following wide resections of bone tumors. folowed by a crutch or a cane. antibiotic treatment is continued postoperatively for about 3 months. Campanacci M. and versatility of allografts and despite the potential complications. Am Surg 1980. the forearm is immobilized in a short-arm plaster cast. Ligament reconstruction of the joint is similar to that used with the distal femoral allograft. In distal radius allografts. Kemp HBS.to 11-year follow-up retrospective evaluation of the massive osteoarticular allografts. et al: Distal femoral replacement by custom-made prostheses. Cervellati C. et al: The UCLA experience in limb salvage surgery for malignant tumors. and 26% failure. our results are 61% good or excellent.oandplibrary.2E: Tumor | O&P Virtual Library When the whole knee joint has to be resected. our 2. et al: Is amputation necessary for sarcoma? A seven year experience with limb salvage. replacing a fractured allograft with a new allograft. followed by protection in a volar splint and gradual mobilization of the wrist joint. pp 364-378. 1987. Grant TT. 3. Eilber FR. In view of the biological advantages. availability. we immobilize the limb in a long-leg plaster cast for 8 weeks to allow soft-tissue and ligament healing.A and B ). Dorey FJ. Mirra JJ. The orthosis is kept until there is radiologic evidence of union at the al-lograft-host junction. a shoulder abduction splint is used for about 6 weeks. 8:612-621. Malinin T. the patient walks by utilizing an abduction hip brace and crutches for 2 to 3 months. Guerra A. followed by protection in a sling and gradual mobilization of the shoulder joint. et al: Knee resection-arthrodesis. Orthop Clin North Am 1989. References: 1. In allografts in the knee region. However. 4. Dick HM. Tibia Proximal tibial osteoarticular allografts have been used successfully ( Fig 2E-10. 20:439-453. 20% fracture of the allograft. POSTOPERATIVE MANAGEMENT Because of the increased potential risk of infection. http://www. Eilber FR. 196:305. 314:1600-1605.oandplibrary. Doppelt S. Taffer J. Malinin T. 150:109-113. 204:9-24. 35. 31. Goorin AM.asp[21/03/2013 21:53:09] . Glatstein E. Cancer 1984. in Musculoskeletal Tumor Surgery. Orthopedics 1985. New York. Martin RG. 18. 106:55-67. 21. Cancer 1983. Contemp Orthop 1986. Eilber FR. 59:223-236. Rao BN. Clin Orthop 1983. 62:1027-1030. 57:499.49:1221-1230. Jaffe N: Chemotherapy for malignant bone tumors. 16. Malinin T. Goodnight JE. Am J Surg 1985. 225:128-132. Ghandur-Mnaymneh L. 51:4021. et al: Massive osseous and osteoarticular allografts in non-tumorous disorders. 30. Bacci G. Orthopedics 1985.org/alp/chap02-05. Ann Surg 1982. Clin Orthop 1986. Lange TA. 72:1477-1485.262:124-128. Spanier SS: The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. 13:13. 64:1121-1127. 18:901-908. Caparros B. Rosenberg SA. Gherlinzoni F. 20:455-467. Picci P. Kroll MA: Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above the knee amputation. Mnaymneh W. vol 1. et al: Primary osteogenic sarcoma. 20. Ghandur-Mnaymneh L. Enneking WF: A system of staging musculoskeletal neoplasms. Malawer M: Surgical technique and results of limb sparing surgery for high grade bone sarcomas of the knee and shoulder. pathologic and pharmacologic studies. Clin Orthop 1985. N Engl J Med 1986. et al: Limb sparing surgery for extremity sarcomas after preoperative intraarterial doxorubicin and radiation therapy. 25. Shirley PO: Resection arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. Angela WM: The effect of adjuvant chemotherapy on relapsefree survival in patients with osteosarcoma of the extremity. or arthroplasty for tumors about the knee. et al: Limb salvage for skeletal and soft tissue sarcomas: Multi disciplinary preoperative therapy. 12. Morton DL. et al: Limb salvage procedure for children with osteosarcoma: An alternative to amputation. 197:76. et al: A randomized trial for the treatment of high grade soft tissue sarcoma of extremities: Preliminary observations. Spanier SS. Leff AR. Lindberg RD. 1983. 45:3040. 24. Harris IE. Mnaymneh W. et al: Osteosarcoma: Intra arterial treatment of the primary tumor with cis-dia-mine-dichloroplatinum II (CPD): Angiographic. 28. et al: Conservative surgery and postoperative radiotherapy in 300 adults with soft tissue sarcomas. 34. Rosen G: Preoperative (neoadjuvant) chemotherapy for osteogenic sarcoma: A ten year experience. J Bone Joint Surg [Am] 1977. Mankin HJ. Eight years experience of adjuvant chemotherapy. Head W. 11. Champion JE. 13. J Pediatr Surg 1983. 174:69. Lane JM. Link MP. 26. Churchill Livingstone Inc. Mnaymneh W: Malinin T: Massive allografts in surgery of bone tumors. J Bone Joint Surg [Am] 1982. Chuang VP. 23. Clin Orthop 1990. Enneking WF: Surgical procedures. 15. Mnaymneh W. Mankin HJ. Romsdahl MM. 20:487-503. Marcove RJ. Pratt CB. Orthop Clin North Am 1989. et al: Scapular allografts-A report of two cases. 14. Makely JT. Glatstein E. 36. 27. 33. 8:659-664. Cancer 1982. Malinin T. Rosenberg SA. 67:606. et al: The treatment of soft tissue sarcomas of the extremities. 9. Eckardt J. Rosen G: En bloc resection for osteogenic sarcoma. Jaffe N. arthrodesis. J Bone Joint Surg [Am] 1990. Cancer 1981. J Bone Joint Surg [Am] 1980. 10. et al: Massive os-teoarticular allografts in the reconstruction of extremities following resection of tumors not requiring chemotherapy and radiation. Otis J. 47:2391. Rosen G. 8. Rosen G. 22. J Clin Oncol 1986. et al: Pelvic allograft. Malinin T. 8:597-607.2E: Tumor | O&P Virtual Library 7. et al: Control of locally advanced extremity soft http://www. Huvos AG: Preoperative chemotherapy for osteogenic sarcoma: Selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. pp 89-95. 4:552. Mnaymneh W: Unpublished data. Cancer 1980. Goodman MA: The surgical staging of musculoskeletal sarcoma. Clin Orthop 1991. 53:2579. Lewis M: The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer 1986. 32. J Cancer Res Clin Oncol 1983. Enneking WF. 29. Tomford WW: Clinical experience with allograft implantation: The first 10 years. Marcove RC. et al: Function after amputation. Or-thop Clin North Am 1989. Enneking WF. J Bone Joint Surg [Am] 1985. Tepper J. Gitelis S. Mnaymneh W. 17. Bargar W. Voegeli T. Knapp J. 19. Huvos AG. 45. 53:1385. 221:188-201. Rosenberg SA. Suit HD. Bowman WE Jr. Chao EY: Reconstruction of musculoskeletal defects about the knee for tumor. Aschliman MA. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 2E The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Nori D. Cancer 1981.oandplibrary. 39. Clin Orthop 1987. Contact Us | Contribute http://www. 44. et al: Preoperative radiation therapy for sarcoma of soft tissue. 42. cisplatin and doxorubicin for the management of patients with non metastatic osteosarcoma. Sim FM. 41.org/alp/chap02-05. 8:574-581. Weiland AJ: Vascularized free bone transplants: Current concepts review. Chapter 2E . et al: Control of locally advanced extremity soft tissue sarcoma by function-saving resection and brachytherapy. Segraves KB. 91:17-23. J Bone Joint Surg [Am] 1986. Weiner MA. 38. Orthopedics 1985. et al: Limb salvage in primary malignant bone tumors.Atlas of Limb Prosthetics: Surgical.2E: Tumor | O&P Virtual Library tissue sarcoma by function-saving resection. J Clin Oncol 1985. et al: Quality of life assessment of patients in extremity sarcoma clinical trials. Simon MA: Psychological outcome of extremity sarcoma survivors undergoing amputation or limb salvage. Beauchamp CP. 37. et al: Neoadjuvant high dose methotrexate. 53:1385. Thomas N. 68:1331-1337. Lewis MM. Surgery 1982. Cancer Treat Rep 1986. 43. 47:2269.asp[21/03/2013 21:53:09] . Mankin HJ. Turnbull AD. et al: Limb salvage treatment versus amputation for osteosarcoma of the distal end of the femur. Wilkins RM. 63:166-169. Cancer 1984. J Bone Joint Surg [Am] 1981. Sim FM. Cancer 1984. Weddington WW Jr. Barofsky I. Shiu MH. 40. Poppe KH. Simon MA. Prosthetic. Sugarbaker PH. 3:1393. Harris MG. 70:1431-1432. Prosthetic.asp[21/03/2013 21:53:15] . Despite significant improvements in the care of the dysvascular amputee (diabetic management. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. The initial. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Postoperatively. Moore.oandplibrary. Advances in trauma management such as arterial and venous repairs. control of diabetics' blood glucose. a wellplanned and executed amputation can remove a painful. and the use of antibiotics in infected patients. Limb Salvage Trauma Modern advances in trauma management such as fracture stabilization and free-tissue http://www. Once an amputation is decided upon. Click for more information about this text. In the United States. bony stabilization. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. M. operative.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 3 Chapter 3 . Although most surgeons consider amputation to be the ultimate surgical failure. Oftentimes. Appropriate surgical technique should be utilized to produce an acceptable stump for subsequent prosthetic fitting. PREOPERATIVE CONSIDERATIONS Amputation vs. vascular reconstructive procedures.D. social. antibiotic management. In peripheral vascular disease. and free-tissue transfers have resulted in limb salvage in severely traumatized limbs that previously would have been amputated. Amputation surgeons must recognize the global problems associated with amputation surgery. etc. ©American Academy or Orthopedic Surgeons. Rosemont. most basic decision is whether to proceed with amputation or to attempt limb salvage.) the contralateral limb amputation rate and long-term survival rates have not significantly changed. nutrition. advances in vascular reconstructive procedures have allowed limb salvage in both nondiabetic and diabetic patients. appropriate judgment should determine prosthetic candidacy in elderly dysvascular amputees. amputation surgery may be considered reconstructive surgery. IL. with results similar to amputation of an arthritic femoral head and prosthetic replacement (total-hip replacement). and postoperative considerations. and Rehabilitation Principles. Reproduced with permission from Bowker HK. American Academy of Orthopedic Surgeons. Planning for optimal function in amputation surgery should consist of preoperative. Modern amputee management involves a multidisci-plinary approach to address the global problems (medical. Several series of dysvascular amputees in the 1960s and 1970s reported contralateral limb amputation rates of 15% to 28% within 3 years of the initial amputation and a 50% mortality rate during the same time period. and economic) involved in amputees. 1992. Prosthetic.Atlas of Limb Prosthetics: Surgical. reprinted 2002. as well as coronary artery and cerebral vascular disease. The environment for wound healing should be maximized by evaluating the patient's nutritional status. Prosthetic.org/alp/chap03-01. In this regard. edition 2. these patients have the same process in the contralateral limb. surgical. and Rehabilitation Principles Planning for Optimal Function in Amputation Surgery Thomas J. Improvements in adjunctive chemotherapy and surgical technique have allowed en bloc resection of certain bony tumors and limb salvage with either custom prosthetic implants or allograft replacement. the most common reason for lower-limb amputation is peripheral vascular disease. preoperatively the most distal level of amputation compatible with wound healing and subsequent satisfactory prosthetic fitting should be determined by clinical evaluation and laboratory evaluation. painless state. rehabilitative. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). dysfunctional limb and allow rehabilitation with a prosthetic limb to a functional. The role of the amputation surgeon involves much more than the actual surgical procedure. with its increased blood supply. The use of a long posterior myofasciocutaneous flap in dysvascular patients. The vast majority of lower-limb amputations for peripheral vascular disease occur in diabetics. patients who underwent primary amputation and of those who underwent segmental limb Survival rates may actually be improved in those patients who undergo an en resection. several series have demonstrated no adverse effect of failed vascular reconstructive procedures on the ultimate level of amputation or clinical outcome. multiple series have demonstrated that when modern techniques of vascular reconstructive surgery are applied to diabetics. (See Chapter 2B for a detailed discussion. The advent of more sophisticated radiographic preoperative staging and the use of preoperative and postoperative adjunctive chemotherapy have improved 3-year survival rates in osteogenic sarcoma to 60% to 85% in some studies. However. several factors combined to reverse the ratio of transfemoral to trans-tibial amputations.asp[21/03/2013 21:53:15] . However. more patients will be evaluated for dysvascular disease in lower limbs. many of these patients should be evaluated limb. As the population of the United States ages. Other groups have developed more comprehensive rating systems to evaluate severe limb injuries to allow objective criteria for limb salvage vs.org/alp/chap03-01.) Site of Amputation Before World War II. 5year survival rates for patients with osteogenic sarcoma were in general less than 20%. Often diabetics with dysvascular disease are thought to have "small-vessel disease" not treatable with vascular reconstructive procedures. improved the success rate in transtibial amputations.oandplibrary. bloc resection because the patients selected for this treatment are likely to have more limited At the present time. dysvascular However. in 1959 that described arteriosclerosis in the arterioles of diabetics that was thought to be unique. Arterial reconstructive surgery is expensive and may delay eventual definitive treatment. (See Chapter 2C for a detailed discussion. early amputation at the most distal level possible and rehabilitation with a prosthesis offer the best solution for a painful. long-term limb salvage rates are comparable to nondia-betics treated in a similar manner. several series have shown that there is significant morbidity. recent series.) Peripheral Vascular Disease The largest number of amputations done in the United States are for peripheral vascular disease. Therefore. Vascular reconstruction in limbs at risk for amputation may have some drawbacks. (See Chapter 2E for a detailed discussion. Lange et al. the amputation rate in grade IIIC tibial fractures is still greater than 50% in In addition. and the outcome is uncertain. In the 1960s and early 1970s. for consideration for vascular reconstructive procedures that may allow either limb salvage or a more distal amputation level. the development of preoperative objective criteria for amputation site viability allowed more distal amputations to be done. In addition. En bloc resection of osteosarcomas and limb salvage with either customized orthopedic implants or allograft implantation has been Several institutions report similar overall survival rates of developed in the last decade. Despite these advances. This concept probably originated in an article by Goldenberg et al. probably be restricted to centers with a large oncology section and is probably contraindicated in patients with large tumors who exhibit minimal response to preoperative chemotherapy. before undergoing amputation.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library transfers have allowed salvage in limbs that previously would have been amputated. and psychological effects involved in limb salvage in severely traumatized limbs. subsequent series have not confirmed small-vessel disease as unique to diabetes mellitus. diabetics should not be automatically excluded for consideration for vascular reconstructive procedures in limb-threatening conditions. In addition. In the 1960s and early 1970s. have developed narrow absolute criteria (prolonged warm ischemia time greater than 6 hours and/or anatomic disruption of the posterior tibial nerve in adults) for primary amputation in grade IIIC tibial fractures. Lower-limb amputations in the dysvascular patient should be performed at the most distal site http://www. Oftentimes. the majority of lower-limb amputations were transfemoral because such procedures yielded healing rates approaching 100% in ischemic limbs.) Tumors The field of musculoskeletal oncology is rapidly evolving. increased economic cost. amputation decisions. en bloc resection with limb salvage in osteosarcoma should disease. Several welldocumented studies have shown that energy expenditure with prosthetic ambulation is found that markedly increased in more proximal amputations. pulse. Mazet and coworkers. of course. blood pressure at the proposed amputation site has been advocated as a predictor of found that transtibial amputations healed in all amputation success.90 mL/min/100 g of tissue. Fisher et al. Wagner has suggested comparing the pressure at the proposed amputation site to that of the brachial artery. 90% healed. Other authors also suggest that the segmental arterial pressure in diabetics is not always helpful in preoperative determination of amputation levels. found that when the skin perfusion pressure was <20 mm Hg. 49% in transfemoral amputees. found that lower-limb amputees expend more energy (kilocal-ories per meter) in ambulation than do nonamputees and have a compensatory decrease in gait velocity. Various methods have been developed to objectively determine the most distal level at which Clinical parameters such as the lowest palpable amputation is likely to be successful. there are inconsistencies with Doppler determinations of the amputation site.asp[21/03/2013 21:53:15] . A calcified. The method is exacting to carry out.. For geriatric patients with bilateral transfemoral amputations. and the trauma of injecting 133 Xe may in and of itself elevate the skin blood flow. In contrast to some older reports. This method involves warming the skin to 44°C with a heated electrode. skin temperature. Preservation of the knee joint has even more significance when the rate of contralateral limb amputation is considered. knee disarticulation or transfemoral amputation is preferable to transtibial amputation to prevent knee flexion contractures and subsequent breakdown of the stump. in elderly debilitated patients with limited or no ambulatory potential. in a study of 60 transtibial amputees. Other authors reported contralateral amputation rates of 15% to 28%. Other authors have not found the skin flow measurements with 133 Xe to be so reliable. in their series of dysvascular amputees. Barnes and coworkers patients with popliteal systolic pressures of more than 70 mm Hg. However. in a review of previous energy studies in amputees.oandplibrary. injected 133 Xe epicutaneously and determined that wound healing was predictable with skin blood flow above 0. ambulation is probably not feasible in most cases. With intradermally injected 133 Xe. Kostuik et al.org/alp/chap03-01. was significantly increased in transfemoral amputees vs. as measured by oxygen consumption per kilogram of body weight per meter traveled. when the skin perfusion pressure was >30 mm Hg. This method is based on the fact that the oxygen tension measured over locally warmed skin reflects the metabolic and perfusion capabilities of the skin and hence its healing http://www. Two methods use clearance of 133 Xe to measure dermal vascularity. In addition. only 25% of these amputations healed. In one method. The skin blood flow per unit volume is inversely related to the time required for the detected activity of the 133 Xe to decrease by half. cutaneous diastolic pressure is estimated by determining the applied pressure necessary to stop clearance of intradermally injected 133 Xe. Waters and coworkers energy expenditure during ambulation. However. and wheelchair locomotion is indicated. From 20 mm Hg to 30 mm Hg of pressure. Holstein et al. non-compressible artery will give falsely elevated values. less than in unilateral amputees.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library compatible with wound healing to achieve the optimal potential for ambulation.. Measurement of transcutaneous Po2 is another method of determining the amputation level. Ambulation ability in bilateral amputees is. cutaneous blood flow is measured by determining the rate of clearance of 133 Xe injected intradermally or epicutaneously. 67% of amputations healed. transtibial amputees. the pressure in a deep artery may not correlate with skin healing. and 280% in bilateral transfemoral amputees when compared with nonamputees. which then measures the oxygen emanating from the skin. It is not invasive and does not require radioactive isotopes.35 is adequate for healing in the nondiabetic. In a second method. recent studies have demonstrated the enhanced ambulation potential of patients with at least one knee joint preserved as compared with patients having bilateral trans-femoral amputations. while a ratio of 0.7 mL/ min/100 g healed successfully 97% of the time. had a 33% contralateral limb amputation rate within 5 years. a ratio of >0. and bleeding at surgery have been used with varying success to The use of Doppler ultrasonography to measure arterial predict healing of amputation sites. Huang and showed that oxygen consumption during ambulation was increased 9% in associates transtibial amputees. Moore found that amputation sites with a value of &#2265 2.45 is adequate for the diabetic. draining wounds or gas-forming infection. However. using serum albumin levels and total lymphocyte counts. In cases of open.asp[21/03/2013 21:53:15] . In dysvascular patients undergoing elective amputation. The use of antibiotics as prophylaxis in patients undergoing lower-limb amputation is less well defined. especially surgery involving implants. transtibial amputations healed.500 cells per cubic millimeter). Other authors found that an increase of 10 mm Hg of transcutaneous Po2 over a baseline value while inhaling 100% oxygen is predictive of wound healing. In a study of 37 dysvascular patients. At Rancho Los Amigos Medical Center.org/alp/chap03-01. If the initial values are abnormal (serum albumin <3. Most lower-limb amputations for dysvascular disease in the United States are in diabetic patients. the effectiveness of prophylactic antibiotics in the perioperative period has not been established. if time permits. enteral or intravenous hyperalimentation should be considered in a malnourished patient being evaluated for amputation. There have been no prospective series to demonstrate decreased mortality or morbidity in malnourished patients treated with nutritional supplementation before amputation. diabetics with dysvascular limbs often have open wounds and systemic sepsis causing increased metabolic demands. the nutritional status of the patient. Protein malnutrition has an adverse affect on morbidity and mortality in hospitalized patients. the infection is usually polymicrobial. surgical technique. infection. Patients undergoing lower-limb amputations are often elderly and debilitated. including a serum albumin determination and total lymphocyte count. patients with infected dysvascular limbs who are being considered for amputation are initially debrided surgically.oandplibrary. including elective total-hip replacements. In addition. Nutrition The significant incidence of malnutrition in hospitalized patients has been well documented. the use of antibiotics in the perioperative period is mandatory. concomitant medical illnesses. Burgess and Matsen have pointed out that preoperative measurements to determine amputation level are more beneficial in predicting failure than in predicting success. The cell-mediated and humoral immune systems are impaired with resultant decreased host resistance. Dickhaut and coworkers. is well established. However. Patients undergoing a semielective lower-limb amputation should undergo at least a baseline nutritional assessment. and pulse volume recordings have been used. Burgess and Matsen found that with transcutaneous Po2 values >40 mm Hg. reported a 42% incidence of laboratory-proven malnutrition in Jensen and associates orthopedic patients undergoing surgical procedures. Factors such as alteration in collateral circulation. broad-spectrum antibiotics should be used initially until specific organisms are recovered in culture. Antibiotics The use of antibiotics as prophylaxis in orthopedic surgery. then a more formal assessment should be done. laser Doppler velocimetry has been used to assess the viability of amputation levels. preoperative laboratory assessment of the amputation level does give an indication whether adequate circulation exists for a favorable outcome. skin temperature measurements.4 g/dL or a total lymphocyte count of < 1. However.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library potential. and postoperative care cannot be assessed in the preoperative period. transtibial amputations in 15 patients healed with no delay. Therefore. http://www. Other preoperative methods of determining amputation level such as fluorescein angiography. Recently. Sonne-Holm and have shown a statistically significant decrease in wound infections in coworkers dysvascular amputees treated with a broad-spectrum (cephalosporin) antibiotic in the perioperative period. Trauma or infection increases energy requirements 30% to 55% from basal values. Three patients with transcutaneous Po2 levels of zero had transtibial amputations that failed. In 17 of 19 patients with transcutaneous Po2 values of >0 mm Hg to 40 mm Hg. decreased distal vascular runoff as a result of surgery. In neurotrophic ulcers in diabetes mellitus. found that successful healing of Syme's amputations (ankle disarticulations) occurred in only 2 of 11 malnourished patients despite adequate preoperative Doppler criteria for healing. including both anaerobic and aerobic species. it is important to salvage the most distal amputation site feasible (transtibial vs. Gonzales et al. handling soft tissue in a nontraumatic manner. Inadequate short transtibial amputation stumps have even been lengthened by the Ilizarov technique. there are problems unique to diabetics that require consideration. tissue forceps should be avoided in handling the skin in these patients. Weight bearing occurs at the distal part of the stump in transfemoral amputations and knee disarticulations. especially in the perioperative period. the amputation surgeon must apply appropriate surgical technique to allow wound healing at the most distal amputation site possible. In cases of noninfected dysvascular amputations. http://www. OPERATIVE CONSIDERATIONS In order to enhance the potential for prosthetic ambulation following lower-limb amputation. the stump should have sufficient soft-tissue coverage to resist the shear forces involved in prosthetic ambulation. then a centimeter of tissue can be obtained for quantitative bacterial counts. They found oxygen consumption during ambulation to be 10% higher in amputees with long stumps and 40% higher in amputees with short stumps when compared with nonampu-tees. can enhance collagen synthesis and the inflammatory response to In some series. Parenteral antibiotic therapy is continued until the sepsis is quiescent. However. The altered metabolic state in uncontrolled diabetes mellitus can decrease granulocyte function and collagen synthesis and result in an increased susceptibility to infection and delayed wound healing.org/alp/chap03-01. In cases of systemic sepsis or severely infected limbs. transfemoral amputations) in potential prosthetic ambulators. They defined the stump as being long if it is 50% of the length of the remaining contralateral leg. Parenteral antibiotic treatment is continued until clinical evidence of infection (e. skin traction should not be used. erythema) is diminished. minor traumatic events in the insensate limb can result in limb-threatening ulcers. a preliminary guillotine amputation is done. Modern management of soft-tissue injuries such as free-muscle transfers and tissue expanders has allowed salvage of longer amputation stumps in trauma. When clinical judgment is not clear on timing of closure of contaminated wounds. Then a definitive amputation can be carried out.g. healing of amputations of lower limbs in patients with diabetes infection.oandplibrary. several series have shown equivalent results with vascular reconstructive procedures in diabetics and nondiabetics. Diabetes Five out of six major lower-limb amputations are done in diabetics. leukocytosis. or free-muscle transfer can be done when local sepsis is diminished. and therefore.. then further debridement is necessary before attempting closure. Large skin defects can be covered by utilization of viable skin from amputated parts. If the quantitative bacterial count is greater than 10 . Neuropathy develops in the majority of diabetic patients. Therefore. the wound can be loosely closed over drains. especially in dysvascular patients. Broad-spectrum antibiotics are begun parenterally until specific organisms and antibiotic sensitivities are available. Delayed primary closure. medium if 20% to 50% the length the contralateral leg. especially in dysvascular amputees. In addition. Vigorous control of blood glucose in diabetics undergoing lower-limb amputation. split-thickness skin grafting.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library and specimens for aerobic and anaerobic culture and sensitivity are obtained at this procedure. In most cases. In addition. amputations in diabetics with dysvascular and neurotrophic ulcers can be avoided with conservative nonoperative care and education. prophylactic antibiotic therapy (usually a first-generation cephalosporin) is begun at the time of surgery and continued for 48 hours following the amputation. As already described. then closure can be done. at which time the definitive amputation is done. Grossly contaminated traumatic wounds and some infected dysvascular limbs with gangrene should not be closed primarily following amputation. Painful neuromas should be avoided at the site of weight bearing by sharply dividing nerves and allowing their retraction into sufficient soft-tissue cover. have shown that there is decreased energy expenditure in transtibial amputees with a long stump. In general. In addition to the goal of obtaining the most distal amputation site possible. This involves. and short if less than or equal to 25% of the length of the contralateral limb. If the quantitative bacterial count is less than 10 .asp[21/03/2013 21:53:15] . mellitus has been similar to healing in nondiabetics. Although previously it was believed that diabetics were doomed to an amputation in a dysvascular limb. 39:355. Government Printing Office. J Bone Joint Surg [Am] 1981. 63:1493. 2. presumably because of insufficient cardiac reserve for the increased energy demands of prosthetic ambulation. Joyce J: Doppler-determined segmental pressures and wound healing in amputations for vascular disease. 6. Am J Surg 1983. Burgess E. evaluated the variables associated with successful prosthetic ambulation in lower-limb amputees. 118:597. Willman V: Blood flow in the diabetic leg. Wyss D. 17. arthritis should be considered prior to prosthetic fitting. 7. JAMA 1976. J Trauma 1988.oandplibrary. and diminish postamputation depression. et al: Prevalence of malnutrition in general medical patients. Thornhill B. Arch Surg 1983. Barnes R. Barnes R. U. IPOP should probably be reserved for young. The presence of coronary artery disease in transfemoral amputees precluded prosthetic ambulation. Buckle R. et al: Distal tibial vein grafts for limb salvage. 12. In general. Blackburn G. Aver A.org/alp/chap03-01. 5. Zettl J. 53:74. Binnington H. 13. J Bone Joint Surg [Am] 1982. 15. et al: Amputation of the lower extremity for peripheral vascular insufficiency. Colter H. Burgess E: Contralateral limb and patient survival after leg amputations. poor balance from concomitant cerebral vascular accidents. others have found significant edema. 11.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library POSTOPERATIVE CONSIDERATIONS In the immediate postoperative period. Instr Course Led 1989. 64:378. Slovmaker E: An index of healing in below knee amputations: Leg blood pressure by Doppler ultrasound. Such factors as impaired vision from diabetic retinopathy. J Bone Joint Surg [Am] 1987. 14. The most basic decision following wound healing in amputees is determination of appropriate candidacy for prosthetic ambulation. Matsen F. Barner H. Shank G. Burgess E. 116:80. Matsen F: Determining amputation levels in peripheral vascular disease. Bodily K. The use of an immediate postoperative prosthesis (IPOP) has been advocated to allow early prosthetic ambulation. 79:13.S. Moore et al. Technical Report 10-5. amputation stumps should be splinted with wellpadded rigid dressings to prevent joint contractures. et al: The medical and economic impact of severely injured lower extremities. The patient's social situation should be evaluated. traumatic amputees. Traub J. DC. References: 1. J Bone Joint Surg [Am] 1971. http://www. decrease stump However. Pritchard D. 9. Blackburn G.asp[21/03/2013 21:53:15] . Hurley J. Washington. In an elderly. Cederberg P. which has been shown to be equivalent in energy expenditure to normal bipedal gait. infection and vascular disease. 4. Surgery 1976. dysvascular lower-limb amputee with significant coronary artery disease. 230:858. 18. et al: Protein status of general surgical patients. 235:1567. An overall assessment of the lower-limb amputee should be done prior to prosthetic fitting. 108:655. In this study. J Bone Joint Surg [Am] 1983. Stern P: Severe open fractures of the tibia. Vitola J. Nix C: Prediction of amputation wound healing. Bowker J: Surgical techniques for conserving tissue and function in lower limb amputation for trauma. 32% of lower-limb amputees fit with a prosthesis did not utilize it. 246:280. 28:1270. Wilson A: Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees. Hallowell E. wound problems with IPOP. optimum planning in amputation surgery may involve wheelchair locomotion. 8. Arch Surg 1981. et al: Segmental transcutaneous measurements of Po2 in patients requiring below the knee amputation for peripheral vascular insufficiency. Burgess E. Cancer Clin Trials 1980. 3:29. Burgess E. 48:1022. Circulation 1971. JAMA 1979. Arch Surg 1974. Burgess E: Immediate postsurgical prosthetic fitting. 10. Carter S: The dilemma of adjuvant chemotherapy for osteogenic sarcoma. 69:801. Burgess E. J Bone Joint Surg [Am] 1966. 3. Bistrian B. significant or additional musculoskeletal problems such as rheumatoid psychological problems. Caudle R. 1967. Bondurant F. Marsden F: Major lower extremity amputations following arterial reconstruction. 43:391. Bistrian B. 16. Kaiser G. Romano R. 49:101. 50:49. http://www. J Bone Joint Surg [Am] 1978. Burgess E: Cutaneous blood flow and its relation to healing of below knee amputation. 48. et al: One stage versus two stage amputation for wet gangrene of the lower extremity: A randomized study. Reyes R: Energy expenditure in below knee amputations: Correlation with stump length. et al: The deleterious effect of immediate postoperative prosthesis in below knee amputation for ischemic disease. 50. 26. Coldman L. J Bone Joint Surg [Am] 1967. David J. Goodson W. Howey T. 39. 43. 59:124. Howery T. Arch Surg 1985. DeLee J. 36. 20. Helfet D. Armstrong P. Eckhardt J. Clin Orthop 1990. Sanders R. Holloway G. Am J Surg 1987. Am J Surg 1985. Gullickson G: Energy cost of ambulation in health and disability: Literature review. N Engl J Med 1985. Gibbons G. 60:18. Fisher S. Cancer 1984. et al: Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. 8:261. Jensen T. 21. J Bone Joint Surg [Am] 1984. et al: Nutrition in orthopaedic surgery. Arch Phys Med Behabil 1989. et al: Natural history of the leg amputee. Frei E: Osteosarcoma-Fifteen years later. Gonzalez E. Surgery 1974. Smith T. 256:80. Knighton D: Amputation prevention in a high risk population through comprehensive wound-healing protocol. Holstein P. et al: Objective criteria accurately predict amputation following lower extremity trauma. Johansen K. J Vasc Surg 1988. 2:220.oandplibrary. Hunt T: Wound healing and the diabetic patient. Am J Surg 1977. et al: Limb salvage versus amputation: Preliminary results of the mangled extremity severity score.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library 65:363. 149:397. J Bone Joint Surg [Am] 1982. 37. Surg Gynecol Ohstet 1979. Dovcette M. Corcoran P. Siembiedig C: Non-invasive prediction of amputation level in diabetic patients. 46. 38. Johansen K. 30. 60:747. Howe H. 85:461. Eldridge J. 133:459. 8:428. et al: Improvement of amputation level by lower extremity revascularization. 313:1637. 55:111. et al: Salvage of lower extremities following combined orthopedic and vascular trauma: A predictive salvage index. Ann Intern Med 1976. Zorn R. Circulation 1967. Surg Gynecol Ohstet 1981. Joshi R. 149:600. Surg Gynecol Ohstet 1978. et al: Amputation: Energy cost of ambulation. 36:83. 21:456 45. Enneking W. 54:2695. 60:731. Bartlett J Jr. Fry R. 42. Jackson R. 53:205. 114:1253. Alex M. Can Med Assoc J 1978. Holeding P: Major amputations following vascular reconstructions (including sympathectomy). 44. Clagett G. 256:80. Hansen F. Goldenberg S. J Vase Surg 1988. Conrad M: Large and small artery occlusion in diabetics and non diabetics with severe vascular disease. Ger R: Prevention of major amputations in the diabetic patient. 120:1317. Gregg K: Bypass or amputation. Coventry M: Osteogenic sarcoma: A study of 600 cases. Burgess E. 27. Fylling C. 74:1. 35. Muria J. Dickhaut S. J Bone Joint Surg [Am] 1978. 40. 153:707. et al: Oxygen inhalation-induced transcutaneous Po2 changes as predictor of amputation level. Ann Surg 1980. Harward T. Couch N. Johnson J: Reconstruction of the pelvic ring following tumor resection. Jorue T. Morton D: Advances in the treatment of sarcomas of the extremity: Current status of limb salvage. 66:71. Golbranson F. 25. Abelson H. 30:568. Eilber F. Clin Orthop 1990. Dahlin D. Volny J. Tally F. Moore N. 24. Page C: Nutritional status: Importance in predicting wound healing after amputation. 41. Wheelock F. Acta Orthop Scand 1979. Arch Phys Med Behahil 1979. 70:78. Eilber F. Lassen N: Wound healing in below knee amputations in relation to skin perfusion pressure. 22. 76:992. J Trauma 1990. Tilney N. Jensen J. 19. 31. Fisher D. et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Arch Phys Med Behahil 1974. 23. Arch Surg 1979. 146:750. 33. Grant T.asp[21/03/2013 21:53:15] . Huang C. Poole G. Arch Phys Med Behahil 1978.org/alp/chap03-01. Hunter G. Diabetes 1959. 64:1263. Sager P. Salzman E. J Invest Dermatol 1980. Darnes M. 34. 49. 29. Cohen S. Krajbich I: Amputation stump lengthening with the Ilizarov technique: A case report. Holloway G: Cutaneous blood flow responses to injection trauma measured by laser Doppler velocimetry. 192:431. Durham W: Resection and reconstruction for primary neoplasms involving the innominate bone. Goorin A. 28. et al: Is amputation necessary for sarcomas? A seven year experience with limb salvage. 32. 47. Bernhard V. 54. Am J Surg 1989. 229:236. 45:3040. 76. Lee B. 115:168. 55. Moore T. Wagner F. et al: Osteogenic sarcoma. 83. Am J Surg 1970. Kostuik J. Becke G: The geriatric amputee. Lange R: Limb reconstruction versus amputation decision making in massive lower extremity trauma. J Bone Joint Surg [Am] 1976. Veazez C.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library 51. Shoemaker W: Prediction of below knee amputation wound healing using noninvasive laser Doppler velocimetry. J one Joint Surg [Am] 1971.org/alp/chap03-01. Smith R. 159:418. Green S. 56. Surg Gynecol Ohstet 1979. Kavner D. J Bone Joint Surg [Am] 1970. 59. J Bone Joint Surg [Am] 1988. et al: The relationship of transcutaneous Po2 and laser Doppler measurements in a human model of local arterial insufficiency. Wood D. 238:219. Clin Orthop 1986. et al: Isolated profunda-plasty for limb salvage. et al: Prevention of amputation by diabetic education. March 1963.oandplibrary. 57. 65. Arch Surg 1980. Barron J. 74. Kihn R. Mazet R. Surg Gynecol Ohstet 1974. Kwasnik E: Limb salvage in diabetics: Challenges and solutions. Kraeger R: Amputation with immediate fitting prosthesis. Cancer 1980. Lane J. Moore T. Clin Orthop 1989. Matsen F. Wyss C. Dunn O. Rosen G: En bloc resection for osteogenic sarcoma. A review of 145 preoperative cases. 69. Mike V. Otteman M. Marcove R. J Bone Joint Surg [Am] 1976. 82:843. et al: Non-invasive hemodynamic evaluation in selection of amputation level. 64:769. Harsh B. Oishi C. Clin Orthop 1982. et al: The Influence of Prosthesis Wearing on the Health of the Geriatric Amputee. Larsen F. 75. McMurray J: Wound healing with diabetes mellitus: Better glucose control for better wound healing in diabetes. 204:93. Pinzur M. Perdue G. et al: Osteogenic sarcoma under the age of 21. Fronek A. Moore T. J Trauma 1989. 139:257. Schiller F. South Med J 1987. et al: Comparison of post-operative stump management: Plaster vs soft dressing. Marcove R. 61. et al: The below knee amputation for vascular disease. 53:481. Anderson G. Mazet R: The geriatric amputee. Golbranson F: The role of noninvasive vascular studies in determining levels of amputation. 158:29. 107:798. 70. 66:305. Christiansen J. 176:305. Clin Orthop 1989. Stahlgrew L: Evaluation of factors which influence mortality and morbidity following major lower extremity amputation for atherosclerosis. 11:33. Harvey J. LoGerfo R. Arch Surg 1973. Hutchinson F. Osterman H: Psychologic testing in amputation rehabilitation. Surg Gynecol Ohstet 1987. 79. 58:365. Mooney V. 311:1615. Hale A. 58.asp[21/03/2013 21:53:15] . 53. 72. 67. Snyder M. Hansen S. Tourfort W: Clinical experience with allograph implantation: The first ten years. Moore W: Determination of amputation level: Measurement of skin blood flow with 133 xenon. Clin Orthop 1988. 78. Barron J: The use of quantitative bacterial counts in open fractures. Boland P. 82. Towne J. Ann Surg 1972. Grahm G. McBride E. et al: Revascularization for severe limb ischemia. 77. J Trauma 1985. 71. Bach A. Law D. Moore W. 97:886. Appel P. Shaw W: Reconstruction of the lower extremity with microvascular free flaps: A 10 year experience with 304 consecutive cases. J http://www. 248:227. 158:520. Coffman J: Vascular and microvascular disease of the foot in diabetes. N Engl J Med 1984. Surg Clin North Am 1986. Mauney C. 52. 243:92. 62. 25:203. California Office of Vocational Rehabilitation. Ebskov B: Prevention and treatment of ulcerations of the foot in unilaterally amputated diabetic patients. Artif Limbs 1967. 73. Dudrick A. Malone J. Hajek L Jr. Lange R. Kram H. Clin Orthop 1989. Rollins D. Waddell J. Mankin H. Arch Surg 1968. 29:1086. Abdow N: The effects of protein calorie malnutrition on immune competence of the surgical patient. 63. Surg Clin North Am 1984. 81. 120:1217. Warren R. 66. Mooney V. 80. et al: The measurement of skin blood flow in peripheral vascular disease by epicu-taneous application of 133 xenon. et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. 64. 58:833. Trainor F. Hornby R. Surg Gynecol Obstet 1965. 70:1520. 120:634. 149:2241. Garland D: Severe trauma to the lower extremity: Long term sequelae. Khouri R. Am J Surg 1989. Acta Orthop Scand 1982. Sacramento. et al: Prosthetic usage following major lower extremity amputation. Robertson C. 60. 52:411. 162:175. 53:241. Project 431. Doppelt S. Wylie E: Below knee amputation for vascular insufficiency. 68. Am J Surg 1975. J Bone Joint Surg [Am] 1985. Surg Clin North Am 1986. 142:110. Steers J. J Bone Joint Surg [Am] 1983. Waters R. 67:800. Strandress D. Perry J. 64:880. et al: Prophylactic antibiotics in amputation of the lower extremity for ischemia. 8:703. 86. Keushkerian S. 91. 129:495. Gibbons G: Combined clinical and pathologic study of diabetes and non diabetic peripheral arterial disease. Mauch H. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 3 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 94.org/alp/chap03-01. et al: Energy cost of walking of amputees: The influence of level of amputation. Keagy B. 93. 2:585. 65:599. Schlenker J. 85. J ase Surg 1988. Wagner F: Transcutaneous Doppler ultrasound in the prediction of healing and the selection of surgical level for dysvascular disease of the toes and forefoot. Chapter 3 . 92. 84. Towne J. Diabetes 1964. Am J Surg 1988. Volpicelli L. Stoney R: Ultimate salvage for the patient with limb-threatening ischemia. 88. Wagner W. Vergu M. Boeckstyns M. Am J Surg 1978. Wolkoff J: Major amputations after femo-ropopliteal bypass procedures. 136:228. 87. 13:366.oandplibrary. Horne J: The assessment of skin viability using fluorescein angiography prior to amputation. Tanzer T. Ann Surg 1965. J Bone Joint Surg [Am] 1976. Stablgren L. Ann Plast Surg 1988. et al: Noninvasive determination of major lower extremity amputation healing: The continued role of clinical judgment. J Bone Joint Surg [Am] 1982. D'Amore T: Microvascular free tissue transfer after arterial revascularization in the elderly: An alternative to amputation. Sonne-Holm S. Prosthetic.3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library Vasc Surg 1985. Priest R.asp[21/03/2013 21:53:15] . 95. 89. et al: A comparison of diabetics and nondiabetics with threatened limb loss. 21:348. Rollins D: Profundaplasty: Its role in limb salvage. Contact Us | Contribute http://www. 90. 66:403. 96. Thomas J. 58:42. Kolb J.Atlas of Limb Prosthetics: Surgical. 162:886. Clin Orthop 1979. 156:481. Chambers R. Otteman M: Review of criteria for the selection of the level for lower extremity amputation for arteriosclerosis. Antonelli D. Wagner F: Ambulation levels of bilateral lower extremity amputees. or angry. and Rehabilitation Principles. and prescriptions were therefore extremely specific. The American Board for Certification in Prosthetics and Orthotics. The AAOP provides numerous national and regional meetings. C. Training in limb prosthetics has advanced from apprenticeship programs without formal academic standards in the 1940s to the present requirements for a baccalaureate degree. PROSTHETIST'S ROLE AND PRACTICE The prosthetist of today is a highly skilled individual who must meet significant educational and professional standards prior to obtaining board certification. and increased difficulty in dealing with third-party payers. national certification examinations. and board certification in prosthetics is usually required if the rehabilitation programs are to receive national accreditation. whose members must be certified by the ABC. Most patient referrals come directly from orthopedic. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Methods. federal and state cost containment programs. and well equipped. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Prosthetists work within the same constraints as other health care workers. (ABC). holds examinations. IL. The field of prosthetics in the United States is represented by three national associations. prostheses were relatively simple. is a certifying body that sets educational standards for prosthetists. Click for more information about this text. Large rehabilitation hospitals may have their own prosthetic and orthotic department or may contract with local private prosthetists and orthotists to have on-site provision of services. insurance carriers. Prosthetic. and recommendations by former patients. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.P. 1992. Prosthetic.oandplibrary. and many individuals achieve certification in both disciplines. and Materials | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 4 Chapter 4 . with the prosthetist given little latitude in exercising clinical judgement. In the period following World War II. many of the details regarding prosthetic configuration are now based on clinical results observed by the prosthetist during the dynamic alignment procedure. Referrals also come from physical therapists. withdrawn. Patient education and counseling can come from several http://www. it is important to inform the patient as early as possible about future rehabilitation. Rosemont. The prosthetists role in the rehabilitation team has become more significant as a result. reprinted 2002. Given the complexity of todays componentry.Atlas of Limb Prosthetics: Surgical. and accredits facilities that are accessible.O. The field of orthotics is closely aligned with prosthetics. and Materials Michael J. physical medicine. it is unusual when amputation seems to have no effect on the persons attitude. Quigley. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. edition 2. The third association is the American Academy of Orthotists and Prosthetists (AAOP). It is not unusual for the recent amputee to become depressed. The prosthetists function as a consultant to rehabilitation programs and hospitals is also now more clearly defined.org/alp/chap04-01. and Rehabilitation Principles Prosthetic Management: Overview. and produces a number of publications including the Journal of Prosthetics and Orthotics. in fact.4: Prosthetic Management: Overview. including the ubiquitous problems of rising malpractice insurance costs. The American Orthotic and Prosthetic Association (AOPA) was founded shortly after the turn of the century and deals with business issues. ©American Academy or Orthopedic Surgeons.asp[21/03/2013 21:53:21] . clean. PATIENT EDUCATION AND ORIENTATION When amputation of a limb is being considered. maintains a mandatory continuing education program. The vast majority of prosthetists are small businessmen or employees of small businesses. and mandatory continuing education. Prosthetic. American Academy of Orthopedic Surgeons. supervised internship. Inc. Reproduced with permission from Bowker HK. and vascular physicians. maintains records. Methods. published jointly with the AOPA. This is sometimes referred to as an early postsurgical fitting (EPSF). by definition. including how long the preparatory prosthesis will be used and when the evaluation for a definitive prosthesis will occur. Whenever a new patient is seen. definitive. the EPSF is generally directly molded on the residual limb by using plaster of paris or fiberglass bandages. in many cases they still have not been informed of the entire process and are confused by the number of health care professionals in attendance. Unfortunately. and this can enhance the overall outcome. but a much smaller number will receive special-purpose prostheses for showering or for swimming and other sports. Such devices are used during the acute phase of healing. both the prosthetist and a support group should be contacted immediately following amputation because each can provide the patient with valuable information. postoperative fittings are currently most commonly prescribed for the younger. The prosthetist frequently has written information on prosthetic options and rehabilitation and can often demonstrate various types of prostheses to the patient or patient's family. elastic bandaging. generally from 1 to 4 weeks after amputation. nurse. An explanation of the different stages of the rehabilitation process is in order. Its use in the elderly or dysvascu-lar individual is controversial but can be successful when meticulous technique and close supervision are available. provided within 24 hours of amputation. An early visit by the prosthetist can also be helpful. Preparatory Prosthesis http://www. only selected amputees will receive the postoperative or initial prostheses. but they are now better organized and more widely available. Many amputees are seen in a prosthetic clinic setting 1 or more months following their amputation. or individuals such as the prosthetist. and special-purpose prostheses. Amputee support groups usually have special training sessions for their members to ensure that the initial visit with a new amputee will be a constructive one. When the amputee is ready for prosthetic fitting. Although progression through all five levels may be desirable. or infection. which are directly molded on the residual limb. trauma. including a formal clinic. Whenever possible. Methods. or social worker. Initial Prosthesis The initial prosthesis is sometimes used in lieu of a postsurgical fitting and is provided as soon as the sutures are removed. Due to the usual rapid atrophy of the residual limb. Postoperative and initial prostheses are most commonly used in rehabilitation units or in hospitals with very active amputee programs. until the suture line is stable and the skin can tolerate the stresses of more intimate fitting.4: Prosthetic Management: Overview. or prosthetic shrinkers is employed to speed the maturation of the residual limb. Amputee support groups are not new in the United States. preparatory. The amputee tends to develop confidence in the person willing to spend the time to provide a clear explanation of the rehabilitation process. These are often referred to by various acronyms including immediate postsurgical fitting (IPSF) and immediate postoperative prosthesis (IPOP). Most support groups have two purposes: (1) to introduce the recent amputee to realistic role models who have gone through the rehabilitation process and are functioning normally in society and (2) to provide ongoing social and educational programs. TYPES OF PROSTHESES There are five generic types of prostheses: postoperative. initial. it is best for the prosthetist to assume that no one has yet explained the process and to offer a concise overview of the prosthetic procedures about to begin. Postoperative Prostheses Postoperative prostheses are. Most amputees will have preparatory and definitive prostheses. additional orientation information should be offered.org/alp/chap04-01. such as "Is a prosthesis worn to bed every night?" or "Are special orthopedic shoes needed whenever the prosthesis is worn?" The prosthetist can also be certain that preprosthetic management with rigid dressings. an amputee support group. An alternative is to use a weight-bearing rigid dressing such as the technique reported by Wu. The prosthetist can also answer many of the basic questions.asp[21/03/2013 21:53:21] . Although technically feasible for virtually any amputation.oandplibrary. and Materials | O&P Virtual Library sources. healthier individual undergoing amputation due to tumor. or health problems. he may be wearing ten plies of prosthetic socks to compensate for atrophy. There are sports-related amputee organizations in every major city in the country.org/alp/chap04-01. special types of feet or suspension. after 3 months. usually incorporates definitive-quality endoskeletal componentry but lacks the protective and cosmetic outer finishing to reduce the cost. particularly one that is used during every waking hour. swimming. but that time can vary depending on the speed of maturation of the residual limb and on other factors such as weight gain. Originally. or weight loss. or any special weight-bearing problems that may arise. with the greatest participation in golf and snow skiing. the preparatory prosthesis was a very rudimentary design containing only primitive components. the amputee wears prosthetic socks over the residual limb for the same reason that people wear socks when wearing shoes: the textile fibers provide cushioning and comfort. Definitive Prosthesis The definitive prosthesis is not prescribed until the patients residual limb has stabilized to ensure that the fit of the new prosthesis will last as long as possible. weight loss. GENERAL PRESCRIPTION GUIDELINES http://www. the fit has degraded sufficiently that socket replacement should be considered. They are also used in marginal cases to assess ambulatory or rehabilitation potential and help clarify details of the prosthetic prescription. it is usually an indication that the definitive prosthesis can be prescribed. Special-use prostheses can be valuable to the amputee who wishes to expand his activities and participate in a full range of sports and recreational pursuits. weight gain. Snow skiing prostheses require an increase in dorsiflex-ion at the ankle and may incorporate additional knee support or auxiliary suspension. The information learned during those months will demonstrate to the clinic team the patient's need for a lightweight design. Most require specialized alignment.oandplibrary. The new amputee may begin by wearing one thin prosthetic sock in the preparatory prosthesis. It is most economical if special-use devices are prescribed at the same time as a definitive replacement is necessary since both can be fabricated from the same positive model. Substantial changes in the amputee's life-style or activities may also dictate a change in the prosthetic prescription. Methods. The modern preparatory limb. and limited gait training is started at that point. The average life span for a definitive prosthesis is from 3 to 5 years. Different types of knee mechanisms or other components can be tested to see whether individual patient function is improved. Special-Use Prostheses A certain number of patients will require special-use prostheses designed specifically for such activities as showering. however. Preparatory prostheses are generally used for a period of 3 to 6 months following the date of amputation. Unless a suction socket is used. and Materials | O&P Virtual Library Preparatory prostheses are used during the first few months of the patient's rehabilitation to ease the transition into a definitive device. Most are replaced due to changes in the amputee's residual limb from atrophy. which decided several years ago to reimburse patients for the cost of special-use prostheses. and absorb perspiration. Once the amputee is wearing ten plies of prosthetic socks. The preparatory prosthesis accelerates rehabilitation by allowing ambulation before the residual limb has completely matured. An additional advantage is the ability to accommodate minor volume fluctuations by wearing more or fewer layers (plies) of prosthetic socks. Preparatory prostheses may be applied within a few days following suture or staple removal.4: Prosthetic Management: Overview. take up shear forces. The definitive prescription is based primarily upon the experience the patient had when using the preparatory prosthesis. or skiing. swimming prostheses are made waterproof and aligned so that the patient can walk without a shoe. Overall physical condition is also a factor since the more debilitated individual generally requires a very lightweight and stable prosthesis. In some cases the foot can be plantar-flexed and have a swim fin attached. The value of amputee sports and recreation has been recognized by the Veterans Administration.asp[21/03/2013 21:53:21] . ( Fig 4-1 ). For example. When the number of plies of prosthetic socks the patient must wear remains stable over several weeks. A definitive prosthesis is not a permanent prosthesis since any mechanical device will wear out. It allows the therapist and prosthetist to work together to optimize alignment as the amputee's gait pattern matures. For example. on the other hand. components. suspension. the person with good strength and balance does not require a stance-control knee. ranging from very basic leather belts to sophisticated suction sockets. suspension. primarily depending on the need for lightweight or sophisticated componentry. the weight-bearing characteristics of the socket are the first concern. Methods. Due to the large and expanding number of options now available in prosthetic componentry. The prosthetist's physical examination should be very detailed and record such factors as adherent scar tissue and neuromas. Sophisticated componentry such as hydraulic knees will increase the cost of the prosthesis as well. -Components need to be matched with the amputee's activity level. Cultural background is also significant. 4. PATIENT EVALUATION It is important for the prosthetist to thoroughly evaluate the amputee before starting to design the prosthesis. Activity level influences weight bearing. while someone who intends to compete in the Boston marathon would require an artificial foot designed for a high activity level.oandplibrary. and circumferences are taken at intervals ( Fig 4-2 ). the exoskeletal prostheses are more durable since the foam coverings of the endoskeletal designs tear easily and need replacement at intervals. Unique considerations. activity level. Each feature of the prosthesis should be considered carefully to provide the most cost-effective solution that fully meets the needs of the individual amputee. It is important to review any previous experience with other suspensions to determine the optimum recommendation. anticipated volume change in the residual limb is a key factor. Asian amputees require a foot that allows the shoes to be removed easily when entering a home since that is customary. Expense. Lightweight prostheses are often made from titanium or carbon fiber. Weight bearing. 2. For very active patients. A careful personal history helps identify the likelihood of weight fluctuations as well as medical factors that may have a bearing on prosthetic fitting. Measurements are then taken of both the residual limb and sound limb. any visual impairments. -A person using the prosthesis only indoors obviously presents different considerations from someone who anticipates being active in his job and in competitive sports. Prosthetic components. Obviously.4: Prosthetic Management: Overview. neuromas. and muscular development. body weight. 6. They are becoming increasingly popular because of the inter-changeability of componentry for trial or repair. Special impactabsorbing materials may be used. the finish carpenter needs more comfort from the prosthesis in the kneeling position than the average wearer does. which may increase the cost of componentry 50% and more. in a trans tibial (below-knee) prosthesis. and structural strength of the prosthesis. including weight bearing. 7.asp[21/03/2013 21:53:21] . 3. -The expense of a prosthesis may vary greatly. These will be discussed in order. a thigh corset might be considered if weight bearing causes severe problems with the residual limb. specific provisions must be made in the design of the socket. Exoskeletal prostheses. edema. -Many patients present unique factors that need to be considered in the design of the prosthesis.-There are two basic structural types: endoskeletal and exoskeletal. -There are many methods of suspension. someone who lives near the ocean may need a prosthesis designed with maximum protection from salt corrosion and water damage. Structure of the prosthesis. Activity level. aerospace materials that are both expensive to obtain and difficult to manufacture. close consultation with the prosthetist is imperative. 1. such as previous fractures. and the presence of concomitant disease including arthritis or diabetes.org/alp/chap04-01. expense. For example. and the good appearance they offer. Those who http://www. and certain unique considerations. Each alternative must be evaluated individually. 5. their relatively light weight. or modifications may be necessary to spread the load over a greater area. En-doskeletal prostheses consist of internal tubes and components covered with a soft foam outer cover. Such personal factors must be added to the more generic factors discussed previously to ensure the proper match between prosthetic configuration and amputee goals. or sensitive areas. Suspension. If the patient has scarring. and functional goals. consist of wood or polyurethane covered with a rigid plastic lamination.-For lower-limb prostheses. range of motion. general prosthesis structure. and Materials | O&P Virtual Library There are many factors to be considered when a new prosthesis is prescribed. The length of the residual limb is measured. In prosthetics.oandplibrary. which hardens to form an accurate positive model of the patients limb. it also simulates the socket design and provides alignment information. Other http://www. and Materials | O&P Virtual Library are being evaluated for powered upper-limb prostheses will have myoelectric control sites identified by electromyographic (EMG) testing. flare of the tibia. 3. A carver that reads the modified computer image of the patient's residual limb and carves a rectified plaster model. the impression procedure provides much more than simply a model of the patients limb. COMPUTER-AIDED DESIGN/COMPUTER-AIDED MANUFACTURING An alternative method of socket design and fabrication is beginning to enter clinical practice: use of the microcomputer to automate repetitive portions of the fabrication process. pretibial muscles. in the transtibial (below-knee) prosthesis. A digitizer that converts information from the negative impression of the patient's residual limb into numerical data that are read by the computer. When combined with an accurate physical examination and personal history. or digitizing arm. The impression is generally taken in a specified position and is usually handmolded by the prosthetist to more clearly define key anatomic landmarks.org/alp/chap04-01. Judicious addition or subtraction of material relieves the bony prominences and tender areas while increasing pressure to more tolerant areas such as soft tissue and broad expanses of bone or tendon ( Fig 4-3 ). For example. Once the measurements are completed. With proper modification. and patella. a negative impression of the residual limb is obtained. This digitizing arm is attached directly to the computer and converts the location of each landmark into numerical data as it slowly spirals upward and records the dimensions of the entire negative impression ( Fig 4-4 ). which holds it in a centered position. the impression forms the foundation for prosthetic design. which is a gelatinous material commonly used for dental molds. fibula head. A software system that provides a visual image of the patient's residual limb on a video screen. hamstring tendons. A probe. and the calf musculature. Conversely. the most practical method of converting information about the residual limb into data that the computer can understand is by taking an impression of the patient's residual limb with plaster or fiberglass and then placing this impression in the digitizer machine. distal portion of the tibia. the prosthetist can create a comfortable and stable socket with good suspension characteristics and can relieve any particular problem areas that the patient has experienced in the past. The purpose of the casting fixture is to preshape the soft tissue so as to result in a negative impression that more closely resembles the finished prosthetic socket. pressure is relieved by adding material in the following areas: tibial crest. POSITIVE MODEL RECTIFICATION The positive model of the residual limb is rectified or modified by the prosthetist to improve the pressure distribution. Some specialized impressions are taken by using alginate. is then used to locate and identify different landmarks in the negative impression. Methods. pressure is increased by removing material at the following areas: patella tendon. Proper angulation for initial static alignment of the prosthesis is recorded by using plumb lines drawn onto the negative impression. Current computer-aided design/ computer-aided manufacturing (CAD/CAM) systems consist of three major components: 1.asp[21/03/2013 21:53:21] .4: Prosthetic Management: Overview. especially for the transfemoral (above-knee) amputee. A number of fixtures have been specifically developed for taking this impression. In summary. It is sealed and filled with liquid plaster. Computer Input Presently. partial-hand and -foot amputations are often molded in alginate rather than plaster. popliteal area. Positive model modification is a difficult and time-consuming procedure requiring much skill on the part of the prosthetist. IMPRESSION PROCEDURE The hollow plaster or fiberglass cast of the residual limb creates the negative impression. 2. but it can also be viewed as if it were a solid model. Methods. but in most cases holes are drilled in the socket at strategic areas such as over bony prominences or areas critical to suspension. test socket fitting is recommended to ensure that the socket fits the patient optimally before it is attached to an artificial limb. it is a logical development that parallels related advances in other professions. TEST SOCKETS Regardless of the method chosen for rectification and manufacturing of the socket. or the test socket may be attached to the components of the prosthesis. Test sockets are made over the modified positive model from a number of materials. Although this first generation of CAD/CAM in prosthetics is very basic. When weight-bearing test sockets are fitted. The extremely high cost of CAD/CAM systems will only be justified if it can be proved that they can provide the patient with a very well fitted prosthesis while saving time for the prosthetist and increasing his productivity and skills. it is likely that such information will be commercialized in the future. Although prosthetists presently freely trade disks of information regarding the modification techniques that they have developed on the computer. Comfort 2. Computer-Aided Manufacturing Once the prosthetist is satisfied with the socket design. Recently.4: Prosthetic Management: Overview. The patient is instructed in the use of prosthetic socks (when applicable).oandplibrary.asp[21/03/2013 21:53:21] . This should reduce the cost of this new technology since the highly expensive carving and manufacturing equipment can be amortized by a large number of prosthetists. Computer-Aided Design Once the digitized impression of the residual limb is in the computer. The replica is generally shown as a wire frame drawing that gives a good three-dimensional perspective. Areas of excessive or inadequate pressure can also be noted by observing the amount of compression to the weave of the prosthetic sock or by the presence or absence of skin blanching if no sock is being worn. computer.org/alp/chap04-01. The following four factors are evaluated during the test socket fitting: 1. and these are put on the patient's limb before the socket is applied. When the test socket is filled with plaster to create a new positive model. During the test socket fitting. Suspension http://www. The prosthetist then modifies the image by sketching the desired changes on the screen by using either a mouse or keyboard control ( Fig 4-5 ). the prosthe-tist will frequently split the socket to make volume adjustments or will heat-modify and trim away portions of the socket. a numerically controlled milling machine can be used to carve the rectified plaster model from a blank ( Fig 4-6 ). Reference marks are made in those areas that cannot be fully relieved during the test socket fitting. Several methods may be used to evaluate the socket fit. The socket is then fabricated in the conventional manner or with a semiautomated machine ( Fig 4-7 ). Future generations of CAD/CAM systems may change the face of prosthetics because the use of a computer enables those with fewer manual skills to make properly fitting sockets. Even distribution of weight-bearing pressure and biomechanical forces 3. CAD/CAM systems in prosthetics were introduced in the mid-1980s and were not used on a clinical basis in the United States until the early 1990s. the socket is placed on an adjustable stand and raised to the proper level so that the patient can bear equal weight on both limbs. several central fabrication companies have purchased the extremely expensive carving and socket manufacturing equipment so that a prosthetist need only purchase the digitizer. the prosthetist can look at an exact replica of the patients residual limb on the computer screen. the prosthetist can modify the mold in this area to ensure proper fit. and software. and Materials | O&P Virtual Library systems are presently under development that utilize light sources or ultrasound to obtain an image of the residual limb in the hope of obviating the need for a plaster or fiberglass impression in the future. blunt rod to determine local skin pressures. a transparent plastic is the most common choice ( Fig 4-8 ). A separate appointment is usually necessary for test socket fitting. The tissue is then probed with a small. No matter how sophisticated the components are. The suspension is tested. 3. including the use of prosthetic socks. they are sometimes referred to a physical therapist for initial gait training prior to completion of dynamic alignment. The new amputee can then practice with the prosthesis. 2. cable attachments. such as how to use the prosthesis while driving a car and during sports activities and dancing. 7. FOLLOW-UP Proper patient follow-up is of critical importance in prosthetics. therefore. and further adjustments can be made as endurance and ability to use the prosthesis improve. Socket design and alignment complement each other and are the fundamental determinants of prosthetic function. More experienced individuals are usually able to provide accurate feedback concerning how the prosthesis fits and feels during walking. It is often useful for the amputee to return to the therapist following fitting with the definitive device to further refine his prosthetic skills (see Chapter 23).4: Prosthetic Management: Overview. and cosmesis ( Fig 4-10 ). The patient begins to use the prosthesis in a controlled manner by walking inside parallel bars or operating the terminal device. and irregular terrain. Patients will have many questions after wearing the prosthesis for a week or two. The prosthetist can then make adjustments in a rapid and accurate fashion. 5. and adjustments are made to increase comfort or function in this position as well. and Materials | O&P Virtual Library 4. These concerns can be http://www. Dynamic function of components is checked during use and adjusted to provide maximum efficiency.asp[21/03/2013 21:53:21] . Fitting and alignment of the prosthesis are not completed until both the prosthetist and amputee are convinced that the prosthesis is functioning as well as possible. Methods. and the amputee is instructed in how to don the prosthesis properly. The length and angulation of the prosthesis is checked. The therapist also helps the amputee master more advanced activities such as negotiating inclines. Static alignment of the components is refined ( Fig 4-9 ). The function of the prosthesis is explained. the overall function will be drastically reduced. or how carefully it is fabricated. a number of minor problems can occur during the first few weeks of prosthetic wear from pressure areas in the socket. and cosmesis by adjusting the relative position of the components while the patient is using the limb in a number of controlled situations. stairs.org/alp/chap04-01. the suspension and control harnesses. efficient function. For example. The patient is instructed to stand in a relaxed attitude while wearing the prosthesis. choosing the proper shoes. 4. how well the prosthesis is finished. or problems when wearing different shoes. Lower-limb alignment generally takes place within parallel bars in a private walking room in the prosthetist's office. also require additional time. Some patients may require more than one visit to optimize the alignment of the prosthesis since the more complex alignments may require several hours of adjustments and new patients are frequently not able to stand and ambulate for more than a few minutes at a time. if required. the prosthesis must be durable and functional but must also be adjustable in all planes. The following procedures summarize the basics of the alignment process: 1. they should be developing not only tolerance to pressures of the prosthesis against the skin but also general physical endurance. 6. In addition. The purpose of dynamic alignment is to provide maximum comfort. and the efficiency of various configurations is measured by the use of prehension gauges and force scales. however. 8. and forearm length are all adjustable. New amputees. Freedom of motion at the next proximal joint DYNAMIC ALIGNMENT Since each patient has a unique gait pattern and activity level.oandplibrary. and the fitting proceeds smoothly ( Fig 4-11 ). Contours are checked to ensure that the socket fits properly and comfortably. New amputees in particular require follow-up at frequent intervals. comfort. cannot always provide accurate feedback. During the alignment stage. dynamic alignment of the prosthesis must be done on an individual basis. and wearing the prosthesis to the beach. Generally. in an upper-limb fitting. Complicated cases. if it is malaligned or uncomfortable. of course. The prosthesis is checked with the patient sitting. discomfort while sitting. 1 week in physical therapy with the prosthesis will afford adequate time for the prosthetist to make decisions concerning the final alignment. but in many cases more extensive modifications are required. must be cleaned and adjusted on a regular basis because they directly affect the function of the prosthesis. thereby redistributing the forces. Since "horsehide" will stretch easily with wear. inexpensive. In some cases. minor alignment changes can be made to further reduce discomfort or pressures. Whether natural or man-made.4: Prosthetic Management: Overview. cushion-heel (SACH) feet have an interior hardwood keel that provides structural strength to the foot. are used for a variety of purposes in prostheses from such things as dorsiflexion stops in single-axis feet to laces for leather thigh corsets. leather. varying the thickness or ply of the prosthetic socks will improve the fit of the prosthesis. elk. willow. Hardwoods are not used in areas where the prosthetist might make an adjustment since the inherent strength of these woods makes them very difficult to reshape. Therefore. particularly during the first month of wearing a new prosthesis. Patients should be seen. Maple and hickory are commonly used for keels in prosthetic feet and to reinforce high stress areas of prosthetic knee units. and poplar wood are most commonly used for prosthetic knees and shins because they are lightweight. they must still conform to the special requirements of the profession: biocompatibility. Methods. Many years ago hides were available from horses. has a soft natural feel.) thick to reduce weight. Solid-ankle. Some components. it is hollowed out until the wood is only 6 mm (1/4 in. but today cowhide is modified by the tannery to provide the same feel and working properties as the hides of other animals. Such information will help guide future decisions regarding socket or component modification and prosthetic design. Other variations such as elk. however. every 4 to 6 months. strong. The inherent properties of wood make it a very difficult material to replace: it is lightweight. Socket adjustments are made only after a careful analysis of the cause of discomfort is completed by the prosthetist. Leather is easy to work with. The most common materials used in prosthetics today are various plastics. The prosthetist then has two choices: relieving the pressure area by removing material from the socket over the area of pressure or adding material elsewhere. strength. When a prosthesis is finished. as well as cattle. it must be reinforced with another material such as cowhide or synthetic fabric. In some cases.org/alp/chap04-01.oandplibrary. Changes in the volume or shape of the patient's residual limb will frequently require socket adjustments. it is used to line waist belts. The prosthesis contains many moving mechanical components that require cleaning. http://www. This keel is bolted to the rest of the prosthesis and provides a strong anterior lever arm when the amputee stands and walks. therefore. suspension straps. and rawhide. Basswood (linden). particularly joint mechanisms. calf. MATERIALS A wide variety of natural and man-made materials are used in prosthetics today. Hardwoods are also used in lower-limb prosthetics. kip. The properties of "horsehide" make it a very attractive material to use when the leather is to contact the skin. waist belts. light weight. metal. and consistent in texture. strong. and ease of fabrication. Wood Wood is often used in lower-limb prostheses to provide shape and interior structural strength. and socket linings. deer. easy to work. soft flexible properties of the original horsehide. and Materials | O&P Virtual Library easily corrected during a follow-up visit. "horsehide" is actually cowhide that has been treated to provide the thin. and is biocompatible. and free from knots and can be shaped easily by using standard woodworking tools. Leather Leather is another material still commonly used in prosthetics for suspension straps.asp[21/03/2013 21:53:21] . at the very minimum. Plastics such as Naugahyde and thermoplastic foam have replaced leather in some applications but will probably never completely replace this readily available biological material. or replacement at intervals. and cloth still have a role to play. but the more traditional materials such as wood. It is important for the prosthetist to keep a good record of all follow-up adjustments. maintenance. durability. and inserts for patellar tendonbearing (PTB) sockets. and harnesses for upper-limb prostheses. Probably the greatest use of cloth is for prosthetic socks. durable. waist belts. cotton. knee joints. which makes it more practical for many uses. pliable.oandplibrary. straps. however. elasticity. Acrylic resin is increasingly popular for laminations in prosthetics because its high strength permits a thinner. and a promoting chemical is added to speed up the setting time. which can be considered analogous to athletic socks since they keep the skin dry. is easier to care for and less expensive than wool. and Materials | O&P Virtual Library Cloth Cloth is used for prosthetic socks. cushion the limb. Thermosetting plastics cannot be heated and reformed after molding without destroying their physical properties. This material can be welded by using hot air or nitrogen. The major advantages of this man-made fiber are its strength. but falls short of wool in all of its properties. acrylics. and some 100% cotton prosthetic socks are available. and nylon stockings to cover prostheses.asp[21/03/2013 21:53:21] . Polyester resin is a thermosetting plastic that is most commonly used for laminations in prosthetics. Polyethylene is an opaque white thermoplastic that looks like polypropylene but feels waxier. A thin sheath worn directly over the skin significantly reduces shear stresses and helps to pull moisture away from the skin into the outside prosthetic socks.4: Prosthetic Management: Overview. absorb shear forces. Nylon prosthetic sheaths are in common use for transtibial amputees. they do not yellow and have good weather resistance. Polypropylene is used for hip joints. The sock should be rinsed in lukewarm water as well since a change in temperature will affect it adversely. Nylon is a thermoplastic material. strong. however. or other man-made materials. suction valves. Acrylic fibers are frequently used in the newer synthetic blends for prosthetic socks since this material is soft. Cotton. or blends of these natural fibers often combined with nylon. Cotton is also blended with wool in prosthetic socks. and take up volume to improve the fit. The blend of domestic and foreign wool fleece used in prosthetic socks provides greater resistance to shrinkage. bushings. Polypropylene is used in great quantities in industry for everything from fan shrouds in passenger cars to carpets and shipping containers. Polypropylene sheets 1 to 9 mm (1/16 to 3/8 in. Polyester resins come in a liquid form that can be pigmented to match the patient's natural skin tone. The recent development of machine-washable wool should reduce the need for hand washing in the future. Acrylic resins tend to have a softer feel than polyester resins but are more difficult to use during fabrication. Orion.) thick are heated and vacuum-formed over the mold of a socket or complete limb. Wool prosthetic socks should be dried carefully by first removing the excess water. Methods. Prosthetic socks are commonly made of wool. and machine washable. Wool also has good resistance to acids from perspiration. and easy to mold. and low coefficient of friction. must be washed carefully in a mild soap that will dissolve in lukewarm water. Clear acrylics have been used for years in the sign and building industry for skylights and enclosures for shopping centers. and absorbent. cushioning. http://www. Three to eight layers of nylon are impregnated with polyester or acrylic resins during the lamination process to provide both structural strength and a pleasant appearance to the finished device. and then drying them away from sunlight or any other direct heat. wrapping them in a towel. which means that it can be heated and remolded without adversely affecting its physical properties. Cotton is a natural vegetable fiber that is soft. A benzoyl peroxide catalyst is then added to this resin to initiate the setting process. Wool is the most common material used for prosthetic socks because of its characteristic elasticity. Plastics Nylon is used for prosthetic sheaths. and ability to absorb moisture without feeling damp.org/alp/chap04-01. Acrylics are thermoplastics that have greater durability and strength than polyester resins do. A nylon stockinette provides inherent strength to nearly all prosthetic laminations ( Fig 4-12 ). and lightweight prostheses. Polypropylene is an opaque white material that is relatively inexpensive. pelvic bands. Cotton is also used for prosthetic socks but is more common in the form of a stockinette used to protect the limb during casting procedures. lighter-weight lamination and its thermoplastic properties allow easier adjustments of the prosthesis by reheating the plastic and remolding it locally. Pure wool. durable. plastic laminations. Although the gel adds weight and bulk to a prosthesis. Methods. Silicone is synthesized from sand (a combination of silicon and oxygen) and undergoes a number of chemical reactions before liquid or solid silicone results. Rigid polyurethane foams compete with wood in providing structural stability to knee units and ankle blocks. In addition to this high strength-to-weight ratio. The room-temperature-vulcanizing (RTV) silicones are used most widely in prosthetics. It is also used to stiffen thin areas and to prevent breakage in vulnerable areas. resist weathering. as the liquid inside hydraulic knee mechanisms. Silicone fluid is used for lubrication of moving parts.4: Prosthetic Management: Overview. are chemically inert. knee joints. FIBER REINFORCEMENTS Two basic types of high-strength fiber reinforcements are used in prosthetics today: glass and carbon.oandplibrary.org/alp/chap04-01. or resins. Polyurethanes. it is used for triceps cuffs in transradial (below-elbow) prostheses and for tongues in plastic thigh corsets and hip disarticulation sockets. rigid foam. The foam is shaped by the pros-thetist from measurements and tracings of the patients limb. SUMMARY Modern prosthetic care is far more complex and far more effective than was the case just a few decades ago. repel water. Silicones have relatively uniform properties over a wide temperature range. while sophisticated knee/ankle/foot mechanisms and myoelectrically controlled http://www. They are also being used by component manufacturers to replace metal. Fiberglass is commonly used to reinforce polyester resin laminations where mechanical attachments such as bolts and screws will fasten. Low-density polyethylene (LDPE) is very flexible and easy to heat and mold. so care must be taken to avoid exposed areas of this material. Prefabricated carbon fiber prosthetic components such as pylon tubes. Silicones can be classified as fluids. particularly those with burns or severe scarring. and elastomers. Silicones are used in prosthetics for distal end pads in sockets. A two-component silicone elastomer is used for foaming end pads in sockets while the patient is weight-bearing to ensure total contact. Polyurethane foams are widely used in prosthetics for both soft cosmetic foam covers ( Fig 413 ) and rigid structural sections. A plastic lamination covers the foam to provide additional strength and cosmesis. Ultrahigh-molecular weight (UHMW) polyethylene is sometimes used in partial-hand or partial-foot prostheses due to its tear resistance. elastomers. and Materials | O&P Virtual Library The properties of polyethylene vary depending on the density of the material. Flexible urethane foams are generally purchased in prefabricated pieces from suppliers as covers for en-doskeletal prostheses.asp[21/03/2013 21:53:21] . The added strength fiberglass provides is proportional to the amount used and also depends on the arrangement of the fibers relative to the stresses it must tolerate. and connectors can significantly reduce the weight of the prosthesis while increasing its strength. it has been proved to work well for many problem cases. Flexible polyurethane foams are also widely used in the manufacture of prosthetic feet. Lightweight endoskeletal devices allow clinical verification of the suitability of specific componentry or permit realignment as the new amputee's gait matures ( Fig 4-14 ). are available in three broad groups: flexible foam. Widespread availability of transparent test sockets allows more precise and more comfortable fittings. and for silicone gel insets. A unidirectional arrangement of fibers found in continuous-strand roving allows the best reinforcement if placed directly in line with the stresses. to provide a flexible rubberlike end in air-cushion sockets. Carbon fibers are generally set in epoxy and can provide a material with a stiffness twice that of steel at a fifth the weight. Prosthetists routinely use this foam to provide both strength and shape to exoskeletal prostheses. and have a high degree of slip or lubricity. Silicone gel-impregnated gauze is an excellent cushioning and force distribution material for weight-bearing prosthetic sockets. Carbon fibers are more expensive than fiberglass but have superior strength and stiffness. Fiberglass is difficult to finish smoothly. Multidirectional fibers such as woven mat or fabrics provide equal strength in all directions but are less effective when only one stress must be tolerated. carbon fiber composites have a fatigue resistance twice that of steel. or fiberglass. also called ure-thanes. and as a parting agent. aluminum. High-density polyethylene (HDPE) is more difficult to modify and is used to make bushings in joint mechanisms. and all three are used in prosthetics. 4: Prosthetic Management: Overview. Wu Y. Krick HJ. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 4 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . the traditional materials such as wood. Keagy RD. Special-use prostheses for sports and recreational uses are now available. Clin Prosthetics Orthotics 1978. 2.asp[21/03/2013 21:53:21] . et al: An innovative removable rigid dressing technique for below-the-knee amputation. Contact Us | Contribute http://www. J Bone Joint Surg Am 1979.oandplibrary. 61:724-729. Rehabilitation begins prior to amputation and continues as the amputee progresses from the postoperative or initial device to the preparatory and definitive designs.Atlas of Limb Prosthetics: Surgical. Although aerospace materials are increasingly common in prosthetic design. 2:33-44.org/alp/chap04-01. and Materials | O&P Virtual Library prehensors have increased the versatility of prosthetic devices. and leather still have a role to play. References: 1. Prosthetic. Wu Y. cloth. Krick HJ: Removable rigid dressing for below-knee amputees. Methods. Chapter 4 . E3 . The functional capacity of the upper limb is determined by the shoulder complex. all other joints being held in extension. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). the limb traces a small arc of displacement just enough for the elbow. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. and E4 . Any more distal point on the lower extremity or on the ground is reached through mobility provided by the hip. Maintaining the extremity in complete external rotation permits exploration of the outer half of the frontal circle with ease. Within this envelope. neck. the upper limb sweeps a circular surface in the frontal plane. whereas with further external rotation from position 6 to 1. Reproduced with permission from Bowker HK. Prosthetic. edition 2. The elbow action dissipates. Prosthetic. a distant point in space comes within the reach of the upper-limb action through a functional integration with gait. From position 5 to 6 the shoulder externally rotates. E2 . and trunk ( Fig 5-1 ). and elbow functional capability in this plane reappears. In this second arc of motion the elbow explores the segment of the space through its action envelope E2 . The elbow envelope of action is clearly visible now in all positions ( Fig 5-2 ). A maximum arcuate field or envelope of action termed "Ex" ( Fig 5-2 ) is traced by the most distal point of the upper extremity through the motion of the shoulder complex. knee.oandplibrary. American Academy of Orthopedic Surgeons.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 5 Chapter 5 . the hand sweeps the space E3 . Prosthetic. and hand to sweep the surface corresponding to the gluteal area and up to the opposite scapular region. M. the motion is quite restricted ( Fig 5-4 ). the elbow action dissipates again. From position 3 the elbow envelope of action scans the posterior aspect of the head. reprinted 2002. and Rehabilitation Principles Kinesiology and Functional Characteristics of the Upper Limb Shahan K. The sweeping of the inner half of the coronal circle is now possible from position 4 to 5 through internal rotation of the shoulder. In the standing position the upper-limb field of motion reaches the midthigh region. the elbow. When the upper limb is maintained in neutral rotation at the shoulder. Given the normal proportion of limb segments. wrist. These contained capabilities enrich the functional performances of the upper extremity. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. SHOULDER COMPLEX Motion in the Frontal or Coronal Plane When the arm and forearm are held in the anatomic position. and Rehabilitation Principles.org/alp/chap05-01. and the digits explore the interior of this space through E4 . The coronal plane is also explored posteriorly in the inner half space ( Fig 5-6 ). and hand developing multiple integrated spheres of action. and complete elevation is achieved at position 4. With a position of internal rotation at the shoulder. and hand develop their own fields of motion. the antecubital surface facing anteriorly. The very distal point of the extremity traces an envelope of action E1 ( Fig 5-3 ). Beyond position 3 the shoulder externally rotates. whereas any functional development in the inner half is very restricted. 1992. Sarrafian. If the wrist is initially held in neutral rotation. elbow. ankle. ©American Academy or Orthopedic Surgeons. Elbow action is possible from position 1 to 2. this capacity is limited in relation to the surrounding space. In position 1 the shoulder is in neutral rotation.Atlas of Limb Prosthetics: Surgical. and shoulder. Placement of the limb in complete internal rotation significantly restricts the field of motion ( Fig 5-5 ). Furthermore. and the extremity can be elevated in the outer half of the circle to positions 2 and 3. http://www.D. and no elbow action is possible in this plane. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. The elbow does not contribute to functional exploration in this segment of the arc of motion. Click for more information about this text.asp[21/03/2013 21:53:26] . IL. wrist. Rosemont. wrist. The teres minor reaches the maximum at 120 degrees and from there maintains the high level of activity. and subscapularis muscles ( Fig 5-9 ). The acromioclavicular and sternoclavicular joints also participate in a synchronized manner ( Fig 5-7 ). and posterior segment of the deltoid ( Fig 5-13 ). infraspinatus. The motor units responsible for scapulohumeral elevation are the middle segment of the deltoid muscle and the components of the rotator cuff: the supraspina-tus. and more humeral articular surface is offered to the opposing glenoid ( Fig 5-8 ). The upward stabilization in the frontal plane is also necessary for functional purposes. the scapula makes a downward rotation. and subclavius ( Fig 5-17 ). reaches a maximum at 110 degrees. The clavicle does not remain still. This motion is controlled by the serratus anterior and the pectoralis minor ( Fig 5-14 ). The latissimus dorsi and teres major also determine the associated internal rotation ( Fig 5-11 ). upper segment of the trapezius. During the anterior adduction-internal rotation. lower segment of the pectoralis major. it is adducted and internally rotated. From 0 to 30 degrees of elevation ( Fig 5-7 ) the motion occurs at the scapulohumeral joint. In the remaining arc of motion of 150 degrees. and diminishes rapidly in action. supplemented by the action of the coracobrachialis ( Fig 5-13 ). and the scapular motion is variable. When the upper limb is in a maximum position of elevation and is brought down in the frontal plane in the outer half circle. A combined acromioclavicular motion of 20 degrees occurs during the initial and terminal phases of elevation. the scapulohumeral (SH) joint motion and the scapulothoracic (ST) motion of upward rotation participate at a ratio of SH/ST=2/1 as measured in the frontal plane.org/alp/chap05-01. In the initial 90 degrees of motion the clavicle is elevated at the sternoclavicular joint for about 40 degrees. External rotation accompanies the elevation for the performance of a smooth motion. maintains a plateau level up to 130 degrees. When the upper limb moves in the lower and inner quadrant of the envelope of action E1 . This function is determined by the depressors of the shoulder complex: la-tissimus dorsi. They act on the scapula as a force couple ( Fig 5-12 ). This is controlled by the elevators of the scapula: levator scapulae. long head of the triceps. motion is determined by the scapulohumeral joint and scapulothoracic upward rotation.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library During elevation of the upper extremity in the frontal plane. and beyond this point its activity diminishes and traces a sine wave. whereas the infraspinatus increases steadily in activity from the initial position to that of full elevation. the limb is once more adducted and internally rotated. whereas the rotator cuff stabilizes the humeral head and acts as the lower vector force of the couple. The action of these two last muscles is necessary to continue the external rotation of the humerus during the last stage of the elevation. teres minor. The posterior adduction is brought about by the latissimus dorsi. indicates that the deltoid action Electromyographic study of these muscles ( Fig 5-10 ) potential increases steadily with elevation.oandplibrary. Adduction is determined by the latter two muscles. The internal rotation is brought about by the subscapularis. and maintains a plateau level of activity with a final peak at full elevation. the scapula is abducted. The deltoid acts as the upper vector component of a force couple. The motor units acting during upward rotation of the scapula are the upper and lower segments of the trapezius and the lower digitations of the serratus anterior. The supraspinatus also reaches a peak at 110 degrees. such as in crutch walking or parallel bar exercising. This is determined by the combined action of the latissimus dorsi. and the levator scapulae.asp[21/03/2013 21:53:26] . pectoralis minor. During this same motion. http://www. Beyond 90 degrees of elevation this external rotation is necessary to free the greater tuberosity from the acromial process. The total contribution of the scapulohumeral joint is 130 degrees. and anterior segments of the deltoid ( Fig 5-11 ). The posterior segment of the deltoid also participates as an external rotator ( Fig 5-11 ). lower segment of the trapezius. pectoralis major. lower segment of the pectoralis major (the pectoralis minor acting as the lower component for a force couple). When the upper limb moves in a similar lower and inner quadrant but posterior to the body. and rhomboidei ( Fig 5-18 ). as in carrying heavy loads on the shoulders. with the rhomboidei acting as the upper component of the rotational couple ( Fig 5-16 ). The subscapularis reaches peak activity at 100 degrees. the scapula is adducted by the middle segment of the trapezius and the combined action of the rhomboidei and latissimus dorsi( Fig 5-15 ). and in the second half of the arc of motion the clavicle rotates on its long axis for another 40 to 50 degrees. teres major. Downward stabilization of the limb in the frontal plane is also of important functional significance. This is the "setting phase" of the scapular motion. it then acts as an an-tigravity muscle. The baseline worker during extension is the medial head of the triceps. Beyond neutral the motion continues as extension. Without load being applied. this rotary capability changes to 90 degrees of external rotation and 70 degrees of internal rotation ( Fig 5-25 ). the distal point of the limb scans the horizontal plane and traces an arc of 165 degrees ( Fig 5-24 ). The brachioradialis and pronator teres are the accessory flexors ( Fig 5-26 ). latissimus dorsi. These last two reserve extensors come into play when resistance is applied to the motion of extension ( Fig 5-29 ). In position 3 the elbow action extends farther posteriorly. When the arm is elevated in the frontal plane. Motion in the Horizontal Plane When the upper extremity is elevated to 90 degrees in the frontal plane. There is an intricate interplay and a wide range of participation in the elbow flexors. the long head is not active. long head of the triceps. The pronator teres does not participate as a flexor unless resistance is encountered during flexion. The rotator cuff is also active in stabilizing the humeral head. with or without load applied to the flexing forearm ( Fig 5-27 ). It is also active in flexed elbow posture or during extension of the forearm. Further movement in the posterior half of the field is possible through the internal rotation of the shoulder followed by gradual external rotation to bring the limb to its neutral initial position ( Fig 5-20 ). and E4 . for example. of 150 degrees. The main flexors of the elbow are the brachialis and the biceps. The flexors and extensors of the scapulo-humeral joint control the motion. or flexion from position 1 to 3.asp[21/03/2013 21:53:26] . FOREARM ROTATION http://www. The extensor of the elbow is the triceps assisted by the anconeus ( Fig 5-28 ). Contributors to this motion are gravity and downward rotators of the scapula. coracobrachialis and clavicular head of the pecto-ralis major ( Fig 5-21 ). wrist. E2 . The brachialis is the baseline flexor and is active at any rotational position of the forearm and any speed.oandplibrary. and its activity is evident as soon as slight resistance is applied. ELBOW The elbow joint determines an arc of motion. Deactivation occurs when the forearm is pronated unless significant resistance is applied to the pronated flexing forearm. the distal point traces an arc of internal rotation of 80 degrees and an arc of external rotation of 60 degrees.org/alp/chap05-01. E3 . It is also a reserve flexor during flexion against resistance. The range of extension is 60 degrees ( Fig 5-23 ). whereas the lateral head is minimally active. the envelope of action E2 of the elbow is located in this plane if the shoulder is in external or internal rotation. Elevation of the upper limb. Rotary Capability of the Shoulder Complex When the upper extremity is held in the neutral rotational position at the shoulder and the elbow is flexed at 90 degrees. The elbow. and pectoralis major ( Fig 5-22 ). From the elevated position 3 the upper limb is brought down by the posterior segment of the deltoid. The scapulothoracic mechanism participates in the motion through upward scapular rotation at a ratio of SH/ST=2/1. The biceps is a flexor of the supine forearm. biceps. and hand are capable of functioning in this plane through their envelopes of action E2 . the hand reaching the posterior aspect of the shoulder. The brachioradialis is active when the forearm is flexing rapidly at any rotational position.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library Motion in the Sagittal Plane From a neutral rotational position the upper limb moves in the sagittal plane and sweeps the surface from position 1 to 3 ( Fig 5-19 ). especially in neutral rotation of the forearm. With the shoulder elevated 90 degrees in the frontal plane. The orientation of the plane of action is closely influenced by the rotational position of the shoulder joint. and all motors continue their action except the pectoralis major. is determined by the anterior segment of the deltoid. The biceps is minimally active as an antigravity muscle or in maintaining a static flexed position. The difference of 17 degrees indicates participation of the radiocarpal and midcarpal joints. In full pronation the styloid process then appears to be less distal relative to the head of the ulna. The forearm is pronated by the pronator quadratus and pronator teres ( Fig 5-32 ). and both flexion and extension are initiated in the midcarpal joint ( Fig 5-37 ). and the radiocarpal joint contributes 66.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library The average range of pronation-supination of the forearm with the elbow flexed at 90 degrees is 173 degrees measured at the level of the hand. When the rotation occurs along the oblique axis passing through the head of the ulna. The styloid process of the radius traces a large arc of motion ( Fig 5-30 ). The main pronator is the pronator quadratus. The hand then makes a circumferential transposition. the motion occurs around the axis passing through the head of the ulna and the little finger. The tension in the membrane is thus minimal in full pronation. The wrist flexes. The extensor carpi radialis longus and brevis are accessory supinators. The biceps is the reserve supinator and reinforces the action when fast supination is required or resistance is encountered ( Fig 5-35 ). the hand is in a position of minimal supination of 11 degrees. flex or carpi radialis and palmaris longus. WRIST The wrist acts as a universal joint. and proximal thirds of the forearm is the largest in neutral position and the smallest in full pronation ( Fig 5-31 ). The participation of the accessory pronators. The radiocarpal and midcarpal joints participate in this motion. the peripheral point of fixation through the finger or through a tool held in the hand determines the location of the axis of pronationsupination. The interosseous membrane uniting the radius and ulna relaxes or tenses during pronationsupination. The average arc of extension is 55 degrees and ranges from 31 degrees to 79 degrees. Starting from the position of supination.5% ( Fig 5-38 ). the elbow being held at 90 degrees flexion. In pronation the ulnar head is flexed and further displaced laterally. The scaphoid belongs anatomically to both rows. When the hand rests on its ulnar border on a surface and rotation is initiated. The midcarpal joint contributes 60% of the arc of flexion. the interosseous membrane is not the main element of pressure transmission to the elbow through the ulna. The average range of pronation is 62 degrees and ranges from 49 degrees to 84 degrees. It develops a spheroid type of motion envelope E3 ( Fig 536 ) that permits the hand to move without digital motion. During a fall on the outstretched pronated hand. the axis passes through the distal end of the radius in line with the third metacarpal or the long finger.asp[21/03/2013 21:53:26] ." In the average habitual motion. the average arc of flexion is 66 degrees and ranges from 38 degrees to 102 degrees. The forearm is supinated by the supinator ( Fig 5-34 ). One can easily appreciate the shift of the rotational axis by supinating and pronating the forearm. and the radiocarpal joint contributes 40%. the head of the ulna is extended and laterally displaced in the neutral position. It extends from the center of the radial head to the distal end of the radius and ulna and passes "anywhere between the radial and ulnar styloid processes. The wrist traces an arc of 121 degrees of flexion-extension with a minimum of 84 degrees and a maximum of 169 degrees. Starting from the neutral position. The interosseous distance measured in the distal. as measured on 55 normal adult wrists. The corresponding rotation measured at the wrist is 156 degrees. extends. the radial styloid traces an arc corresponding to the base of a cone. the head of the ulna traces a much larger arc of motion than the radius. The head of the ulna remains still. When the distal end of the radius and the head of the ulna are aligned in the vertical plane delineating the neutral position at the level of the wrist.5% of the arc of extension. When rotational motion occurs along an axis passing through the middle finger and near the radial styloid process. deviates laterally. middle. The pronator teres is a reserve pronator reinforcing the power when speed is required or resistance is applied to the motion ( Fig 5-33 ). is controversial. and yet functionally it is part of the distal row in extension and part of the proximal row http://www. The axis of pronation-supination is variable in location. with the tip of an extended finger applied against the wall or the border of a table. the radius transmits 57% of the load directly to the humerus and 43% to the ulna . when the wrist flexes. the average range of flexion is 40 degrees at the midcarpal joint and 26 degrees at the radiocarpal joint.org/alp/chap05-01. and participates minimally in pronation-supination. the action of the muscle being independent of the position of the elbow. The average range of supination is 104 degrees and ranges from 86 degrees to 122 degrees. During extension the average range of extension is 19 degrees at the midcarpal joint and 37 degrees at the radiocarpal joint. In other words. When load is applied to the forearm from a distoproximal direction.oandplibrary. The midcarpal joint contributes 33. During this rotary motion the distal third of the radius and the head of the ulna trace arcs of motion quite comparable in size ( Fig 5-30 ). In ulnar deviation. on the other hand. and long extensors of the middle. palmaris longus. and the proximal row. The flexed wrist. The rigidity of the carpal mass in extension favors fracture of the scaphoid or the distal end of the radius on impact. when rotated.oandplibrary. turns radialward. The degree of participation of the digital motors determines. the hand functions within the action envelope E3 of the wrist. When the wrist is extended. Pronation occurs when the hand extends in a radial direction starting from a neutral rotation position.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library in flexion. and palmaris longus. When the fingers are gently extended and the wrist is held in extension. The flexing finger traces an action envelope. HAND Fingers Located at the end of a multisegmented system. the scaphoid derotates and exposes its full profile ( Fig 5-41 ). long extensors of the index. E4 . http://www. The digital extensors are the accessory extensors of the wrist. all three extensors are maximally active ( Fig 5-42 ). The long digital flexors are the accessory flexors of the wrist. The wrist is a key joint with regard to the functional activities of the hand. This latter motion is concerned more with functional activities related to the body. Grip power is maximal when the wrist is extended to 35 degrees and minimal with the wrist maximally flexed. During radial deviation the scaphoid rotates posteroanteriorly. The center of rotation during radioulnar deviation is located in the head of the capitate. The proximal and distal rows of the carpus participate and move in the opposite direction. and flexor carpi radialis ( Fig 5-43 ). The lunate follows the scaphoid and flexes. The radial deviators of the wrist are the abductor pollicis. The wrist is flexed by the flexor carpi radialis. the following additional wrist motors: extensor carpi radialis brevis. With wrist flexion the action envelope E4 of the fingers extends beyond the field of motion of the wrist ( Fig 5-36 ). and the flexor carpi radialis. the extensor carpi ulnaris and flexor carpi ulnaris are active. The motion of lateral deviation of the wrist averages 40 degrees. The range of ulnar deviation is greater when the hand is supinated. Separately the distal joint is flexed by the flexor profundus. The forceful opening of the fingers brings into action. The reverse motion occurs during radial deviation. including the scaphoid. If the fingers are to be used for the purpose of prehension. recruitment of the wrist motors. extensor carpi radialis longus. the interphalangeal and metacarpophalangeal joints must flex in a coordinated fashion to permit wrapping of the digital palmar surface over the surface of the object. that is an equiangular spiral ( Fig 5-36 ). and extensor carpi radialis longus. With a tight fist. ring. flexor carpi ulnaris. Supination accompanies the motion of flexion with ulnar deviation.). the following wrist motors are active in a descending order: extensor carpi radialis brevis. flexor carpi ulnaris. the field of motion of the fingers is within the wrist envelope E3 . permits the hand to explore the inner half of a circle ( Fig 5-40 ). The combination of wrist extension and pronation-supination permits the hand to explore the outer half of a circle ( Fig 5-39 ). During ulnar deviation the distal row rotates with the metacarpals ulnaward.asp[21/03/2013 21:53:26] . This combination of motion becomes quite evident during manipulative functions of the hand and wrist when involved in power-type performance (hammering. and little fingers. This behavior of the scaphoid correlates well with the concept of the carpus becoming a rigid "close-pack" mass in extension and "loose-pack" mass in flexion. The coordination of flexion at the interphalangeal joints and the metacarpophalangeal joint is brought about by the instantaneous participation of the extrinsicintrinsic motors commanded by the motor cortex. Functionally the hand is used more frequently with the wrist extended and radially deviated or with flexion combined with ulnar deviation. the proximal pole turning dorsally and the distal pole with its tuberosity anteriorly. in a descending order. swinging a club. extensor pollicis brevis.org/alp/chap05-01. The ulnar de viators are the extensor carpi ulnaris. casting a fishing line. extensor carpi ulnaris. etc. The wrist extenders are the extensor carpi radialis longus and brevis and the extensor carpi ulnaris. with 30 degrees in the ulnar direction and 15 degrees on the radial side. the middle joint by the flexor superficialis and the metacarpophalangeal joint by the intrinsic muscles. extensor carpi radialis longus and brevis. When the wrist is in extension and the fingers make a soft fist. A fundamental function of the thumb is opposition with the fingers. There is more abduction to the finger in extension and less in flexion. Any break in this system of activation and coordination interferes immediately with the function of prehension. and terminal tendon. This occurs as the pad of the thumb is set against the pulp of a corresponding finger. A final passive mechanism of flexion-extension of the finger is present through a tenodesis effect: wrist extension flexes the fingers. When the finger reaches a position of flexion close to 70 degrees at the proximal interphalangeal joint. The oblique retinacular ligaments participate in the constitution of this tendon ( Fig 5-45 ). To bring about this opposition. the oblique retinacular ligament attached to the terminal tendon also increases in tension and. thus relaxing the middle slip. which is essentially formed by the long extensor lateral slip but also receives a contribution from the corresponding intrinsic tendons. and this pattern of flexion prevents the palmar skin from making the necessary surface contact with the object. the previously relaxed middle slip goes under tension. An indirect action of extension is exerted by the long extensor on the proximal phalanx through the volar attachment of the transverse or quadrilateral lamina. the terminal extensor tendon is displaced distally. and superficial head of the short flexor. The dorsal interossei abduct or spread the fingers. A direct action is present through a tendinous attachment of the long extensor to the dorsum of the proximal phalanx. The side motion and rotation of the fingers are determined by the intrinsic muscles. The distal joint is extended by the terminal tendon. automatically flexes the middle phalanx. opponens. the lateral slips are at the level of the axis of motion of the joint. the oblique retinacular goes under tension and This is another mechanism of coordination on the automatically extends the distal joint. In maximum flexion. Extension of the metacarpophalangeal joint is controlled by the long extensor. The mechanism is dual. This curved surface is flattened on the palmar aspect ( Fig 5-46 ). As soon as flexion is initiated at the level of the distal joint ( Fig 5-44 ) by the flexor profundus. lateral tendons. This unloading of the extensor tendon at the distal joint allows completion of the flexion at this joint without encountering undue resistance.5% of dissected hands. The three joints flex successively from a distoproximal direction rather than simultaneously. The thumb and the pulp of the finger make contact along the equiangular spiral curve of the finger. a fine mechanism of coordination is present locally in the fingers at the level of the interphalangeal joints as presented by Landsmeer. The absence of intrinsic muscle action not only breaks the contour of the longitudinal arch of the finger but also creates an abnormal pattern of function. Stage I is a function of the median nerve. Thumb The thumb sweeps a conoid surface through circumduction. Stage II of the opposition is the clamping of the thumb pad against the opposed finger. Through flexion-adduction the thumb traces the segment of the base of the cone along the palmar surface. The curve traced during this motion is an equiangular spiral ( Fig 5-47 ).asp[21/03/2013 21:53:26] . The flexing finger increases gradually in skeletal length due to the noncircular contour of the metacarpal head. This creates undue tension in the extensor system. The opening of the fingers is an essential prerequisite for the act of prehension. This is a passive mechanism of interphalangeal joint coordination. whereas the volar interossei adduct the fingers relative to a functional axis passing through the third metacarpal. Simultaneously. When the middle joint extends actively. but immediate adjustment occurs by the distal shift of the entire extensor mechanism and the volar displacement of the lateral slips at the level of the middle joint. extensor side of the finger. This displacement relaxes the lateral slips. This is determined by the abductor pollicis bre-vis. Through extension-abduction the ray returns to its initial position. and the extensor trifurca-tion is carried distally through the lateral tendons. and the extensor trifurcation is displaced further distally. the thumb is abducted in a plane perpendicular to the palm and flexed and rotated pronated) on its long axis ( Fig 5-48 ). and wrist flexion extends them.org/alp/chap05-01.oandplibrary.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library Furthermore. passing volar to the axis of motion at the proximal interphalangeal joint. The proximal interphalangeal joint is extended by the long extensor middle slip and spiral fibers arising from the intrinsic tendons. This band is present in only 38. In stage I the thumb is positioned against the pulp of a corresponding finger. There are two phases to the opposition. All functional activities of the thumb occur within this envelope. This phase provides http://www. Anat Rec 1968. The spherical grip is an interesting grip. The long flexors. the thumb will adopt a longitudinal position of adduction that allows for small adjustments of posture. held in a precision grip for exact work or in a power grip for bold cuts. and middle finger to form a three-jaw chuck. During soft opposition of the thumb with the index finger-palmar prehension-the opponens. 47:1585-1594.87:169-184. Christensen JB. J Bone Joint Surg [Br] 1956.oandplibrary. Functional Activities The functional activities of the hand are extensive but can be grouped into nonprehensile and prehensile activities. When the pulp of these digits comes into contact. grip involves contact of the pulp of the thumb with the lateral aspect of the corresponding finger in its distal segment. If the object held by the digits is large. Precision grip involves participation of the radial side of the hand with the thumb. The index finger is an The thumb brings its exception. The flexor superficialis is a reserve flexor and participates when more power is necessary. and the abductor digiti quinti. All fingers are flexed maximally. Salter N: The amplitude of pronation and supination with the elbow flexed to a right angle. 4. index. With a smaller spherical object the fingers are adducted. A typical power grip is the cylindrical grip. whereas for very precise work contact with the tip of the same digits. the radial intrinsics are silent. and short flexor are active in a decreasing order ( Fig 5-49 ). It is controlled by the adductor and deep head of the short flexor and is a function of the ulnar nerve ( Fig 5-48 ). stirring. This pattern is used in carrying a suitcase. this pattern of prehension is of the precision type. Capener N: The hand in surgery. except for the abductor pollicis longus. Chicago. If an element of precision is necessary. the short flexor becomes the more active.org/alp/chap05-01. 6. the grip is of the power type with minimal flexion of the fingers. When pressure is exerted. here the flexor superficialis pattern predominates. are active. around the handle of a tool. and the counterpressure to the flexing fingers is provided by the thenar eminence. et al: A study of the interosseous distance between the radius and ulna during rotation of the forearm. The hook power grip involves flexion of both inter-phalangeal joints and minimal participation of the metacarpophalangeal joint. American Academy of Orthopaedic Surgeons: Joint Motion . any prehensile act when arrested instantaneously might fit in one of these patterns in a pure or combined form.38:128-151. abductor pollicis brevis. Prehensile activities are grouped into precision and power grips. In the hook type of prehension. 1969. fourth dorsal interosseous. the grip is of the palmar type. J Anat 1953. Darcus HD. and the thumb is in opposition. Cho KO. Basmajian JV: Functions of human thenar and hypothenar muscles: An electromyographic study of 25 hands. The activity of the abductor pollicis brevis is negligible.Method of Measuring and Recording. The radial three digits also participate actively either in a pure power pattern form or by adding an element of precision to the power grip.asp[21/03/2013 21:53:26] . Forrest WJ. 3. contribution with the thenar muscles and the long motors. tapping. Gemmill JF: On the movement of the lower end of the radius in pronation and http://www. 5. Despite the multitude of functional activities of the hand. Adams JP. vibrating the cord of a musical instrument. In the lateral grip the flexor pollicis brevis and the opponens are very active. J Bone Joint Surg [Am] 1965. which are abducted and rotated. for example. More power is provided to this grip when the thumb wraps around the flexed fingers. and the thumb participates at the opposite pole by stabilizing the object and providing the necessary counterpressure. 160:261271. Power grip predominantly involves the ulnar aspect of the hand with involvement of the little and ring fingers.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library the power for the opposition. or key. etc. The former includes touching. feeling. In general. lifting or pushing with the hand. the pattern of the grip during prehension is A scalpel is determined by the intention and not necessarily by the shape of the object. lumbricales. References: 1. creates a tip type of grip. 2. A lateral. pressing down with the fingers. In the cylindrical grip the motors responsible are the flexor profundi and the intrinsic muscles except for the second dorsal interosseous and the three radial lumbricales. followed by the opponens and abductor pollicis brevis. 150:243-247. Long C. Landsmeer JMF: The anatomy of the dorsal aponeurosis of the human finger and its functional significance. Symp Reconstr Hand Surg 1974. 17. JB Lippincott. Am J Phys Med 1971. Philadelphia.asp[21/03/2013 21:53:26] . Hall EA. Sarrafian SK. 11. Chapter 5 . Kaplan EB: Functional and Surgical Anatomy of the Hand. ed 2. Travill A: Transmission of pressures across the elbow joint. Goshgarian GM: Study of wrist motion in flexion and extension. 50:57-71. J Anat Physiol 1901. Napier JR: The prehensile movements of the human hand.Atlas of Limb Prosthetics: Surgical. Clin Orthop 1977. Prosthetic. 8. J Bone Joint Surg [Br] 1956.. J Bone Joint Surg 1944. Baltimore. Halls AA. 1975. Anat Rec 1962.oandplibrary. Littler JW: Hand structure and function. Radonjic D. 12. 1965. Abbott LC: Observations on the function of the shoulder joint. 35:101-109. Travill AA: Electromyographic study of the extensor apparatus of the forearm. Saunders M. Contact Us | Contribute http://www. 9. Hand 1973. Anat Rec 1964. 15. Littler JW: On the adaptability of man's hand.9:187-191. 14. Inman VT. 10. 7. Williams & Wilkins. Sarrafian SK.org/alp/chap05-01. et al: Intrinsic-extrinsic muscle control of the hand in power grip and precision handling: An electromyographic study. MacConaill MA. 104:31-44. 126:153-159. Melamed JL: Unpublished data. 38:902-913. 13. Anat Rec 1949. Long C: Kinesiology of the wrist.5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library supination and on the interosseous membrane. 26:1-30. 9:3-12. Melamed JL. 1969. 18. 52:852-867.a Basis for Human Kinesiology. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 5 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . J Bone Joint Surg [Am] 1970. 16. 19. Conrad PW. 144:373-376. Basmajian JV: Muscles and Movements . O. John W. reprinted 2002. The amputee must exert effort to generate sufficient force and excursion to operate the component. M. You can help expand the O&P Virtual Library with a tax-deductible contribution. The prosthetist may also design specialized passive terminal devices as is illustrated in Chapter 12C. Since passive devices have no moving parts and require no cables or batteries for operation. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). A much less expensive production hand is also available.). Some have specialized shapes to facilitate particular activities ( Fig 6A-2. externally powered components may be utilized. contemporary versions are battery-powered electronic devices. and other power sources have been utilized in the past. They are often recommended for infants and for sports activities. Prosthetic.). Another category of passive terminal devices resembles children's mittens.oandplibrary. As a group. Prosthetic. the higher-level amputee may find it impossible to generate sufficient motion or strength due to the very limited leverage offered by short bony remnants (see Chapter 6B). the robotlike appearance of some body-powered components can be disconcerting to the general public as well as to the amputee. and hence they are called "mitts. http://www. however. remote from the amputation site. The term body powered acknowledges that the force to operate such components comes from mechanical transmission of muscular effort generated elsewhere in the body.S. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists TERMINAL DEVICES The most distal component of an upper-limb prosthesis is termed the terminal device and subdivided into two functional classes: passive and prehensile devices. light weight.asp[21/03/2013 21:53:31] . Reproduced with permission from Bowker HK. Some find this objectionable. and high reliability due to mechanical simplicity. Finally. ©American Academy or Orthopedic Surgeons. they are typically extremely lightweight and reliable. M. Passive Terminal Devices The most commonly prescribed passive terminal device is the passive hand ( Fig 6A-1. IL. edition 2. Michael. When body power is insufficient or undesirable. and Rehabilitation Principles Upper-Limb Prosthetics: Body-Powered Components Charles M. body-powered devices enjoy the triple advantages of low cost. which discusses sports and recreational devices in more detail.Ed. "External power" comes from a source outside the body.. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. The harness required to transmit muscle forces inevitably restricts the amputee's work envelope and often encumbers the noninvolved side. Rosemont.. Chapter 7C discusses the custom-sculpted hand in more detail and emphasizes the functions of static grasp and social acceptance offered by these devices. B. They also share significant disadvantages. Click for more information about this text. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. flexible humanoid shape similar to the cupped human hand. and Rehabilitation Principles. American Academy of Orthopedic Surgeons. OVERVIEW Body-powered components have been used in upper-limb prostheses for centuries and are still commonly prescribed today. The production passive hand is created from a donor mold that is similar to (but not identical to) the missing appendage and offers acceptable cosmesis to some patients." The passive mitt is usually a soft. C. Fryer.Atlas of Limb Prosthetics: Surgical.P. 1992. hydraulic.S.org/alp/chap06-01. Prosthetic.6A: Upper-Limb Prosthetics | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 6A Chapter 6A . Their widespread application today throughout the world verifies the practical advantages offered by such components. although pneumatic. Because the fingers are hollow alloy. which facilitates visual inspection during fine motor tasks. "Voluntary-closing" devices operate in a converse manner. the specialized shapes tend to be more commonly prescribed for the bilateral upper-limb amputee.). Originally designed by an upper-limb amputee in 1912. a small switch at the base of the thumb permits the amputee to engage either one spring (1. The Dorrance "555" series has more rugged solid fingers in the same "lyre" shape and is available in steel or aluminum alloy ( Fig 6A-6.). the versatility and reliability of the voluntary-opening hook with canted fingers made it the most commonly prescribed terminal device in North America ( Fig 6A-3.This device is most popular for small children. The combination of one canted hook and one straight hook offers two different grasp patterns. In some cases. The CAPP terminal device (originally developed at the Child Amputee Prosthetics Project at UCLA) offers a voluntary-opening utilitarian shape that is not a hook. knives. the amputee must rely on vision to confirm that grasp has been successful. chisels. The specialized fingers also have a number of subtle contours that facilitate holding. but it is also available in adult size ( Fig 6A-8. Voluntary-Opening Hook Terminal Devices Hosmer-Dorrance is the name associated with a broad range of body-powered. Since no prehensor yet offers sensation.oandplibrary.). The "two-load" hook has "lyreshaped" fingers for this reason. Hand tools and sports equipment can be modified by mounting serrated attachments that allow the amputee to lock the implements securely onto the hook. The series 8 hooks are slightly smaller and intended for females but offer similar options in materials and finger linings. The term canted refers to the slanted configuration of the hook fingertips. Variations add a larger opening or a locking mechanism to the basic hook. The alloy hooks are satisfactory for all but the most rugged users. the movable hook finger can then be used to pull the trigger on a drill.6A: Upper-Limb Prosthetics | O&P Virtual Library Prehensors Prehensors offer active grasp and may be classified according to their mode of operation. or similar object ( Fig 6A-7. Since most amputees find the canted approach satisfactory.).2 kg. Many have a similar characteristic shape and differ principally in size and materials.asp[21/03/2013 21:53:31] . "Voluntary-opening" devices are normally held closed by a spring or rubber band mechanism but open when the control cable is pulled. and series 12 is an infant's hook. and carrying such items as buckets. The "contour" hook is a recent addition that uses two "C"-shaped fingers to facilitate cylindrical grasp. stainless steel device reserved almost exclusively for adult male amputees. Steel remains available but is usually reserved for the heavy-duty. voluntaryopening hook terminal devices. Prehensors may also be subdivided into handlike and utilitarian shapes." identified by the large opening between the two fingers that is designed to grasp shovel handles and similar objects ( Fig 6A-4. It has a small triangular opening in the stationary finger that can latch onto a serrated attachment. nails. The United States Manufacturing Company (USMC) hook is a steel design similar to the series 5 type.org/alp/chap06-01. Clever use of contours and rubber materials provides a reasonably secure grasp despite a limited pinch force. The series 5 hooks are intended for adults and were originally manufactured only in stainless steel. Addition of the letter "P" indicates that it has been coated with "plastisol. It is sometimes referred to as a "farmer's hook" but has value for anyone engaged in manual tasks including workshop activities.). grasping. The letter "X" indicates the addition of neoprene rubber finger linings to improve friction and grasp. http://www. whose ability to generate body-powered force is limited. but on one side only. 3½ lb) or two springs (3. 7 lb) to vary the pinch force. The letter "A" indicates aluminum alloy and reduces weight about 50% over the steel versions. As its name suggests. The traditional utilitarian shape is the split hook. A second characteristic shape is the "work hook. series 10 is for children. This is a heavy-duty. transradial (belowelbow) user. Some hook fingers offer a more symmetrical shape that grasps cylindrical objects such as bottles more readily than the canted approach ( Fig 6A-5.6 kg. The series 9 hooks are for adolescents. pistol. and carpentry tools. A few other manufacturers offer voluntary-opening hooks." a soft rubber material available in both Negroid and Caucasion tones. it is not suitable for heavy-duty use.). particularly those with long residual limbs ( Fig 6A-11. Although this is physiologically normal. A large finger opening (7.). A selector switch permits the amputee to choose either a. Voluntary-Closing Hands Although voluntary-closing hands theoretically offer the same advantage of graded prehension as do hook devices. None have a locking mechanism. The USMC has recently announced a series of adapters that allow direct attachment of standard mechanics' tools to the prosthetic wrist unit ( Fig 6A-9. ).. This device was originally developed to use biceps cineplasty as a source for body power. 3 in. Large opening (with the thumb in the second position) ( Fig 6A-12. which means that the amputee must maintain continuous force to grasp an object. 2.4 cm.6A: Upper-Limb Prosthetics | O&P Virtual Library European manufacturers. c.). particularly for children and sports-minded adults (see Chapter 12C). Many are really "tools" that interchange for specific tasks rather than multipurpose devices. A small finger opening (3. Combined with the waning popularity of cineplasties. some find it objectionable. b.org/alp/chap06-01. The rubber cosmetic glove that covers the hand further impedes motion. ). the frictional losses in the mechanism are much greater. Automatic locking when grasp is accomplished 2. The voluntary-closing mode provides graded prehension: the pinch force is as gentle or strong as the force generated by the amputee.. have recently made a number of terminal devices available to the American market. Bob Radocy. few if any are used as active terminal devices. the mechanical complexity of this device makes it both expensive and prone to breakdown. available in an adult male size only. ). The APRL hand. Unfortunately. they have not developed widespread popularity in the United States ( Fig 6A-9. l 3/8 in. and contours that block visual inspection.A). In addition to the problems of frictional loss. The APRL hook is a voluntary-closing device. 4. has similar features to the APRL hook: 1. The hollow aluminum lyre-shaped fingers it shares with the "two-load" hook make it somewhat fragile. has introduced a series of voluntary-closing utilitarian devices. glove restriction of motion. ) Otto Bock of Germany exports a lightweight and inexpensive voluntary-closing hand in several sizes.5 cm. Small opening (with the thumb in the standard position) 3. Acceptance has been greatest for unilateral transradial amputees. Patient acceptance has been good. most notably Otto Bock and Hugh Steeper. this can improve proprioception. For all these reasons. Voluntary-Closing Hooks The APRL hook was developed by the Army Prosthetics Research Laboratory after World War II. 3. The graded prehension may also be of value to selected bilateral upper-limb amputees. It differs from all hooks previously discussed in several major respects: 1. and the contours often block visual inspection of the fingertips. Thus far.oandplibrary. all voluntary-opening devices offer only limited pinch http://www. Particularly with a cineplasty. voluntary-closing hands have never enjoyed widespread popularity.B). these factors limit its prescription primarily to previous wearers. "Freewheeling"-a small opening with the locking function eliminated. They are available in both aluminum and steel versions as well as plastic-coated styles for children. It uses many of the same internal components as their electronic hand and has an identical external appearance and cosmetic glove. Voluntary-Opening Hands Although a number of voluntary-opening hands are available. It is also available in a voluntary-opening configuration ( Fig 6A-13. a recreational therapist and transradial amputee. The fingers automatically lock in any position once grasp is accomplished.asp[21/03/2013 21:53:31] . The operating lever or thumb is located on the ulnar side of the device ( Fig 6A-10. 7. A custom production glove is manufactured from a donor mold of a hand similar in shape to the amputee's. The Sierra voluntary opening hand is available in size 8 only.6A: Upper-Limb Prosthetics | O&P Virtual Library force. A "Bac Loc" feature operates in all finger positions and permits the amputee to hold heavy objects securely. 3. -The Robin-Aids soft mechanical hand is a voluntaryopening hand ( Fig 6A-17. Robin-Aids Soft Mechanical Hand. -The Robin-Aids mechanical hand is a voluntary-opening hand with control cable tension that causes digits 2. The thumb can be manually prepositioned for normal or large opening prehension. 4. This is the only commercially available hand with an adjustable length feature that permits its use with very long transradial and wrist disarticulation amputation levels. and 5 to move away from a stationary thumb ( Fig 6A-16. Finger opening and release of the Bac Loc mechanism are operated simultaneously through a single control cable.3-cm (½-in. like the APRL hand. The hands are available in four sizes: 8.) increments from size 6½ to size 10. The endoskeletal frame is encased in plastisol and covered with a urethane foam of low density that provides "softness. Three levels of cosmetic restoration are possible. 7.) increments (e. voluntary-opening hand that is available in sizes 6 to 10 in 1. ). ). Finger opening from the fully closed position can be effected only by control cable tension. An optional locking mechanism that locks the thumb in the closed position is available. and 9.) in thickness. ). A stock glove is the most common covering and is ordered by the prosthetist on the basis of hand size and skin tone. lightweight. Many amputees find the manni-kin-like appearance quite acceptable. Becker Lock-Grip and Imperial Hands. As tension on the control cable is relaxed. COSMETIC GLOVES A cosmetic glove is the rubberized covering that determines the external appearance of the prosthesis. . Robin-Aids Mechanical Hand. The only moving component is the thumb. 8) ( Fig 6A-14. ).A and B). The Lock-Grip model contains a mechanism that locks the fingers in the closed position. Many new amputees desire an interchangeable hand for social occasions in addition to a hook device for manual work.asp[21/03/2013 21:53:31] . ). As a result of their extremely limited functional capabilities.g. -Hosmer-Dorrance functional voluntary-opening hands permit the prosthetist to adjust finger prehension by the installation of different tension springs ( Fig 6A-19. springs cause the fingers to move close toward the thumb. As will be discussed in Chapter 6C. externally powered hands offer far greater pinch force and function and are therefore often preferable to bodypowered hands. It is applied over the shell of a passive hand or over the mechanism of an active prehensor and can be replaced when it deteriorates from use. 6. they are rarely appropriate for bilateral upper-limb applications. Most come in generic male and female.oandplibrary.5 cm (3 in. -The Sierra voluntary-opening hand. Lock-Grip hands are available in 1. permits easy adjustment of finger prehension force with the use of a screwdriver. The appearance can be improved by subtle painting of the veins and other structural details. Becker Plylite Hand. has a two-position stationary thumb ( Fig 6A-18. adolescent and child's contours in a few shades of Caucasion and Negroid plastic.org/alp/chap06-01. The larger models permit sufficient thumb movement to grasp objects of up to 7. and 5½. The Imperial model. available in size 8 only. Sierra Voluntary-Opening Hand. 6½." Both of the Robin-Aids hands are available in sizes 7. Hosmer-Dorrance Functional Hands. control cable tension causes the first two fingers to move away from the thumb. -The Becker Lock-Grip and Imperial hands are voluntary-opening hands with control cable tension that causes all five fingers to open ( Fig 6A-15. The prosthetist sends a precise mold of the remaining hand to the factory so that the best match can be selected. http://www. A wider selection of skin tones are available than in the stock glove. The force of prehension is generated by springs and may easily be increased or decreased by the prosthetist. 6½. 7½.3-cm (½-in. From the fully closed position. artistic painting and fingernail polish can add realism. Tension on the central cable causes the thumb and first two fingers to open. -The Becker Plylite hand is a simple. 7½. This is the most common indication for body-powered hands. 8. 8½. fingernail polish can be applied and removed by the amputee.. 8 cm. As the terminal device stud is screwed into the wrist unit. ). As the terminal device is unscrewed. friction is reduced. Even a myoelectric hand can be covered with a sculpted glove. Constant-Friction Wrist Units Constant-friction wrist units are designed to provide constant friction throughout the range of rotation of the terminal device. child (3. l¼ in.] diameter) and medium (3. 1¾ in. a rubber washer is compressed to create friction. It is highly desirable that wrist units provide constant friction. Constant-friction wrist units are available in both the round and oval configurations ( Fig 6A25. Damage to the insert threads may be repaired by simply removing and replacing the entire insert. The foregoing wrist units do not provide constant friction. and adult (5 cm. Quick-Change Wrist Units http://www.4 cm. the upper-limb amputee must be provided with a device that permits some form of substitution for active forearm rotation. thus creating constant friction. Turning a small set screw in the body of the wrist causes the nylon thread to be deformed against the stud of the terminal device.] diameter).). To the uninitiated. ). Most units of this type employ a nylon-threaded insert with steel lead threads ( Fig 6A-24. Also. ). Oval-shaped friction wrist units are available in adult and medium sizes ( Fig 6A-22. Friction wrist units are available in aluminum or stainless steel in the adult size (5-cm [2-in. The oval configuration provides better cosmesis in cases of long transradial levels of amputation. The transradial amputee with a short residual forearm (50% or less than the length of the nonamputated forearm) no longer retains active transmissible supination and pronation.). Modern units permit the amputee to rotate the terminal device through 360 degrees of motion without a change in the effective friction. 2 in. In the oval configuration two sizes are available: adult and medium. the importance of the second function of wrist units may be less clear. In the round configuration.] diameter).4-cm [l¾-in. Friction Wrist Units Commercially available wrist units permit the amputee to substitute for supination and pronation by manually rotating the terminal device with the remaining normal hand ( Fig 6A21.oandplibrary. The above-elbow (transhumeral) amputee has lost all ability to supinate and pronate the prosthetic forearm. Friction wrist units designed specifically for wrist disarticulation levels of amputation are made as thin as possible to conserve the length of the prosthetic forearm ( Fig 6A-23. Some prosthetists refer the amputee.). Even at the very long transradial levels of amputation. thereby rotating it to the desired position of function. Consequently. to a cosmetic restorationist who creates the custom-sculpted glove to match the amputee and to fit over the prosthetic mechanism ( Fig 6A-20. the motions of supination and pronation are severely restricted. since most prosthetic hands have an oval base.1 cm. four sizes are available: infant (3. The units are available in two sizes: adult (5-cm [2-in. These wrists do not provide constant friction and function in the same manner as previously described units. medium (4. the oval-shaped wrist unit provides for a smoother transition from the prosthetic hand to the prosthetic forearm. with the completed prosthesis.asp[21/03/2013 21:53:31] . Such artistic restorations are usually made of a special silicone rubber that is more durable than the polyvinylchloride (PVC) plastic commonly used for the less expensive gloves (see Chapter 7C).] diameter) and medium size (4.4-cm [1 3/8-in.). ).6A: Upper-Limb Prosthetics | O&P Virtual Library The custom-sculpted glove offers the greatest cosme-sis: it is hand-made from a sculptured reverse copy of the remaining hand. The need for the first function is obvious.org/alp/chap06-01. 1½ in. ). Bilateral amputees usually preposition the terminal devices for use by striking one device against the other. ). This wrist unit does not provide constant friction. WRIST UNITS Prosthetic wrist units are designed to serve two basic functions: to attach a terminal device to the forearm of the prosthesis and to permit the amputee to preposition the terminal device prior to operation. 3. these units permit manual prepositioning of the terminal device in almost any attitude of supination or pronation through a 360-degree range. tension on the terminal device control cable causes the terminal device to rotate back to the "neutral" position. On the other hand. The "Flexion Wrist" replaces the common constant-friction wrist and allows manual prepositioning of the hook in neutral. shaving. Because the entire unit can rotate where it mounts to the wrist. 2. The magnitude of the friction http://www. Quick-change units are available from the Hosmer-Dorrance Corporation in the adult size and round configuration only ( Fig 6A-27. Heavy downward pressure on the activating lever causes ejection of the adapter and attached terminal device. The bilateral amputee may find that rotational wrist units facilitate prepositioning of the terminal devices. In these units light downward pressure on the activating lever by the amputee unlocks the terminal device but does not cause its ejection. Wrist Flexion Wrist flexion is particularly useful for activities at the midline: toileting. However.org/alp/chap06-01. ). or 50 degrees of volar flexion ( Fig 6A-28. Friction and constant-friction wrist units tend to permit unwanted rotation when subjected to very high torsional loading. the terminal device covers a much wider arc than with the first alternative. positive-locking mechanisms ( Fig 6A-30. it is sometimes prescribed only for the dominant side. In the unlocked mode. With the terminal device unlocked. the application of a proximally directed axial force with the sound hand causes the terminal device to be locked in the new position. these units provide much greater resistance to rotation than do friction units. it is of crucial importance for the bilateral upper-limb amputee who must perform all daily functions with prostheses. which is screwed tightly on the studs of the two (or more) terminal devices to be interchanged.asp[21/03/2013 21:53:31] . 30.oandplibrary. The "Sierra Wrist Flexion Unit" is used in addition to the friction wrist ( Fig 6A-29. ). Such activities are performed more easily with the remaining hand than with a prosthesis. The hook can also rotate about its mounting stud in any of the positions. Two types of mechanism can provide wrist flexion. 30 degrees of volar flexion. All commercially available quick-change units permit the amputee to do the following: 1. ). ). The unit permits universal prepositioning of the terminal device with constant friction. Because the mechanism adds weight near the termination of the prosthesis. Rotational wrist units are cable-controlled. Remove the terminal device from the wrist unit Replace the terminal device with a different terminal device Manually position the terminal device in supination or pronation Lock the terminal device in the desired attitude of supination or pronation Most quick-change units employ an adapter. This can be advantageous for the bilateral amputee struggling to perform midline activities.6A: Upper-Limb Prosthetics | O&P Virtual Library Quick-change wrist units are designed to facilitate rapid interchange of different terminal devices. prosthetic wrist flexion is seldom necessary for the unilateral amputee unless there is a restricted range of motion in the more proximal joints. 4. and 50 degrees of volar flexion. For this reason. ). ). the amputee manually rotates the hook or hand to the desired attitude of pronation or supination. Rotational Wrists Previously discussed friction wrist units may present difficulties for those amputees who engage in work or avocational activities that exert high rotational loads on the terminal device. this unit is significantly heavier than the Flexion Wrist. This dome-shaped device also has three locking positions at zero. Once locked in position. With the wrist unit unlocked and the terminal devices fully supinated or pronated. et cetera. Next. Ball-and-Socket Wrist A ball-and-socket wrist unit is also available ( Fig 6A-31. dressing. usually a hook and a hand ( Fig 6A-26. eating. Attached proximally to the triceps pad and distally to the prosthetic forearm. protheses employing step-up hinges are frequently referred to as split-socket prostheses. the transradial prosthesis is controlled in much the same manner as a transhumeral prosthesis ( Fig 6A-36. Inadequate range of elbow flexion 3. the amputee retains a limited amount of active supination and pronation. Single-axis hinges are available in both adult and child sizes. adult and small. a splitsocket prosthesis is used. Single-Axis Hinges. Step-up hinges are available in adult. amputations at or above the midforearm level obviate the possibility of transmitting active supination or pronation to the terminal device. At these levels of amputation the amputee must resort to manual prepositioning of the terminal device. ).-Amputees with very high transradial levels of amputation are often unable to operate a conventional transradial prosthesis for the following reasons: 1. ). Correctly aligned single-axis hinges should not restrict the normal flexion-extension range of motion of the anatomic elbow joint. http://www. ). The use of step-up hinges requires that the prosthetic forearm and socket be separated ( Fig 6A-35.-Short transradial levels of amputation require that the anteroproximal trim line of the prosthetic socket be close to the elbow joint. The increased range of motion requires that the amputee exert twice as much force to flex the step-up hinge. Stump-activated locking hinges are available in two sizes. Polycentric hinges help to increase elbow flexion by reducing the tendency for bunching of the soft tissues ( Fig 6A-34.oandplibrary. With a high anterior socket wall. Step-Up Hinges. medium.6A: Upper-Limb Prosthetics | O&P Virtual Library loading can be easily adjusted by the amputee. Sixty degrees of flexion of the anatomic elbow joint causes the prosthetic forearm (and terminal device) to move through a range of approximately 120 degrees of motion. Flexible hinges facilitate the transmissions of this residual forearm rotation to the terminal device.org/alp/chap06-01. ). Stump-Activated Locking Hinge. ELBOW UNITS Elbow Units for the Transradial Amputee With amputation through the distal third of the forearm. Consequently. Consequently.-Single-axis hinges are designed to provide axial (rotational) stability between the prosthetic socket and residual forearm during active prosthetic use ( Fig 6A-32. Inability to tolerate the high unit pressure on the volar surface of the forearm when step-up hinges are used With stump-activated locking hinges. step-up hinges may be employed. Polycentric Hinges. complete elbow flexion tends to be restricted by the bunching of soft tissues in the antecubital region. Flexible Hinges Flexible hinges of metal or leather are commercially available. Polycentric hinges are available in adult. these hinges permit the transmission of approximately 50% of the residual forearm rotation to the terminal device ( Fig 6A-32. ). Step-up hinges amplify the excursion of anatomic elbow joint motion by a ratio of approximately 2:1. In those situations in which a full range of elbow flexion is essential. flexion of the anatomic elbow joint is often restricted to 90 degrees or less. Dacron webbing may also be used. Rigid Hinges For all practical purposes. As in the case of step-up hinges. The residual limb is used only for locking and unlocking the mechanical joint.asp[21/03/2013 21:53:31] . and child sizes. and child sizes. thereby minimizing the requirement for manual prepositioning by the amputee. medium.-Amputations immediately distal to the elbow joint require a prosthetic socket with extremely high trim lines. Inadequate strength of the elbow flexors 2. Shoulder flexion on the amputated side flexes the mechanical elbow joint. they are often appropriate for cosmetic restorations. and large sizes.A) allow abduction and flexion.org/alp/chap06-01. The standard units provide seven different locking positions throughout the range of flexion and come in adult. the spring lift assist is commonly prescribed. Reduced force requirements may permit subtle harnessing adjustments that require less excursion from the amputee. pediatric applications. http://www. ). The turntable permits manual preposi-tioning of the prosthetic forearm as a substitute for external and internal rotation of the humerus. Friction Units Friction elbows require passive positioning of the forearm but are very lightweight and simple to operate. Outside-locking hinges are available in standard and heavy-duty models ( Fig 6A-37. congenital anomalies. They may be used singly or in pairs depending upon the degree of counterbalance desired. Transhumeral. Single-axis units permit only abduction. as necessary. For this reason. Inside-Locking Elbow Units Amputations through the humerus approximately 5 cm (2 in. double-axis units ( Fig 6A-39. similar in function to the flail arm hinge. the unit must permit the amputee to lock and unlock the elbow at numerous points throughout the 135-degree range of motion. . Although optional. the use of standard prosthetic elbow units. and triple-axis ( Fig 6A-39.B) and ball-andsocket configurations permit universal passive motion. In addition. The simplest design is termed a bulkhead when the humeral segment is directly connected to the socket and no motion can occur. SHOULDER UNITS Shoulder mechanisms vary according to the degree of motion allowed.oandplibrary. ).) proximal to the elbow joint provide adequate space to accommodate inside-locking elbow mechanisms. The function is to counterbalance the prosthetic forearm and reduce the force necessary for elbow flexion. Inside-locking units permit the amputee to lock the elbow in any of 11 positions of flexion ( Fig 6A-38. .asp[21/03/2013 21:53:31] . medium. and instances when brachial plexus injury or other factors preclude active elbow function.6A: Upper-Limb Prosthetics | O&P Virtual Library Elbow Units for Elbow. Many unilateral amputees find this acceptable and appreciate the weight savings from omitting the joint. In addition. The length of the residual humerus preeludes. particularly for use with heavier steel terminal devices or hand prehensors. and child sizes. medium. for both aesthetic and functional reasons. inside-locking units incorporate a friction-held turntable. Spring Lift Assist The spring lift assist is a clock spring unit. The heavy-duty model provides five locking positions and comes in the adult size only. Passively movable friction-loaded shoulder joints are available and provide some assistance with dressing and desktop activities. Flail Arm Hinges Flail arm hinges contain an oversized clock spring mechanism to partially counterbalance the weight of the forearm. Most are available in small. Outside-Locking Hinges Elbow disarticulation and transcondylar levels of amputation usually require the use of a specially designed elbow unit. They may also be combined with a single free joint or a single locking joint. that can be added to any mechanical elbow. and Below-Shoulder Disarticulation Amputees Loss of function of the anatomic elbow joint requires a mechanical substitute that permits controlled flexion and extension through a range of approximately 135 degrees. modular prostheses are lighter in weight than conventional artificial limbs. ). including flexion and rotation wrist units. In addition to improved cosmesis and softness. trans-humeral. For the shoulder disarticulation level. For the shoulder disarticulation level. ). passively positionable shoulder units: a ball-and-socket joint and a flexionextension. Prosthetic. the Otto Bock system offers two friction-loaded. NUDGE CONTROL UNIT The nudge control unit is a paddle-shaped lever that can be pushed by the chin or phocomelic digit or against environmental objects to provide a small amount of cable excursion. They are composed of tubular humeral and forearm elements. ENDOSKELETAL UPPER-LIMB PROSTHESES Two endoskeletal upper-limb prosthetic systems are currently available in the United States. All terminal devices with the standard W-20 thread can be used with the Hosmer-Dorrance system. ) provide a wide variety of terminal device options: cablecontrolled. a manually positionable flexion-extension. the completed prosthesis affords a high degree of cosmetic acceptability ( Fig 6A41. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 6A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .org/alp/chap06-01.6A: Upper-Limb Prosthetics | O&P Virtual Library As noted in Chapter 10B. Three elbow units are available for either cable-controlled or manual operation: a constantfriction elbow. The endoskeletal system of the Hosmer-Dorrance Corporation includes components for transradial. and shoulder disarticulation levels of amputation ( Fig 6A-45. abduction-adduction hinge ( Fig 6A-44.oandplibrary. ). It is usually prescribed when other body motions are not available. Fig 6A-40. Socket attachment turntables permit passive rotation of the humeral and forearm segments. A separate wrist unit allows for manual prepositioning of the terminal device in flexion. and an elbow joint with a cable-controlled locking mechanism. The Otto Bock Pylon Arm system for transhumeral and shoulder disarticulation amputees permits passive or cable-operated elbow flexion with manual locking ( Fig 6A-42. Although originally designed to provide elbow locking and unlocking. Contact Us | Contribute http://www. abduction-adduction hinge is available. illustrates one such design commercially available on a limited basis. an elbow with a manual lock. Passive prepositioning of the humeral segment in internal or external rotation and the forearm in supination or pronation is achieved by the use of rotation adaptors. and the components allow for encasement in cosmetic foam covers.asp[21/03/2013 21:53:31] . The system hands ( Fig 6A-43. ). Chapter 6A . voluntary-opening or -closing units and a passive hand unit with a spring-activated thumb and fingers. prosthetists sometimes must custom-build shoulder joints if locking functions are desired. it can also be adapted to operate other body-powered components. After final shaping and covering with a skin-colored stockinette.Atlas of Limb Prosthetics: Surgical. . In effect.org/alp/chap06-02. The amount of body motion used to operate the terminal device remains essentially the same with the elbow flexed to 135 degrees or with the elbow completely extended ( Fig 6B-4. When cable tension is relaxed. American Academy of Orthopedic Surgeons. The cable tension is transmitted to the operating lever or "thumb" of the terminal device and causes one finger of the hook to move away from the other stationary finger ( Fig 6B-2.. To understand the two main functions of a prosthetic harness it is first necessary to examine the mechanical operating principles of prosthetic control systems. The force of prehension is. In body-powered upper-limb prosthetic applications. For most of its length the control cable is encased in a flexible stainless steel housing ( Fig 6B-3. and Rehabilitation Principles.oandplibrary. Fryer.S. The cable housing is an integral part of the transradial single-control system. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. usually referred to simply as "terminal devices. the housing maintains a constant length of the control cable regardless of the angular attitude of the anatomic elbow joint. As a general rule each rubber band produces approximately 0. the cable terminates at some type of prehension device (Fig 6B-2)..Atlas of Limb Prosthetics: Surgical." In a well-designed harness the same straps are strategically positioned in relation to the shoulder girdle and/or thorax so that the amputee can control the prosthetic components with a minimum of exertion and body motion. determined by the number of rubber bands located at the bases of the hook fingers. IL.45 kg (1 lb) of prehensile force between the hook fingers.S. B.). http://www." may be either prosthetic hands with one or more movable fingers or two-fingered devices with a hook-type configuration. Reproduced with permission from Bowker HK. With this type of terminal device the amputee uses shoulder motion on the amputated side to apply tension to the control cable ( Fig 6B-2. At its upper end. M. Distally. in this particular case. the housing through which the control cable passes is attached to the triceps pad of the prosthesis by a fixture called a "crossbar assembly.)-wide Dacron webbing. Prehension devices. STANDARD TRANSRADIAL HARNESS The standard harness for the unilateral adult transradial amputee is composed of 2. Prosthetic. MECHANICS OF THE BELOW-ELBOW (TRANSRADIAL) CONTROL SYSTEM The transradial prosthetic control system is a one-cable or "single-control" system.). and Rehabilitation Principles Upper-Limb Prosthetics: Harnessing and Controls for Body-Powered Devices Charles M. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. A stainless steel control cable is firmly attached at its proximal end to one of the Dacron straps of the harness ( Fig 6B-1.B). edition 2.). 1992.asp[21/03/2013 21:53:36] . Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.A). and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 6B Chapter 6B .). Click for more information about this text. Prosthetic. The webbing is arranged to form a horizontally oriented figure of 8 ( Fig 6B-5. The prosthesis is suspended on the residual limb by the intimacy of the socket fit and by a system of Dacron straps collectively referred to as a "harness." A base plate and retainer serve to anchor the distal end of the cable housing at approximately the midforearm level of the prosthesis. reprinted 2002.). the functions of control and suspension are closely interrelated. the movable finger closes on the stationary finger ( Fig 6B-2. Prosthetic. Rosemont. ©American Academy or Orthopedic Surgeons.5-cm (lin. ). As indicated by its name. mechanical efficiency will be enhanced if the cross point is located below the spinous process of C7 and slightly toward the nonamputated side. HEAVY-DUTY TRANSRADIAL HARNESS A major disadvantage of the standard figure-of-8 harness for transradial amputees relates to the axilla loop. particularly the repeated lifting of heavy objects. the axilla loop encircles the shoulder girdle on the nonamputated side ( Fig 6B-6.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library The axilla loop serves as the primary anchor from which two other straps originate. as it is sometimes called. whenever significant tension is applied to the anterior support and control attachment straps. When terminal device operation close to the midline of the body is required. The shoulder saddle is anchored in place by the use of a chest strap. it is recommended that a nonstandard transradial harness system be considered. ). ring-type harnesses enjoy a high degree of acceptability by most transradial amputees.oandplibrary. When it is anticipated that the transradial amputee will engage in very strenuous work activities.) Whether the harness straps are sewn together or attached to the axilla loop by a steel ring. Since the control attachment strap is located in essentially the same place as in the standard harness. passes over the shoulder on the amputated side. Even so. The posterior junction of the axilla loop with the anterior support and control attachment straps-the cross point of the harness-may be either sewn together ( Fig 6B-9. excessive pressure in the axillary area may cause skin irritation and. The primary function of the anterior support strap is to resist displacement of the socket on the residual limb when the prosthesis is subjected to heavy loading ( Fig 6B-7. leather shoulder saddle on the amputated side. BILATERAL TRANSRADIAL HARNESS The harness pattern for the bilateral transradial amputee differs only slightly from the previously described standard transradial harness. and is attached to the anteroproxi-mal margins of the triceps pad of the prosthesis. the midscapular level. the harness is referred to as a "transradial. ). as when buttoning a shirt. Likewise. Viewed from the rear. and Fig 6B-14. Over a period of time. This redistribution of loading is accomplished by fitting a fairly wide. "the inverted Y suspensor. The control attachment strap originates at the axilla loop and terminates at the proximal end of the prosthetic control cable ( Fig 6B-8.) or connected by a stainless steel ring ( Fig 6B-10. the standard transradial harness permits the amputee to use biscapular abduction for terminal device operation ( Fig 6B-12. ).). in effect." The anterior support strap originates at the axilla loop. ). the amputee uses glenohumeral flexion and/or scapular abduction for terminal device operation ( Fig 6B-13.). in extreme cases. With the heavy-duty harness. the control attachment strap permits the use of scapular abduction and shoulder flexion on the amputated side for operation of the terminal device. Glenohumeral flexion is excellent for the generation of force and provides more than enough cable travel for full terminal device operation. The primary body control motion for operating the terminal device of a transradial prosthesis is flexion of the glenohumeral joint ( Fig 6B-11. tension loading on the prosthesis is distributed over the shoulder on the amputated side rather than being transmitted to the axilla on the nonamputated side. The second component of the transradial harness is the anterior support strap or. the tension drives the loop vertically upward into the axilla on the nonamputated side. The axillary portion of the loop should always be padded and worn on top of an undergarment.org/alp/chap06-02. Two support straps are extended from the posterior portion of the shoulder saddle through D-rings located on the medial and lateral surfaces of the triceps pad and terminate on the anterior surface of the saddle. In the latter case. the control attachment strap acts.asp[21/03/2013 21:53:36] . the control attachment strap for operation of the right terminal device extends obliquely upward across the back and terminates as the anterior support strap for the left prosthesis ( Fig 6B-15. ). as an extension of the control cable. Anchored by the axilla loop. ring-type harness. the control attachment strap for operation of the left terminal device becomes the http://www." (Because they are less restrictive. Located between the spine and inferior angle of the scapula. produce neurotrophic changes from brachial plexus pressure. The nonstandard transradial harness is generally referred to as a "heavy-duty" or "shouldersaddle" harness. the harness consists of a simple axilla loop around the shoulder on the nonamputated side. The ease with which the amputee can operate the elbow unit and terminal device depends. which obviates the need for the suspensory function of a harness. Generally. The proximal piece of housing is attached to the triceps pad and the distal piece to the prosthetic forearm. ). As in the case of the standard harness. ). . The control cable is now exposed as it passes anterior to the elbow joint. Higher transhumeral levels of amputation require a more proximal placement of the attachment to minimize the excursion required. A second cable permits the amputee to lock and unlock the prosthetic elbow. Passing through the proximal portion of the split housing. Since the housing is in two separate pieces and the control cable passes in front of the elbow axis. the control attachment strap runs from the axilla loop to the terminal device control cable. In selected instances the unilateral transradial amputee can be fit with a socket. Greater force and less cable excursion are required where the elbow flexion attachment is closest to the elbow axis.oandplibrary. Extending obliquely downward across the amputee's back. to a considerable extent. The proximal portion of the split housing is attached to the posterior surface of the humeral section of the prosthesis. on the location of the elbow flexion attachment. a more distal placement of the attachment requires less force but greater cable excursion. Tension applied to the control cable by glenohumeral flexion on the amputated side assists in elbow flexion ( Fig 6B16. for terminal device operation as does the unilateral transradial amputee. the extra force requirement may cause considerable discomfort on the volar or radial surfaces of the remaining portion of the amputee's forearm. shoulder flexion and/or scapular abduction on the amputated side are the control motions for terminal device operation ( Fig 6B-17. In such instances. the further the elbow flexion attachment may be placed from the elbow axis. point C).asp[21/03/2013 21:53:36] . The elbow flexion/terminal device control cable continues through the distal portion of the split housing and terminates with its attachment at the terminal device ( Fig 6B-19. the control cable is exposed anterior to the mechanical elbow axis ( Fig 6B-19. Conversely. MECHANICS OF THE TRANSHUMERAL CONTROL SYSTEM Transhumeral prostheses are usually operated by two distinctly separate control cables ( Fig 6B-18. ). point D). The distal portion of the split housing is fixed to the prosthetic forearm by a device called an "elbow flexion attachment. One cable serves both to flex the prosthetic elbow joint and to operate the terminal device. the longer the residual limb. Since these fittings eliminate the need for a triceps pad and anterior support strap." The elbow flexion/terminal device control cable originates at the control attachment strap of the harness (Fig 6B-19. The modification consists of splitting the cable housing into proximal and distal segments similar to those used for the above-elbow (transhumeral) prosthesis.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library anterior support strap for the left prosthesis. the posterior cross point may be sewn together or connected by a stainless steel ring. The bilateral transradial amputee uses the same body control motions. Elbow Flexion/Terminal Device Control Cable The housing through which the elbow flexion/terminal device cable passes is split into two separate parts ( Fig 6B-19. . a relatively simple control system modification may be used to minimize discomfort and facilitate elbow flexion. TRANSRADIAL HARNESS MODIFICATIONS Step-up hinges used with a split socket may be used for a short transradial stump to provide a 2:1 ratio of elbow flexion to stump motion but require the amputee to use approximately twice as much force to flex the prosthetic forearm. point E). glenohumeral flexion and/or biscapular abduction. Since split sockets are used only at very short transradial levels of amputation. As in the case of the standard unilateral harness. tension applied to the cable causes the prosthetic elbow to flex. ). Such self-suspending prostheses are held on the residual limb by the intimacy of the socket fit proximal to the olecranon and humeral epicondyles and in the antecubital fossa. The disadvantage of this type of harnessing is that long-sleeved clothing is difficult to wear.org/alp/chap06-02. http://www. The flexion is limited to the gap between the two cable housings. STANDARD TRANSHUMERAL HARNESS Full operation of the terminal device of a transradial prosthesis requires only 5 cm (2 in. the strap continues down the anteromedial surface of the humeral section of the prosthesis. the posterior intersection of the harness straps should be positioned slightly toward the nonam-putated side of the body ( Fig 6B-23. To maintain a fairly snug axilla loop. the operating sequence of the two cable systems used with most transhumeral prostheses is as follows: (1) tension applied to the elbow flexion/terminal device control cable causes the elbow to flex. The anterior support strap serves several functions in the transhumeral harness systems. right ). left ). while others provide the amputee with volitional control of the prosthetic components. ). The transhumeral amputee uses glenohumeral flexion on the amputated side to flex the prosthetic elbow and/or operate the terminal device. snug axilla loop. Precision in the location of the harness and control system components is essential for achieving satisfactory comfort and function. The anterior support strap running downward mediolaterally resists external rotation of the socket. ). ). glenohumeral flexion tends to cause the socket to externally rotate on the residual limb. However. When viewed from the front. The axilla loop acts as the fixed anchor from which other harness components originate. it should be noted that the distal two thirds of the anterior support strap consists of elastic rather than Dacron webbing (see Fig 6B-21.oandplibrary. the rapid sequential application and release of tension on the elbow lock control cable locks the elbow. In summary. ).org/alp/chap06-02. The anterior support strap. Some of the straps originating at the axilla loop serve to suspend the prosthesis on the residual limb. provides the most positive prosthetic suspension and control. Since the proximal control cable housing is attached on the posterolateral surface of the humeral section of the prosthesis. As a key element of the entire harness. left ).25 in. one that does not compromise amputee comfort to an excessive degree. Elbow Lock Control Cable The proximal end of the elbow lock control cable originates at the anterior suspension strap ( Fig 6B-21. Passing over the shoulder on the amputated side. and elbow lock control strap. pull and release to unlock. the distal end of the cable engages the elbow locking mechanism.3 cm (½ in. The elbow lock works on an alternator principle: pull and release to lock. The anterior support strap terminates with its attachment on the anterior surface of the prosthetic socket slightly proximal to the mechanical elbow joint (see Fig 6B-21. Passing down the anteromedial surface of the humeral section of the prosthesis. this strap helps to suspend the prosthesis against axial loading. originates at the axilla loop (see Fig 6B-21. (2) when the desired angle of elbow flexion is achieved.) distal to the elbow axis is usually satisfactory.) and a force of approximately 0. the transhumeral harness consists of a system of interconnected Dac-ron and elastic straps laid up in a figure of 8 (see Fig 6B-21). control attachment strap. its precise location should be determined on an individual basis ( Fig 6B-20. The common elements of the standard trans-humeral harness are the axilla loop. since the anterodistal two thirds of the strap consists of elastic webbing.asp[21/03/2013 21:53:36] . . http://www. the reapplication of tension on the elbow flexion/terminal device control cable permits operation of the terminal device ( Fig 6B-22. More than twice that amount of excursion is required for full elbow and terminal device operation of a trans-humeral prosthesis.1 cm (1. anterior support strap. Consequently. A small. A second function of the anterior support strap is to help prevent rotation of the prosthetic socket on the residual limb during prosthetic usage.) of cable excursion. Anchored to the axilla loop posteriorly and to the humeral section anteriorly.9 kg (2 lb) are necessary to cycle the elbow unit. An excursion of 1. suspensory function is obviously limited.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library Although the initial placement of the elbow flexion attachment 3. lateral support strap. sometimes referred to as the elastic suspensor. in most instances. the axilla loop should encircle and fit the shoulder on the nonampu-tated side as securely as possible. Like the standard transradial harness. and (3) with the elbow locked. much greater attention must be paid to the details of fitting the trans-humeral harness. the amputee will usually be able to achieve full operation of the components through the application of a moderate amount of force. nonelastic portion of the anterior support strap and is attached at its distal end to the elbow lock control cable ( Fig 6B-27. The use of a cross-back strap in such instances helps to reduce the magnitude of the vertically directed force created by a snug axilla loop. An elastic strap provides less positive control but greater degrees of comfort and mobility of the shoulder girdle. and latissimus dorsi tendons by the axilla loop during strenuous prosthetic usage. With the posterior intersection of the harness on or superior to the spinous process of C7.C). The elbow lock control strap originates at the upper. Whether or not the amputee is able to generate this much cable excursion depends to a great extent on the path of the control attachment strap as it crosses the amputee's back. To either lock or unlock the prosthetic elbow the amputee must first apply tension and then. If the control attachment strap lies too high on the amputee's back. midway between the spine and inferior angle. the amputee is uncomfortable. relax tension on the elbow lock control cable. approximately 1.3 cm (4½ in. in rapid sequence. ).3 cm (½ in. Although the cable excursion requirement for prosthetic elbow operation is small. Since a snug harness fit requires a relatively small axilla loop. .oandplibrary. The lateral end of the strap passes just anterior to the acromion and is attached close to the proximal trim line of the prosthetic socket ( Fig 6B-24. The control attachment strap originates at the posterior intersection of the axilla loop. teres major.A and B). Too low a strap position requires the amputee to use unnecessarily forceful shoulder flexion for full operation. the loop may tend to cause axillary discomfort on the non-amputated side. the strap is directed horizontally and stitched to the anterior support strap at their intersection ( Fig 6B-24.) of cable excursion for full elbow and terminal device operation. the strap helps to prevent external rotation of the socket on the limb when tension is applied to the elbow flexion/terminal device control cable. Originating at the axilla loop close to the posterior axillary fold. The nonelastic strap provides the amputee with more positive control of the prosthetic components and overall tautness of the harness. Indications for the use of this strap relate primarily to amputee comfort and ease of prosthetic operation. . Cross-back straps may be made of either elastic or Dacron webbing. This discomfort is due. Originating posteriorly from the upper portion of the axilla loop. With the control attachment strap firmly fixed at its proximal end by the axilla loop. Cable excursion. the body motion is somewhat complex. ). Another indication for the addition of a cross-back strap is when the posterior intersection of the harness rides too high on the amputee's back.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library The lateral support strap is the primary suspensory element of the harness. normally produced by glenohumeral flexion on the amputated side. the path of the control attachment strap should run between the spine and inferior angle of the scapula.asp[21/03/2013 21:53:36] . ). With the control attachment strap located at approximately the midscapular level. Ideally. A cross-back strap is sometimes used as an adjunct to the standard transhumeral harness ( Fig 6B-26. The proper location of the control attachment strap as it passes from the axilla loop to the elbow flexion/terminal device control cable is important. it is easy to visualize how shoulder flexion on the amputated side creates both the cable tension and cable excursion required for elbow flexion and terminal device operation. to vertical compression of the pectoral. and the work efficiency of the entire harness and control system is diminished.org/alp/chap06-02.). the control attachment strap terminates with its direct attachment to the elbow flexion/terminal device control cable ( Fig 6B-25. In addition to its suspensory function. shoulder flexion will not produce sufficient cable excursion for full operation of the mechanical elbow and terminal device. diminishes as the path of the control attachment strap moves closer to the shoulder joint. the standard transhumeral prosthetic control system requires approximately 11. The cross-back strap helps to maintain the posterior intersection of the harness below the spine of C7. The amputee applies tension to the elbow lock http://www. the cross-back strap passes horizontally across the amputee's back and terminates at the distal end of the control attachment strap. At midhumeral and higher levels of transhumeral amputation it becomes increasingly important that the harness be fitted as intimately as possible. primarily. As noted earlier in this chapter. The addition of a cross-back strap helps to keep the path of the control attachment strap positioned lower on the back. Running obliquely downward across the amputee's back. oandplibrary. The bilateral transhumeral harness permits the amputee to use glenohumeral flexion and/or scapular abduction for elbow flexion and terminal device operation. Particularly vulnerable are the skin. Alleviation of axillary discomfort for the transhumeral amputee who engages in unusually heavy work is best achieved through the use of a shoulder-saddle harness. This motion. Consequently. the left control attachment strap becomes the right anterior support strap. At their posterior origins the over-the-shoulder straps are sewn to the control attachment straps. but both terminal devices cannot be operated to effect simultaneous opening and closing on opposite sides without relaxing tension on one of the cables. and neurovascular structures of the axilla on the nonamputated side. ). on a regular basis. However. the elbow lock control straps of the bilateral harness originate on the nonelastic portion of the anterior support strap. Posteriorly. at the higher transhumeral levels the ring-type harness is found wanting in that it does not provide a very high degree of positive control of the prosthetic components. Whereas a cross-back strap is considered optional in the standard unilateral transhumeral harness. First. With the rapid return of the prosthesis to the starting position. The standard figure-of-8 harness is suitable for and acceptable to the great majority of unilateral transhumeral amputees. it is an essential component in the bilateral harness. The transhumeral shoulder harness distributes tension loading on the prosthesis to the shoulder on the amputated side. the relatively narrow straps of a standard transhumeral harness tend to subject the soft tissues over which they pass to inordinately high unit pressures. the cross-back strap runs horizontally between the two control attachment straps. As seen in Figure 6B-29.org/alp/chap06-02. The over-the-shoulder straps terminate anteriorly by attachment to the nonelastic portions of the anterior support straps ( Fig 6B-30. there is some difficulty in operating both prostheses simultaneously. Two major problems confront the bilateral amputee with the harness just described. The ring-type harness does not enjoy the same degree of acceptability in transhumeral harnessing as it does at the transradial level. tendons. Likewise. As in the unilateral harness system.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library control strap and cable by slight extension and abduction of the gle-nohumeral joint combined with equally slight shoulder depression on the amputated side. The control attachment strap for the right prosthesis is continued over the amputee's left shoulder and becomes the anterior support strap for the left prosthesis. The problem is further compounded at the transhumeral level because maximal control of the components of the prosthesis requires the use of a small. A second major deficiency of this harness system is that it does not permit the amputee to lift any significant amount of weight in the terminal device of either prosthesis. Consequently. unless the straps are sewn in place after adjustment. Elbow lock control is effected by slight glenohumeral extension and abduction combined with shoulder depression. ). At their intersection in the midline of the amputee's back the two straps are sewn together. the elastic tension of the anterior support strap serves to complete the lock/unlock cycle. the possibility of active bimanual manipulation of objects is minimal. SHOULDER DISARTICULATION HARNESS At the shoulder disarticulation level of amputation the absence of glenohumeral flexion as a http://www. in addition to exerting tension on the elbow lock control strap and cable. the lateral support straps are stitched to the anterior support straps. also stretches the elastic portion of the anterior support strap. engages in unusually strenuous physical activity may find the standard harness uncomfortable. the body control motions for prosthetic operation remain essentially unchanged ( Fig 6B-28. ). the unilateral transhumeral amputee who.asp[21/03/2013 21:53:36] . Ring-type harnesses do not permit the same degree of tautness in the straps of the system as do stitched harnesses. The lateral support straps consist of a continuous piece of Dacron webbing attached close to the proximal trim lines of both sockets and pass slightly anterior to the acromion processes. snug axilla loop. Prior to passing over the amputee's shoulder. Two over-the-shoulder straps complete the bilateral figure-of-8 harness for the bilateral transhumeral amputee. the straps are also stitched to the lateral support straps. At midhumeral and higher levels of amputation it becomes increasingly important that the harness fit be as snug as possible. Since the control attachment and elbow lock control straps run along the same paths as they do in the standard harness. During periods of heavy work. Tension applied to both elbow flexion/terminal device cables permits opening (or closing) of both terminal devices. The harness for the bilateral transhumeral amputee consists essentially of two figure-of-8 harnesses without axilla loops ( Fig 6B-29. Running horizontally across the amputee's thorax.org/alp/chap06-02. The proximal end of the elbow flexion/terminal device cable passes through the pulley and is attached to the posterior surface of the prosthetic shoulder cap.oandplibrary. the suspensor terminates with its attachment to the proximal surface of the shoulder cap. A simple excursion amplifier consists of a small pulley attached near the posterior end of the chest strap of the harness. With this type of amplifier each 2. The waist belt serves to anchor the distal end of the elbow lock control strap. shoulder disarticulation harnesses frequently require the addition of an excursion amplifier ( Fig 6B-32. With the waist belt system.) of cable excursion required for full elbow and terminal device operation. A third option for achieving elbow lock control requires the use of a nudge control mounted http://www.8-cm (l½-in. the anterior suspensor helps to prevent external rotation of the socket on the shoulder during use of the prosthesis. a poor body motion for generating adequate cable excursion. the primary body control motion for cycling the elbow unit is shoulder elevation on the amputated side. locking and unlocking of the elbow unit of a shoulder disarticulation prosthesis can be effected in one of several different ways.5 cm (1 in.asp[21/03/2013 21:53:36] . passes laterally between the two legs of the split strap. this increased force requirement does not generally pose a major problem for most adult shoulder disarticulation amputees. Passing over the shoulder on the amputated side along a diagonal path.3 cm (4½ in. It should be noted that although the incorporation of a pulley in the harness system doubles the cable excursion. From its anchor on the waist strap the control strap runs obliquely upward where it is attached to the proximal end of the elbow lock control cable. The preferred method involves the incorporation of the elbow lock control strap as an anterior extension of the chest strap.) of cable excursion generated by biscapular abduction causes the elbow flexion/terminal device control cable to move through an excursion of 5 cm (2 in. In this method the anterior attachment of the chest strap is bifurcated ( Fig 6B-33. the strap passes immediately inferior to the axilla on the nonam-putated side. it also doubles the input force required for elbow flexion and/or terminal device operation. Vertical suspension of the chest strap and prosthetic socket is augmented by the use of an elastic suspensor strap. The lower leg is nonelastic at its extremities-its origin on the chest strap and attachment on the socket-but has a segment of elastic webbing at its center. Biscapular abduction is usually strong enough to produce sufficient cable tension for fully operating the elbow and terminal device of a shoulder disarticulation prosthesis. through biscapular abduction. ). Very few shoulder disarticulation amputees are capable. The force generated by active biscapular abduction is best harnessed through use of a chest strap ( Fig 6B-31. Biscapular abduction is. Abduction of the scapulae is. . Incorporation of the elbow lock control strap with the chest strap makes it easier to don the prosthesis but requires a fairly high level of neuromuscular coordination for successful operation. Nevertheless. A nonelastic elbow lock control strap originates at the chest strap.6 cm (2¼ in. . however. Since biscapular abduction is a good source of force generation. a satisfactory body motion for generating sufficient cable tension to flex the elbow and operate the terminal device of the prosthesis. ). ). of creating enough cable excursion to permit complete elbow and terminal device operation. In addition to assisting with vertical support. An alternative arrangement for elbow lock control requires the use of a waist belt ( Fig 6B34. The chest strap terminates posteriorly with its attachment to the proximal end of the elbow flexion/terminal device control cable. Consequently 5.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library control source requires the use of other body motions for prosthetic operation. Depending on factors such as body build. an effort should be made to maximize the mechanical efficiency of the cable system by reducing friction to its lowest possible level.) of chest expansion produces the 11.)-wide nonelastic webbing. Composed of 3. cable tension for locking and unlocking the elbow is created by scapular adduction on the amputated side. the chest strap originates by a buckle on the anterior surface of the shoulder cap of the socket.). at least for most adult male amputees. and attaches directly to the proximal end of the elbow lock control cable. Since biscapular abduction is a good source for generating cable tension but a poor source of cable excursion.B). The anterior suspensor originates posteriorly on the chest strap ( Fig 6B-31. availability of adequate range of scapulothoracic motion. A). With this harness arrangement. and the neuromuscular coordination of the amputee. The upper leg of the split strap consists of nonelastic webbing. and eating. dressing. Absence of the humeral heads narrows the girth of the shoulder girdle and reduces the effectiveness of biscapular abduction as a work source. the specifics of the harness and control system are left to the experience and ingenuity of the prosthetist. The unilateral prosthesis should permit active operation and passive prepositioning of a lightweight terminal device. active flexion and locking of the elbow unit. Chapter 6B . patient.asp[21/03/2013 21:53:36] . Nudge control is usually reserved for severely disabled persons such as bilateral shoulder disarticulation amputees. Realistically. Biscapular abduction and the use of an excursion amplifier should permit adequate cable excursion for producing a reasonable degree of elbow flexion and terminal device operation. and a unilateral prosthetic replacement. Contact Us | Contribute http://www. it may be possible to achieve a reasonable degree of partial independence in the basic functions of personal hygiene. the functional expectations for persons with acquired bilateral shoulder disarticulation amputations are extremely limited. Harnessing patterns for the forequarter amputation do not differ significantly from those used in the shoulder disarticulation. ).org/alp/chap06-02. environmental modifications. and passive prepositioning of the shoulder joint in flexion and abduction. passive external and internal rotation of the humeral section. thereby preserving this important control source ( Fig 6B-36. Although most authorities agree that fittings should be unilateral rather than bilateral. except that the efficiency of operation is less. active or passive flexion of the wrist unit. and members of the patient's family. physician. A small well-padded plastic cap covering the apex of the acromion on the side opposite the prosthesis enhances the available range of biscapular motion. The nudge control for locking and unlocking the elbow is operated by force exerted by the amputee's chin. Most persons with high-level amputations benefit from the use of externally powered (electronic) componentry.Atlas of Limb Prosthetics: Surgical. modifications of clothing. as discussed in Chapter 6C and Chapter 6D. ). Shoulder elevation on the amputated side may be used for elbow lock control. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 6B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .oandplibrary. Prosthetic. There is no such thing as a "standard" harness for bilateral shoulder disarticulation amputees.6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library on the an-teroproximal surface of the prosthetic shoulder cap ( Fig 6B-35. With the help of adaptive equipment. therapist. enhancements to body-powered elbows. designers. as measured by continued use of a prosthesis: Technological advances in actuators.E. Both uses are technically accurate. and where data are available. but four factors stand out as contributing to the increase in the numbers of successful implementations. externally powered components have been used with increasing frequency in upper-limb fittings. Rosemont. performance characteristics. Heckathorne. IL. as a field of endeavor. and Rehabilitation Principles. An effort has been made throughout the discussions of control options to clarify differences and similarities.org/alp/chap06-03. wrist mechanisms. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and control systems offered by the manufacturer of the device. as well as compatible control systems offered by other manufacturers. therapists. and Rehabilitation Principles Upper-Limb Prosthetics: Components for Adult Externally Powered Systems Craig W. of necessity. This section on electric-powered components is drawn from that pool of knowledge and thus represents the contributions of many individuals. physicians. (There are no commercially available electric-powered shoulder components. and controllers Conceptual advances leading to designs with improved performance characteristics The accumulation of a body of experience guiding successive clinical fittings The willingness of a diverse community of prosthe-tists. social workers. Prosthetic. edition 2. commercially produced. 1992. The text is divided into four sections: prehension mechanisms. materials. Click for more information about this text. Further confusion results when the same word is used in different contexts. The difficulty is most evident in the variety of descriptive names given to the control systems. There is also evidence that the percentage of persons continuing to use prostheses having these components has increased. The content has been selected to emphasize design aspects influencing the performance and use of these components and is limited to components intended for adults. and elbow mechanisms. and readily available in North America. such as the term "proportional." One manufacturer uses the term in the context of "time proportional. Many factors have been suggested as contributing to the increase in clinical utilization of electric-powered components. During the last decade. reprinted 2002. http://www. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Prosthetic.oandplibrary. Following the general description are detailed subsections describing each of the components available within the category.E.6C: Components for Adult Externally Powered Systems | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 6C Chapter 6C . engineers. In addition. M. The component sections include construction and mechanical specifications for each device.asp[21/03/2013 21:53:42] ." to indicate that the response of the device to the control signal is proportional to the duration of time the signal is applied. Writing on this topic is hampered by the absence of a standardized terminology. comparisons are drawn to the physiologic counterpart for which the device is intended as a replacement. a common control terminology is used in association with the name assigned by the manufacturer to identify the number of distinct control sources and Reproduced with permission from Bowker HK.S. ©American Academy or Orthopedic Surgeons. Common characteristics and features are described. It is. is nourished. and exemplary users to share their knowledge and experience Community knowledge is fundamental. Prosthetic. It is the pool into which individual accomplishments flow and from which the art and science of prosthetics. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. a distillation intended to acquaint the reader with the topic. but the controllers differ significantly in the capability they offer to regulate the action of the device. American Academy of Orthopedic Surgeons. Other manufacturers use the same term to denote that the action of the device is proportionally determined by the amplitude of the control signal.Atlas of Limb Prosthetics: Surgical.) Each section begins with a general description of the components to be covered. even among those that are essentially similar in character. the Otto Bock "digital two site" myoelectric controller is also described in the text as a two-site. an expectation that was taken literally with the adoption of shape as a principal characteristic. The "off" condition is generally assumed. These are areas of specialization that warrant separate and detailed treatment.. PREHENSION MECHANISMS Electric-powered prehension devices are available in a variety of forms. In the case of control by means other than muscle signals or in cases where myoelectric control is one of several options. and these parts can be damaged by heavy use. mutually reinforcing appearance. the broad contact surfaces of the electric hand and frictional acceptance. increased comfort associated with the absence of control harnessing in myoelectri-cally controlled prehensors. considerations. Over two decades of experience with commercial electric hands have underscored the technological limitations of the designs and the deficiencies in our understanding of the physiology of the human hand. Power is lost in compressing and stretching the cosmetic plastic forms and gloves enclosing http://www. the more general term "source" is used in place of "site.6C: Components for Adult Externally Powered Systems | O&P Virtual Library distinct device functions. appearances aside. however." In keeping with the intention of this section as a component review. "open" and "close") can be controlled voluntarily. some of which resemble the anatomic hand while others do not and several of which are interchangeable. Although quality of appearance can vary considerably. and aesthetic qualities associated with the human hand.oandplibrary. integrated systems that are provided by a manufacturer as a specific option are described. However. The reader is referred to the technical manuals and courses offered by the various manufacturers. Both of these considerations are as valid today as they were in the early years of electric hand design. Fidelity to a handlike shape entails engineering compromises that diminish not only the prehensile function but also the overall mechanical function of electric prehensors. because it is not practical to have a battery-powered device continuously "on" in the absence of a control signal. properties of the cosmetic glove offer good grasp and retention of held objects. For example. reduced operating effort. two-function controller to indicate that two separate and independent muscle sites are required to operate the controller and that two functions (e. inks. None of the devices offer independent movement of individual fingers. The handlike shape and fixed orientation of the fingers make precise tasks difficult to perform-a special consideration of persons with bilateral amputations but also cited by persons with unilateral amputations. especially with regard to control.asp[21/03/2013 21:53:42] . Early work on electric-powered prehension devices emphasized preservation of a handlike This preferential effort grew out of two broad. and it cannot be compensated by changing the orientation of the fingers. and prehension control independent of the position of the prehensor with respect to the body-would apply equally well to electric-powered prehensors without a handlike shape. and all have fixed prehension patterns.org/alp/chap06-03. The electric hand's size and shape can visually obstruct the object being grasped or the work area in general. all commercially available electric-powered prehension devices function in much the same way with a single degree of freedom of motion that brings two (or three) surfaces in opposition to allow for the grasping of objects. from the cultural vantage point. was a sensitivity to the sociological. qualities that can be powerful shapers of individual perceptions. The material (polyvinylchloride [PVC]) from which most cosmetic gloves have been made has not been very durable and is susceptible to staining from common dyes. and other materials. proved to be the ideal prosthetic solution that early developments were thought to foreshadow. First. techniques for incorporating components into prosthetic systems and for fabrication of prostheses are not covered. The second consideration was a general expectation that in an environment of objects manufactured to be handled by human hands. (Other significant factors cited for the acceptance of handlike prehensors-higher prehension force. unless noted otherwise.) Electric hand prehensors have not. symbolic. the cosmetic function of a prehensor with a handlike shape continues to be a strong determinant of personal In addition. a device with handlike characteristics would offer the best prehension function. Techniques for integrating multiple systems into a single prosthesis and for designing hybrid systems combining body-powered and electric-powered componentry are also not discussed. It is important to note that. The capability for reorienting the electric hand is significantly limited because of the associated loss of the physiologic wrist for most persons with upper-limb amputations. Shape constraints have also limited the form and arrangement of structural frames and finger armatures.g. and Hugh Steeper (Roehampton. Additionally.2 lbf) for lateral prehension. However. determined that palmar prehension predominated in the holding of objects for use.0 lbf) for tip prehension.75 lb). Los Angeles (UCLA). The persistence of this configuration in prosthetic hand designs and its general acceptance over the years supports their observation. Prehension Force Force is a relatively easy characteristic to quantify.52 kg (7. both manufacture adult prehension devices with a handlike shape and devices not shaped like the hand. but generally support the UCLA results.6C: Components for Adult Externally Powered Systems | O&P Virtual Library the mechanisms. and 400 newtons (90 lbf) for cylindrical More recent studies of larger populations have produced slightly different means grasp.org/alp/chap06-03. little is known about how prehension force capacity. It is generally recognized that changes in either of the latter two characteristics can significantly alter the effectiveness of the applied force. The multiplication factor was found to depend on the friction between the skin and the surface material of the object held: the lower the coefficient of friction. Inc. Force should not. Keller et al. The resulting finger shape also creates a concave inner prehension surface that is useful for cylindrical grasp. then. To achieve the palmar prehension pattern. frictional properties of the surfaces in contact. Of these. Therefore. A study. Rationales for force requirements of prosthetic pre-hensors are typically based on physiologic performance.oandplibrary. More recently. be considered in isolation from the other prehensile characteristics when drawing comparisons between particular devices. Hosmer Dor-rance Corporation also manufactures an electric prehensor that does not have a handlike shape. adaptors and tools that can be held within the electric hand and mechanical tools that can be interchanged with the hand prehensors are available. Specific characteristics of these devices are presented in Table 6C-1 for handlike devices and in Table 6C-2 for devices that do not have a handlike appearance. Additionally the frictional properties of the entire surface of the cosmetic glove of the electric hand provides for fixation and stabilization of objects against surfaces or against the body. These results suggest an upper limit (based on applied force and frictional properties) on external forces against which human grip can be maintained without slippage. As a result of these observations. General Characteristics of Commercial Electric Prehensors Otto Bock Orthopedic Industry. prostheses with hook-type prehensors is frequently cited in association with use of electricpowered prostheses. the greater the force needed to hold the object. Both the Bock and Steeper handlike prehensors are configured for palmar prehension-the opposition of the distal palmar pad of the thumb with the distal palmar pads of the index and middle fingers-and only the thumb and these two fingers are driven.6 newtons (21.asp[21/03/2013 21:53:42] . Of the prehension patterns identified by Schlesinger. The prehension patterns of prehensors that do not have a handlike shape (those in Table 6C-2 ) are considered in the separate sections describing each type of device. the fingers of both types of electric hands are fixed in slight flexion at positions approximating the interphalangeal joints. Studies of forces applied in holding objects with the physiologic hand using palmar and opposition of the thumb and index finger have shown that the static prehension holding force is approximately one to two times the weight of the held object for objects weighing up to 3. 93.5 pounds-force [lbf]) for palmar prehension. and conformability to surface features contribute to adequate grip. it is often cited as a "figure of merit" for a prehension device. England). Limited. and the speed of movement of the fingers merit some discussion because of their impact on the prehensile function of the devices. Table 6C-1 and Table 6C-2 list a variety of mechanical characteristics. of human prehension force indicated that adult males could produce maximum mean forces of 95. the maximum prehension force. 103 newtons (23. there has been increasing recognition that handlike prehension devices are most useful if supplemented with other prosthetic devices that have Use of body-powered characteristics not constrained by fidelity to a handlike shape. done at the University of California. the maximum width of opening.4 newtons (21. Using the UCLA data for maximum palmar prehension http://www. several electric-powered prehensors that do not have a handlike shape have been introduced commercially to be used alternatively with or in place of electric hands.. and this contributes to the degradation of overall performance. some of them approaching or exceeding physiologic levels. Peizer et al. proposed that this be a minimum standard for the maximum prehension force of an electric prehensor. the frictional properties of the materials lining the prehension surfaces and the ability of these materials to conform to the surfaces of held objects have not been specified.2-cm (3. Keller et al.2-cm (3.8 newtons (10. the maximum velocity at the finger tip would be 400 cm/sec (157 in. although it was not used often. all of the prehensors incorporate some method for opening the fingers when. Data on physiologic finger speeds from an unpublished study at Northwestern University indicate maximum human finger velocities of approximately 40 radians/sec (2290 degrees/sec) for movements through a range of 75 degrees.0 in. These data provide an appreciation for the upper limit on physiologic finger speed. determined that 5. finger velocities were measured for an untimed pick-and-place task involving blocks of various sizes. Consequently. measured at the fingertip.org/alp/chap06-03. it would be necessary to continue to drive the motor in stall to hold an object. recommended a minimum closure rate of 8.) opening as a minimum opening. All of the electric prehensors include some mechanism for maintaining the applied force in the absence of a control signal and without additional power to the motor.). a motor draws high currents. one could expect that the maximum force acting on an object that could be held without slipping could not exceed 47.6C: Components for Adult Externally Powered Systems | O&P Virtual Library force. The maximum opening of any prehensor in Table 6C-1 or Table 6C-2 does not exceed 10. The same mechanism that maintains the applied force also prevents the fingers from being pried open by external forces while an object is grasped.25-in. suggested the 8./sec). For safety and to prevent damage from excessive forces. This is an important feature. During stall. one should be cautious in leaping to the conclusion that devices capable of achieving higher prehension forces can apply that force as effectively or more effectively than a device with a lower maximum prehension force.2 cm (4 in. Average finger velocities in this functional activity were http://www.) opening was occasionally needed. a suggestion that was adopted by the Panel on Upper-Extremity Prosthetics of the National Research Council.1 cm (2.) of prehensile opening was needed most of the time.25 cm/sec (3. Regulation of the applied force below the maximum is a function of the control system of the particular device and is discussed in the component sections. This feature is certainly helpful when using tools and other implements held in the prehensor.43 cm (4. Without such a mechanism.) indicated a preference for the wider opening. All of the devices in Table 6C-1 and Table 6C-2 have specified maximum prehension forces. Assuming a finger length from the metacarpophalangeal joint to the tip of 10 cm (3.7 Peizer et newtons (15 lbf) were necessary to carry out a variety of activities of daily living. which would deplete a battery supply within a relatively short time. An unpublished investigation at UCLA indicated that prehension forces to a maximum of 66. the prehensor does not respond to an opening control signal. but that an 8. similar to the function of a vise./sec). reasoning that higher forces could only improve the prehensile utility of a prosthetic al.oandplibrary.9 in. However. Width of Opening In the handling of common objects.asp[21/03/2013 21:53:42] .. Experience by users of prosthetic prehensors with an opening of 11. Peizer et al. which is far in excess of the speeds attainable by any of the prosthetic prehensors. essential to the overall performance of a prehensor. considered a "high standard" in 1969.25-in.8 lbf) for a low coefficient of friction and 95. It should be noted that no commercial system provides direct sensory feedback of applied force and that force must be estimated indirectly through its effect on the object being grasped or the response of the prehensor as force increases.5 lbf) for a high coefficient of friction.6 new-tons (21. is exceeded by all of the prehensors in Table 6C-1 and Table 6C-2 . prehensor. This minimum standard.5 in. for one reason or another.25 in. In the same study.) Speed of Movement Based on a study of user's experiences with electric prehensors available at the time. A. in Table 6C-2 . if necessary. because the inner surfaces of the hand are able to accommodate to the shape of objects. an automatic gear transmission. Without this automatic transmission. The elegance of the Bock transmission is not without compromise. and a cosmetic glove. Although the back lock obviates the need to power the motor to maintain the prehension force. possible to override the effect of the back lock. For very wide objects (near the limit of the hand opening). a support structure. The drive mechanism also includes a back-lock feature to maintain the prehension force when the motor is off and to prevent the fingers from opening. The 7 1/4 electric hand is suggested for adult females and juvenile males. The use of a pliable hand form over the mechanism also improves the grasp. for appearance. When the fingers are in motion (i. It is available in three adult sizes denoted by the circumferential dimension (in inches) at the knuckles. The mechanical arrangement of the thumb and fingers also provides cylindrical grasp for objects of moderate dimensions. it is still possible to drive certain System Electric Hands in stall. the lower the torque).4 lbf). It is. as in Fig 6C-1.oandplibrary.. however. a proportional relationship between the magnitude of the control signal and the response of the prehensor appears necessary to achieve confident and acceptable operation. the fingers are not able to encircle the object to secure it. Bock has recently introduced an "energy-saving" design (in addition to their existing models) that senses the motor current and automatically cuts off power to the motor when a stall condition exists. Otto Bock System Electric Hands (Adult Size) The Otto Bock System Electric Hand is the most common type of electric hand prehensor used in North America. in general. When an object is gripped tightly. and the finger assembly. the primary prehension pattern of the System Electric Hand is palmar prehension. single-motor drive units are limited by a trade-off between speed and torque (the higher the speed.B) includes the electric motor (mounted in line with the long axis of the arm).. it would not be possible to achieve both the speed and maximum prehension force of the Bock hand with a single-motor design..asp[21/03/2013 21:53:42] . at which point it can shift to high gear and open the fingers. Operation of the slip clutch does not damage the mechanism.0 radians/sec (172 degrees/sec). The hand mechanism (shown in Fig 6C-1. but the plastic of the cosmetic glove provides friction that maintains a reasonably effective grasp.6C: Components for Adult Externally Powered Systems | O&P Virtual Library considerably less than the maximum and were on the order of 3. it is not possible to release it immediately because the transmission must reduce the prehension force while in low gear until it reaches the lower limit. The mechanism for all three hand prehensors. At higher speeds. until the control problem is corrected.e. The 7 3/4 size and 8 size hands are designated as being for adult males. is the same regardless of size. The efficacy of having prosthetic finger speeds on the order of functional physiologic speeds is greatly dependent on the control scheme with which the prehensor is operated. The plastic form added over the mechanism incorporates the smaller two fingers.B. at which point it will automatically downshift to drive the fingers slower but at higher torque to a maximum prehension force of about 80 newtons (18 lbf). Only the Synergetic Prehensor. achieves this speed. each hand prehensor is therefore composed of three separate As described by Nader. a handlike form. Users of these particular prehensors must be advised to avoid this condition to conserve battery power. As previously mentioned. not gripping an object). which allows the fingers and thumb to move at the speed noted in Table 6C-1 . thus giving many points of contact between the prehension surfaces and the object being grasped. by levering the hand to create very high forces at the fingertips and exceed the torque setting of a slip clutch. Different sizes are determined by the dimensions of a plastic hand-shaped form that is pulled over the skeletal mechanism.. When an object is grasped. and the fingers can be closed manually. In general. Only the thumb and index and middle fingers are part of the mechanism and are oriented to provide palmar prehension. parts: the inner mechanism. the transmission is in high gear. shown in Fig 6C-1. Gender differences and cosmetic coloration are provided by a separate glove made of PVC that is pulled over the plastic form. the transmission remains in high gear until the prehension force reaches 15 newtons (3. The motor drives the fingers (as one unit) and the thumb simultaneously in a plane perpendicular to the axis of the finger joints.org/alp/chap06-03. A wire frame within the form links these fingers to the middle finger so that they move somewhat in concert with the mechanized fingers. http://www. which was one of its design criteria. but it must also do so within a short period of time. also has a twosource. Other manufacturers of myoelectric controllers have interfaced their systems with a special version of the Bock System Electric Hand that contains no electronics. the amplitude of the myoelectric signal must not only exceed the threshold. but the degree to which the signal exceeds the threshold does not alter the action of the mechanism. Steeper Electric Hands (Adult Size) Two adult-sized Electric Hand prehensors are available from Hugh Steeper and are denoted http://www. Both Hosmer Dorrance Corporation and Motion Control provide two-site. Bock terms the three myoelectric systems "digital two site." "grip force. the myoelectric signal is activating an electronic switch. A variety of techniques are available for controlling the System Electric Hand alone. These controllers are notable because they enable the user to regulate the action of the prehensor (the speed of motion or rate of force application) in proportion to the amplitude of the myoelectric signal. and the user cannot alter the speed of motion or the rate at which force is increased by varying the myoelectric signal. These tools are not electrically powered. the prehensor will close and apply force up to a maximum of about 15 newtons (3. The third Bock myoelectric system. the prehensor opens.oandplibrary. the prehensor closes. or tweezer. The "grip force" control is also a two-site. Otto Bock provides three myoelectric controllers as well as switch control. and a rocker switch. "double channel. including a cable pull switch. Otto Bock provides several types of electromechanical switches. Thus. the controller is of the myoswitch variety. it can be removed. the prehensor will move at only one speed or generate grip force (in low gear) at only one rate. that is keyed to fit the fingers of the hand prehensor can provide tip prehension for handling small objects. To effect the function associated with the second threshold of either system. To exceed this level. two-function threshold myoelectric controller. two-function myoswitch controller. lower signal levels produce slower movements or lower rates of prehension force application." and "double channel. Regardless of the strength of the contraction generating the signal. Alternatively.4 lbf). the user generates a stronger myoelectric signal. a harness pull switch. To be completely accurate in describing either the "grip force" or "double channel" system.asp[21/03/2013 21:53:42] . One could also exchange the hand prehensor for a System Electric Greifer (or Steeper Powered Gripper if the control system is compatible). to cause the automatic transmission to downshift and the prehensor to apply higher force. In effect. When the signal is above the lower threshold but below the higher threshold. depending on its amplitude with respect to one of two thresholds. If the myoelectric signal from the "closing" site is above the lower threshold but below the higher threshold. it must be noted that the rate at which the myoelectric signal is generated is also important.org/alp/chap06-03. The myoelectric signal from one muscle controls both opening and closing of the prehensor. Universal Artificial Limb Co. Although two thresholds are involved. if the prehensor is equipped with a quick-disconnect wrist. When the signal is above the higher threshold. a control signal is generated to open or to close the prehensor. The higher threshold only provides a means of "manually" shifting the transmission. For switch control.6C: Components for Adult Externally Powered Systems | O&P Virtual Library Several options are available from Otto Bock to supplement the prehension features of the System Electric Hand. two-function "variable speed controller" that can be used not only for proportional myoelectric control but also for control proportional to the output of variable position or force transducers." is a one-site. For the duration that the amplitude of the myoelectric signal is above the threshold. When one or the other muscle site generates a myoelectric signal that exceeds the threshold. and for this reason this type of control has been termed "myoswitch" control. the prehensor will continue to operate. A pincer. two-function proportional myoelectric controllers. two-function system and is a variation on the "digital two site" controller that provides for two thresholds during closing. This is a subtlety of the decision process of the electronic controller that will not be elaborated here except to note that the lower-threshold function is generally associated with slower lighter contractions of the controlling muscle and the higher threshold is associated with faster and more forceful contractions. and one of a variety of Bock work tools can be connected to the wrist of the forearm for special functions. and higher signal levels produce faster movements or faster rates of force application. All switches provide operational positions for both opening and closing the prehensor. above the higher threshold." The "digital two site" system is a two-site. and middle fingers are molded of hard plastic directly over the armature of the finger assembly and are separate from the shell. the shell and fingers are covered by a PVC cosmetic glove. and it can be manually reset to its normal position.org/alp/chap06-03. A Touch Activated Switch. the prehension surfaces cannot conform to the shape of the held object.. Therefore. twofunction myoswitch controller using two of the Ampli-fier-Myoelectrodes. The smaller two fingers are molded of pliable plastic and are attached to the plastic shell. The thumb and finger arrangement of the Steeper Electric Hands provide both palmar prehension and cylindrical prehension. all held within a support structure ( Fig 6C-1. All of the control configurations operate the Myoelectric Hands in a switchlike manner. Operation of the breakaway does not damage the thumb. index. Two electromechanical switches are also available: the Momentary Contact Switch (similar to a push-button membrane switch) and a Single-Action Pull Switch. All models of the Steeper Electric Hands include current sensors that prevent the motor from running in a stall condition that draws high currents. Steeper offers two options. similar in appearance to the Amplifier-Myoelectrode. For safety purposes and to prevent damage to the mechanism under excessive forces. identical for the two sizes. For finishing. thereby preventing the motor from running in a stall condition in opening.. such as from skin contact. which is activated by a cable." The Myoelectric Hand is somewhat of a misnomer since the prehensor model can be operated by means other than myoelectric signals.A). The size of the prehensors are determined by the dimensions of the fingers and the enclosures around the drive mechanism. two-function hybrid controller by using one AmplifierMyoelectrode over an available muscle site to provide one function and a Single-Action Pull Switch operated by joint motion to provide the second function. a Digital Connector Ring (external to the hand prehensor). a microswitch cuts off motor current when the Electric Hand is opened to its full extent.asp[21/03/2013 21:53:42] . however. The thumb. the fingers and thumb pivot and move in a palmar prehension pattern in a plane perpendicular to the joint axes of the fingers (the same prehension arrangement as used in the Otto Bock hand prehensors). users need not consciously monitor their application of prehension force (when handling non-fragile objects) and are prevented from prematurely depleting their batteries. For situations where a single control source is all that is available. Electric Hands. two-function controller. The first two fingers (as one unit) and thumb are linked to the nut and to the stationary support structure. and the 3 1/4 in. and whenever that control signal is absent. hand prehensor has a circumference of 7 3/4 in.oandplibrary. An Amplifier-Myoelectrode produces a control signal in response to a myoelectric signal that crosses an adjustable threshold. the Steeper Electric Hands achieve less than half the maximum prehension force of the Bock design. because of the hardness of the hand shell and molded fingers. To create a two-source. All of these transducers operate from a single source and produce one control signal. The PVC glove adds to the effectiveness of the prehension force by increasing the friction between the prehensor and the object being held. one can configure a two-source. between two of its metal surfaces. Alternatively. the 3-inch Steeper hand prehensor has a circumference at the knuckles of 7 3/8 in. produces a signal in response to a resistance change. Several types of transducers are available from Steeper. The enclosure is a two-piece hard plastic shell without fingers that gives the prehensor its handlike shape proximal to the finger joint (see Fig 6C-1.B). For comparison to the Otto Bock adult hand prehensors. any two of these transducers are connected to the Digital Connector Ring. A back-lock feature is inherent in the design of the drive screw and nut actuator. Steeper has two models of their Electric Hands: the "Myoelectric Hand" and the "Servo Hand. one can have a two-site. Any combination is possible. the http://www. However. This adapter accepts input from any one of the four transducers to provide one function. and an electronic assembly (in the prehensor itself). Additionally. As the nut travels along the screw. The fingers move at a speed only slightly less than that of the Otto Bock hand prehensors. The first is the One-Action Two-Function Adapter. and the user cannot vary the speed of motion or the rate at which prehension force builds while generating the control signal. the thumb incorporates a breakaway device that allows it to hyperex-tend. The mechanism. and 3 1/4-in. and the fingers cannot be forced open in typical usage when the prehensor is not powered. includes a single motor with a gear reducer and drive screw and nut actuator. constrained by the trade-off between speed and torque of a single-motor design and lacking an automatic transmission like that used in the Bock mechanism.6C: Components for Adult Externally Powered Systems | O&P Virtual Library by their width across the knuckles: the 3-in. For example. The Steeper controllers for the Myoelectric Hand include several parts: one or two transducers. With respect to control. 6C: Components for Adult Externally Powered Systems | O&P Virtual Library adapter itself provides the second function automatically. This type of arrangement can be used to provide voluntary opening with automatic closing (up to the maximum prehension force) or voluntary closing with automatic opening (to full opening and activation of the limiting microswitch in the prehensor). The second option is the One-Muscle Two-Threshold Control, and as indicated by the name, it can be applied only if a myoelectric site is available. This single-site, two-function controller produces a "closing" command when the myoelectric signal crosses the lower of two thresholds and an "opening" command when the signal crosses the higher threshold. The University of New Brunswick (UNB) single-site, three-state (single-site, two-function) controller can be used as an alternative to the Steeper single-site, two-function controller. The UNB controller can be adjusted more specifically to the characteristics of an individual's myoelectric control signal, a feature that may be helpful if the myosignal is marginal. UNB also offers a two-site, two-function myoswitch controller compatible with the Steeper Myoelectric Hands and a single-site, single-function myoswitch controller that provides voluntary-opening control with automatic closing. The second type of Electric Hand, the Steeper Servo Hand, offers a control method unique among commercial electric components. With this controller, the opening of the hand prehensor is determined by the degree to which a cable attached to a position transducer is pulled. ( Fig 6C-2.). The further the cable is pulled, the more the prehensor opens, and the more the cable is slackened (and retracted by a spring in the transducer), the more the prehensor closes. The opening of the prehensor is therefore proportional to the displacement of the cable attached to the transducer, with full opening corresponding to about 9 mm (3/8 in.) of cable displacement. When the fingers close on an object, the force automatically increases to a maximum of 25 newtons (5.7 lbf) before the current sensor cuts off the motor. It is important to note that although a cable is used to position the fingers, this control technique is not like an electric-power-assisted version of a body-powered voluntary-opening prehensor. In the case of a body-powered prehensor, the user has a direct sense through the control cable of not only the position of the prehensor's finger but also of its speed of movement and the force (inversely) exerted by it. With the Steeper servo hand, the user is linked by cable only to the transducer, which is remote from the prehensor and linked electrically to it. Therefore, the user directly perceives only the action of the transducer and force exerted on it, and not the action of the fingers and forces exerted by them. Otto Bock System Electric Greifer The System Electric Greifer, shown in Fig 6C-3., was developed by Otto Bock as an alternative to the System Electric Hand in work situations that require higher prehension force or that might damage the mechanism of the hand prehensor or damage or discolor the cosmetic glove. It can be easily interchanged for the hand prehensor when used with the Bock quick-disconnect wrist unit. The Greifer is available in one size and can be either a right or left unit. The mechanism is encased in a multiple-piece shell made of a durable hard plastic and is available with or without rubber pads lining the prehension surfaces of the fingers. The Greifer's two fingers are broad surfaced and arranged to move symmetrically in opposition. They are articulated so that as they move, the distal prehension surfaces remain parallel to one another. The shape and articulation of the fingers provide lateral prehension and, for moderate-sized objects, cylindrical prehension. Adjustable tips, with or without rubber lining, provide tip prehension for handling smaller objects. The tips can be replaced with optional blanks machined for specific applications. (A screwdriver is required to adjust the position of the tips or to interchange them.) In comparison to the System Electric Hand, the Greifer is longer by 3 cm (1.25 in.) and slightly heavier and has about the same maximum width of finger opening. In terms of mechanical performance, the Greifer is slightly faster and can develop significantly higher prehension force, 50% or 75% greater depending on the Greifer model. The Greifer also incorporates an automatic transmission to enable the fingers to move relatively fast through space but to exert high forces when closed on an object. When the Greifer first closes on an object, it will grip up to a maximum force of 15 newtons (3.4 lbf), after which the transmission will downshift for gripping at higher forces. The short delay before the transmission downshifts enables users to grasp lighter and more delicate objects at http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library the lower force and cease the "closing" signal before higher forces are applied. The transmission of the Greifer differs from that of the System Electric Hand in that there is very little delay between an "open" command and movement of the fingers even after high prehension forces have been applied. As with the System Electric Hand, a back-lock mechanism prevents the Greifer's fingers from opening when power is not applied. For safety, this feature can be circumvented by one of two ways if the Greifer is not responding to an "opening" command. First, an external control wheel, in line with the motor, can be manually turned to drive the fingers open. (This control wheel also provides visual feedback of the action of the Greifer's drive mechanism during normal operation.) Second, a lever near the base of the fingers disengages the fingers from the drive transmission which enables them to be moved freely. Neither method damages the Greifer in any way. In addition to the same wrist rotation capability of the System Electric Hand, the Greifer has built-in wrist flexion. The plane of flexion is parallel to the plane of motion of the fingers, which is perpendicular to the opposing prehension surfaces. The Greifer can be operated by any of the control schemes available from Otto Bock for the System Electric Hand-a necessary capability if the Greifer is to be used interchangeably with the hand prehensor. The exception is "grip force" control, which is inherent in the design of the Greifer and thus available in association with the other control arrangements. As is the case for the hand prehensor, the Otto Bock controls for the Greifer are all of the myoswitch variety. A model of the Greifer without electronics is available and can be operated with the twosource proportional controllers from Motion Control, Hosmer Dorrance, and Universal Artificial Limb Co. Therefore, an interchangeable Greifer and System Electric Hand can be used with any one of these controllers. Hosmer NU-VA Synergetic Prehensor The NU-VA Synergetic Prehensor, shown in Fig 6C-3., was designed as an alternative to a hand prehensor and with speed and force characteristics approaching those of the physiologic hand. It was developed by the Prosthetics Research Laboratory of Northwestern University with the support of the Department of Veteran Affairs and is manufactured by Hosmer Dorrance Corporation. The performance objectives of the prehensor are achieved with a twomotor design utilizing the concept of synergy. Separate motors and gear trains are used to drive the two opposing fingers such that one finger is driven at high speed but low torque and the other finger is driven at low speed but high torque. Therefore, in the act of grasping an object, the prehensor's fast finger can quickly close on the object and the high torque finger apply the force, as necessary, to secure the object. The synergetic design also permits immediate release of objects when an "open" signal is generated because the high torque and high-speed fingers are driven simultaneously. In keeping with the design objectives, the maximum speed of movement of the fast finger of the Synergetic Prehensor is approximately that of the average speed of functional physiologic finger movements, and the maximum prehension force applied at the tip of the high-torque finger is approximately that measured for palmar prehension of adult males. The mechanism and support structure of the prehensor are encased in a two-piece plastic shell, and the fingers of the Synergetic Prehensor are the same removable hook-shaped fingers as developed for the body-powered APRL (Army Prosthetics Research Laboratory) Voluntary-Closing Hook. The hook-shaped fingers provide powered lateral and tip prehension and passive hook prehension. For objects of moderate diameter with respect to the size of the prehensor, the lyre-shaped contour of the opening between the fingers provides for cylindrical grasp. The fingers are lined with neoprene to achieve higher contact friction during grasping. Neoprene pads are also arrayed on the case to facilitate activities in which the prehensor body is used to hold objects in place against other objects or to exert pushing forces on objects. The drive train of the fast finger incorporates a back-lock mechanism that prevents the hightorque finger from pushing the faster, lower-torque finger back as objects are grasped. The back-lock, as with other prehensor designs, also enables objects to be held without continued operation of the motors. Should the prehensor not respond to an "open" signal when closed http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library on an object, the fingers can be opened by a safety breakaway when external forces on the fingers exceed 133 newtons (30 lbf). This mechanism can be manually reset, and its operation does not damage the prehensor. In addition to near-physiologic speed and force, the synergetic design is also energy efficient. Once the fast finger closes on an object and ceases to move, its motor is electronically cut off; therefore it does not run in stall during the application of force by the high-torque finger. To close on an object and grasp it with a force (at the fingertips) of 75 newtons (17 lbf), the prehensor draws an average of 138 mA or about 1.2 W. With a 100-mAh (milliampere hour), rechargeable 9-V transistor-type battery, the prehensor can perform approximately 1,300 cycles of opening and then closing to 75 newtons prehension force on a single battery charge. Therefore, it is possible to use these relatively small readily available batteries for a full days' use of the Synergetic Prehensor. If the Synergetic Prehensor is used in association with an Otto Bock System Electric Hand, it is not advisable to use the 9-V transistor-type battery because of the current draw of the System Electric Hand. The Otto Bock battery could be used for this arrangement; however, its lower voltage will reduce the speed and force characteristics of the Synergetic Prehensor. For fittings of this type, it is recommended that an array of six or seven rechargeable AA batteries be used to provide the voltage requirements of the Synergetic Prehensor and the current requirements of the System Electric Hand. Control of the Synergetic Prehensor is best achieved with a proportional system because of the speed of response of the device. A two-site, two-function proportional myoelectric controller is available from Hosmer Dorrance. This controller differs somewhat from other proportional myoelectric controllers in that the myoelectric signal is not smoothed by filtering but is used to generate full-voltage pulses that increase in width and number in proportion to the amplitude of the myoelectric signal. By processing the muscle signal in this manner and using the mechanical smoothing inherent in the drive system, the time delay associated with electronic filtering is eliminated, and the stiction of the mechanism is overcome. These two factors contribute to the almost instantaneous response of the Synergetic Prehensor and the ability to have good control even at low signal levels. The two-source, two-function variable-speed controller from Universal Artificial Limb Co. can also be used with the Synergetic Prehensor. As noted, this controller can accept signals from myoelectrodes or from position or force transducers. The characteristics of the method of signal processing may result in some difference in the response time of the prehensor. Steeper Powered Gripper As has been the driving force for the design of all non-hand prehensors, the Powered Gripper was developed by Hugh Steeper, Ltd., to address various functional deficiencies associated with existing hand prehensors, constrained by their handlike shape and appearance. Interchangeable with the Steeper Myo-Electric Hand, the Powered Gripper ( Fig 6C-3.) weighs approximately 25% less, moves with about twice the finger speed, and generates 70% higher maximum prehension force than does the adult Electric Hand. The improved performance was achieved by the synergetic action of separate drive systems and a different geometric arrangement for each of the two fingers. The Powered Gripper uses the concept of one finger driven at high speed but low torque and the other at high torque but low speed, similar to that used in the design of the Synergetic Prehensor; however, the effect is produced differently. In the Synergetic Prehensor, the two fingers are pivoted about the same axis but are driven with greatly different gear ratios to achieve their individual speed/torque characteristics. With the Steeper Gripper, the fast finger has a gear ratio similar to that of the gear ratio of the slow finger, but its axis of movement is considerably closer to its drive screw than is the axis of the slow finger. The effect of the different pivot locations is a fast finger that moves over eight times faster than the slower finger but a slower finger that can produce four times the force of the fast finger. In comparison to physiologic performance, the fast finger of the Powered Gripper moves at about 70% the average velocity measured for functional finger movements and generates a prehension force about 63% the maximum palmar prehension force of adult males. The body and fingers of the Powered Gripper are metal castings. The fingers are contoured to provide passive hook prehension and have flattened opposing surfaces for powered lateral and tip prehension. The opening between the fingers is also contoured to accommodate cylindrical objects. The prehension force of the Powered Gripper is made more effective by http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library the use of relatively soft frictional rubber pads to line the fingers. The pads are grooved over a portion of their surfaces, and the fingers are hollowed beneath the material. The grooves and hollowing allow the pads to deform and mold to the shapes of held objects, which distributes the prehension force over a broader contact area. The mechanism of the powered griper includes a drive screw and nut assembly as the last stage in actuating the fingers. As with the Steeper Electric Hands, this assembly cannot be back-driven and therefore provides a back-lock feature keeping the fingers in place when unpowered. The drive screws for both fingers are connected to plastic wheels on the outside of the pre-hensor's case. These wheels can be turned manually to open the fingers in the event that the prehensor does not respond to an "open" command. The same control schemes as used for the Steeper Myoelectric Hand are compatible with the Powered Gripper. (There is no Servo version of the Gripper.) In closing, the fingers operate sequentially. The fast finger first moves to establish contact with the object to be grasped and, at a force of 15 newtons (3.4 lbf), stalls. A 600-ms delay follows before the slow finger becomes active. Since the Steeper controller does not provide proportional control of motion, the delay gives the user time to cease the closing signal if a low-force grasp is wanted. If the closing signal is not interrupted during the 600-ms delay, the slow finger is activated, increasing the prehension force to 60 n ewtons (13.5 lbf), at which point the slow finger stalls. It is important to note that the Steeper electronics prevents the motors from running in a stalled condition. Therefore, only one motor is active at a time, and once the slow finger stalls, no additional motor current is drawn while an object is held. The opening sequence is the reverse, with the slow finger opening first (if it had been activated in closing), followed, without a delay, by the opening of the fast finger. As mentioned, the control schemes for the Steeper Powered Gripper are switchlike, and the user cannot regulate the speed at which the fast finger moves or the rate at which the slow finger increases the force. This arrangement is compatible with the Otto Bock "digital two site" (two-site, two-function) myoswitch control and the Otto Bock electromechanical switch controllers. Versions of the Gripper are made with an Otto Bock quick-disconnect wrist for interchange with Otto Bock System Electric Hands using either of these control schemes. NY-Hosmer Prehension Actuator The NY-Hosmer Prehension Actuator (PA) is not of itself a prehension device and for that reason is not listed in Table 6C-2 . The PA, shown in Fig 6C-4., is a motorized winch that provides electric-powered operation of the cable-actuated Hosmer Dorrance voluntaryIt was originally designed by William Lembeck of New York University opening split hooks. as a complete forearm setup for use with a body-powered or electric-powered Hosmer Dorrance elbow. In that configuration, the mechanism occupies the distal 10.8 cm (4.25 in.) of the forearm with a rotation joint proximal to the mechanism. The forearm segment proximal to the rotation joint contains the forearm saddle assembly for the elbow and, because of the saddle's dimensions, has a minimum length from the elbow axis of 9.5 cm (3.75 in.). The complete forearm setup has a minimum length from the elbow axis to the distal face of the wrist of 20.3 cm (8.0 in.). Longer forearms are provided by lengthening the distal forearm segment, thus keeping the weight of the mechanism (about 218 g; 0.48 lb) as proximal as possible. Rotation to orient the split hook is done proximal to the PA in order to maintain an efficient alignment between the cable attachment post of the split hook and the cable leading from the actuator mechanism. The PA is typically powered by a 6-V battery pack and, at that voltage, can open a split hook having four or five rubber bands. The time to open the hook to its limit is dependent on the number of bands used with the hook but is on the order of one second. Operation of the PA is with a single-source controller. Hosmer offers a single-site, singlefunction myos-witch controller and a variety of single-function electromechanical switches. A three-function cable pull switch is also available for operation of the PA and the NY-Hosmer electric elbow by using one control action. (This is the configuration shown in Fig 6C-4.). The first two functions of the switch are for the elbow; the third is for the PA. Controlled activation of the PA causes it to pull the split hook open. If the control signal stops before the PA pulls the hook to full opening, the hook is closed by the rubber bands. If the control signal is maintained after the hook reaches full opening, the PA is electrically cut off (so that it does not draw motor current), and the motor is dynamically braked. The dynamic braking, which is maintained as long as the control signal is present, allows the split hook to http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library close but at a slow speed. This action gives the user time to adjust the position of the split hook relative to the object being grasped. When the control signal is withdrawn, the braking is removed, and the split hook closes freely. Since the original introduction of the PA forearm setup, it has been adapted to below-elbow (transradial) fittings with single-site myoswitch control. To use this configuration, one must take into account the forearm length requirement of the PA and the placement of the PA battery pack. A transradial fitting of this sort can be done with a supracondylar selfsuspending socket and does provide some advantage over fitting of an electric prehensor by shifting most of the weight proximal to the wrist. Commentary on Electric Prehensors The interplay of psychological and social aspects associated with the human hand and the need for prehension function and independent capability are complex. Generalizations favoring one type of prehensor over any other are limiting, and there is little consensus among users of prosthetic prehensors as to which device is best suited as a replacement for the physiologic hand. Even the similarity to the anatomic hand that is possible with the present-day Electric Handlike prehensors is not universally desired. Some persons, particularly those with bilateral amputations, are sensitive to the prehension and performance advantages of prehensors not having a handlike shape. Other persons, finding the apparent cosmesis of Electric Hands insufficient and being repelled by it, prefer a device that has a form "truer" to its gripping function. Until a more versatile anthropomorphic prehension device is developed, the need for a variety of options will remain. WRIST MECHANISMS Studies of persons using their hands to perform various common activities and occupational tasks have shown significant utilization of forearm rotation and wrist motions in the performance of these actions. Most of the activities studied revealed a range of motion through which the joint moved during the course of an activity as opposed to a variety of fixed positions across the activities. In studies having many different activities, the total range of motion spanned was found to be approximately 100 degrees for forearm rotation, 80 degrees for wrist flexion and extension, and 60 degrees for wrist radial and ulnar deviation. For the specific task of eating, the total range of motion was about 100 degrees for forearm rotation, 30 degrees for wrist flexion and extension, and 30 degrees for radial and ulnar deviation of the wrist. Except for the Otto Bock Electric Wrist Rotator, all commercial prosthetic wrist components are purely mechanical. There are many factors that make development of electric-powered wrist components particularly difficult. From a component design viewpoint, there are the constraints of size and weight imposed by the location of the joint. The device must fit within a cylinder of about 5 cm (2 in.) in diameter and occupy as little length as possible so as to accommodate (ideally) a variety of residual-limb lengths. The component must also be relatively lightweight to minimize counterforces exerted on the residual limb in the case of a transradial fitting or minimize the counter-torque that would reduce the lift capacity of a prosthetic elbow in higher-level fittings. And although lightweight, the structure of the component must be robust enough to withstand the forces exerted on the prehensor and transferred back to the residual limb through the wrist joint. Also a consideration with respect to weight is the need for relatively low power consumption to eliminate an additional battery if used in conjunction with other electric components. With regard to function, there is the question of what joint motions should be provided. The anatomic forearm and wrist joints can be approximated by a triaxial joint with the axes of rotation, flexion, and deviation (roll, pitch, and yaw) having a point of intersection near the base of the prehensor. All three motions have been shown to contribute to functional activities. There is the issue of control. At least one additional control source would be needed for each powered joint of wrist motion, unless the control system operates in a sequential manner. http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library Even sequential control would require at least two control sources-one for selection and one for movement control. Finally, the performance of the component must be exceptionally better than the alternatives for the user to be attracted to its operation. For the person with a unilateral amputation, the primary alternative is the intact limb, which can be preferentially used for activities involving significant forearm and wrist motion. On the prosthetic side, one could use compensatory motions of proximal physiologic joints and have manually positioned mechanical wrist components that would offer adjustable fixed orientations of the prehensor. Although operation of these components typically involves the physiologic hand, the operation is relatively quick and straightforward. (The fact that this technique is so widespread underscores the remarkable qualities of the physiologic wrist. Persons using this technique do so without giving much thought to what they are doing with their intact wrist and hand while using them to position the prosthetic wrist.) For persons with bilateral arm amputations, there are alternative methods for actuating and positioning mechanical wrist components that do not necessarily require the contralateral limb. However, these components cannot, in general, be operated so as to perform work such as turning a handle. Neither can they typically be adjusted dynamically during a motion, such as adjusting the wrist attitude while raising a utensil to one's mouth. Although these deficiencies have inspired many designers to attempt a more versatile electric-powered wrist, advances have been slow to come, and no multiaxis components have been realized commercially. Otto Bock Electric Wrist Rotator The Electric Wrist Rotator developed by Otto Bock, shown in Fig 6C-5., addresses many of the difficulties outlined in the preceding section to provide the functional analogue of forearm rotation. The drive unit is a single motor with a gear reducer having a rotation axis in line with the longitudinal axis of the forearm. It is structurally supported within the lamination collar of the Bock quick-disconnect wrist and can fit any of the three sizes of wrist lamination collars, which have diameters of 4.0, 4.5, and 5.0 cm (1.6, 1.8, and 2.0 in.). Its length is 6.7 cm (2.6 in.) from the distal edge of the lamination collar to the proximal surface of the motor housing. The rotator is relatively lightweight at 96 g (0.21 lb), approximately 20% of the weight of a Bock System Electric Hand. It is also relatively energy efficient and draws a no-load current of 150 mA. (The stall current is 700 mA.) The power requirements are such that it is feasible to operate a Bock System Electric Hand, or Greifer, and the Electric Rotator from a single 6-V Bock battery. However, the ability to get through a full day's use on one battery will vary according to the degree to which the devices are utilized. The rotator mechanism is also protected from external forces through its attachment to the wrist lamination collar. Side forces and axial forces exerted on the prehensor are transferred to the lamination collar and prosthetic forearm rather than to the rotator mechanism. Excessive torques on the prehensor will cause the ratchet of the prehensor's portion of the quick-disconnect wrist to slip rather than back-drive the wrist mechanism. The coaxial electrical coupling of the Bock quick-disconnect wrist allows the rotator to turn an electric prehensor continuously in either direction. In general, however, the performance characteristics of the rotator have been compromised to achieve the necessary size, weight, and power characteristics. The rotator does not generate high torque and cannot be used for work, e.g., turning valves or door handles, unless the resistance is minimal. The rotation is primarily for preposi-tioning and changing the orientation of the prehensor prior to an action or while the prehensor is holding a lightweight implement, such as a utensil with food or a cup of liquid. The speed of response is also compromised. At a no-load speed of 8.33 rpm (0.87 radians/sec or 50 degrees/sec), it is perceptibly slower than physiologic forearm rotations. Physiologic forearm rotation can achieve time-averaged maximum velocities in excess of 14 radians/sec (800 degrees/sec) for pronation and 20 radians/sec (1,150 degrees/sec) for supination. Otto Bock provides two control schemes for the Electric Wrist Rotator: control by electromechanical switches or myoswitch control in conjunction with a Bock electric prehensor. The Bock two-function switches include a cable pull switch, a harness pull switch, and a rocker switch. The myoswitch control, termed "four channel control", is a two-site, fourfunction controller that operates both an electric prehensor and the wrist rotator. In this http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library system, one muscle site controls one function of the prehensor (e.g., closing) and one function of the rotator (e.g., pronation) by using the magnitude and rate of contraction to distinguish the component to be controlled. The second muscle site controls the other function of each component, again using the magnitude and contraction rate to direct the control to the appropriate component. Both muscles are needed to control each of the components. As with all Bock control systems, the performance of the component is not influenced by the amplitude of the myosignal once the component is selected. The rotator will operate at a single speed. Motion Control provides a two-site, four-function version of their proportional myoelectric controller to operate both an electric prehensor and the electric wrist rotator. This system channels the signals from both muscle sites to each component and uses cocon-traction of the agonist-antagonist pair to switch from prehensor to rotator and vice versa. The approach has the advantage, in comparison to the Bock two-site, four-function controller, of allowing the user to regulate the action of either selected component in proportion to the amplitude of the myosignal. In practice, the proportional control is of more obvious a benefit for operation of the prehensor. The speed of the rotator is such that users appear to operate it near its maximum even for small corrective actions. The rotator can be independently controlled by the proportional two-site, two-function myoelectric controller from Hosmer Dorrance. It can also be controlled with the two-source, two-function "variable speed controller" from Universal Artificial Limb Co. As described in the section on prehensors, this controller can accept input from myoelectrodes or from force or position transducers. Wrist Flexion Units Although there are no commercial components that provide electric-powered wrist flexion, this is an important function for the person with bilateral arm amputations and for some persons with unilateral amputations. Therefore, it is useful to know how this function can be provided in prosthetic fittings involving electric prehensors. The Otto Bock System Electric Greifer is unique among commercial prehensors because it incorporates a flexion joint within the prehensor. The joint is a manually positioned friction joint that can be adjusted for more or less friction. The range of motion is plus and minus 45 degrees and occurs in a plane perpendicular to the prehension surfaces of the fingers. For other electric prehensors, engineers and pros-thetists have devised a variety of techniques for adapting commercially available mechanical flexion components for use with electric prehensors. The Sierra Wrist Flexion Unit, the Hosmer Flexion-Friction Wrist, and the United States Manufacturing Company (USMC) E-Z Flex Wrist have all been used in clinical electric-powered fittings. Modifications to both the wrist component and the wrist coupling of the prehensor may be required, depending on what specific components are being used together. The Hosmer Universal Shoulder Joint, with appropriate-sized proximal and distal lamination collars, has been adapted as a friction-type wrist flexion joint. In any of these configurations, the important considerations are to provide a pathway for the electrical wires to the prehensor and to limit, with a mechanical stop, any rotation joint crossed by the wires so that the wires will not be damaged by unrestricted continuous rotation in one direction. A configuration developed to use a flexion wrist unit with the Bock Electric Wrist Rotator in a forearm setup used with a prosthetic elbow is shown in Fig 6C-6.. The forearm is composed of two sections joined by a Bock quick-disconnect wrist. The proximal section contains the wrist rotator, positioned as close to the elbow as possible without interfering with the full flexion of the elbow. The distal section, essentially a hollow cylinder, incorporates a modified Bock quick-disconnect adaptor at the proximal end to mate with the wrist rotator and a flexion wrist unit at the distal end, which may require an adaptor to mate with a specific prehensor. The rotator is electrically operated. The flexion unit is manually positioned. Commentary on Wrist Components The significant participation of forearm and wrist motions to provide fine orienting and positioning of the human hand is well documented. The need for this capability in a prosthetic limb is no less great. It is even possible that the prosthetic wrist takes on more significance in the context of the total prosthesis. Prosthetic fingers cannot be repositioned within the prehensor to accommodate orientation needs as changes in the position of physiologic fingers can be made to complement the anatomic wrist position. And compensatory motions of http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library proximal physiologic joints may be restricted by the suspension of the prosthesis or the harnessing for control actions. As one considers persons with bilateral amputations, especially persons with amputation levels above the elbow, the need for assisted wrist function, on at least one side, becomes even more demanding. The technological obstacles and control problems are severe. However, the potential functional advantages of better wrist components will likely continue to drive development efforts. ENHANCEMENTS TO BODY-POWERED ELBOWS Hugh Steeper, Limited, offers two optional electrical enhancements for its body-powered mechanical elbows. The first is the Steeper Interlock System, which is an electromechanical switch actuated by the locking mechanism of the elbow. The second is the Steeper Electric Elbow Lock, which is a motorized lock for an otherwise body-powered elbow. Steeper Interlock System The Interlock System was developed to allow single-cable control of a mechanical elbow and an electric-powered cable-actuated Steeper Servo Hand. In this configuration, the control cable is routed from the control harness, through a forearm flexion attachment, and to a termination on the position transducer (mounted distally in the forearm) that operates the Servo Hand. When the elbow is locked, the elbow interlock switch is in the "on" state, and pulling on the control cable operates the Servo Hand. When the elbow is unlocked, pulling on the control cable both flexes the elbow and actuates the transducer for the Servo Hand. However, the interlock switch within the elbow is in the "off state, and the Servo Hand is prevented from responding to the transducer actuation. Therefore, pulling on the control cable operates one or the other component depending on the state of the elbow lock. While this arrangement is operationally similar to that of a body-powered elbow used with a body-powered, voluntary-opening split hook, forces used to flex the Steeper elbow (with interlock switch) do not alter the force of prehension of the Servo Hand. In a total bodypowered prosthesis, the force in the control cable that flexes the elbow is also transferred to the split-hook prehensor and proportionally diminishes the prehension force exerted by the rubber bands. As the elbow flexion force is increased because of the weight of an object being actively lifted, a limit is eventually reached where the prehensor exerts no holding force. In a prosthesis with the Steeper Interlock System, the Servo Hand is electrically disconnected whenever the elbow is unlocked and free to move. The force of prehension remains constant regardless of how much force is exerted on the control cable to flex the elbow. The Steeper mechanical elbow and Interlock System can be used in combination with other prehensors, such as the switch-controlled versions of the Bock System Electric Hand and Greifer. In this configuration, a Bock Harness Pull Switch is sewn into the control strap (with a shunt strap to protect the switch from high forces), and one of the battery leads for the Bock prehensor is connected through the interlock switch. When the elbow is locked and the interlock is in the "on" state, pulling on the harness extends the harness switch and operates the prehensor. When the elbow is unlocked and the interlock is in the "off" state, the harness switch extends during elbow flexion but has no effect on the prehensor. It is important to note that the control configuration with the Steeper Interlock provides sequential control of the elbow and prehensor. It is not possible to operate both devices in a coordinated manner as is possible with independent-control hybrid configurations, such as a body-powered elbow and myoelectrically controlled prehensor using biceps and triceps muscles. Steeper Electric Elbow Lock The electric lock for the Steeper mechanical elbow is a straightforward alternative to the body-actuated mechanical lock. Just as with the mechanical elbow lock, each operation of the electric lock changes its state: from locked to unlocked or from unlocked to locked. The electric lock, powered by a 6-V battery, is operated by an electromechanical switch or by a single-site myo-switch control. Steeper offers a variety of switches, and any other commercially available switch that provides a momentary switch closure can be used as well. The variety of control arrangements possible with the electric lock is a major advantage for persons who could benefit from a cable-actuated mechanical elbow but who have difficulty producing the control motions or forces required by the mechanical lock. http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library ELBOW MECHANISMS Three electric elbows are available for adults: the Boston Elbow, the NY-Hosmer Electric Elbow, and the Utah Arm. These elbows differ from one another in mechanical configuration, drive mechanism, and control options. Table 6C-3 summarizes various characteristics of these devices, and each of the elbows will be discussed individually in following sections. In addition to the powered elbow joint, all of the elbows incorporate a friction joint, or turntable, for manual humeral rotation. With the Boston Elbow and the NY-Hosmer Electric Elbow, the friction is adjusted by a crown nut on a threaded stud centered in the proximal surface of the elbow enclosure. Access to this nut must be provided in the fabrication of the humeral shell. The Utah Arm utilizes an external split collar for friction adjustment of the humeral rotation joint; therefore, no special accommodation must be made in the fabrication of the humeral shell for access to the adjustment. Much concern is given to the lifting capacity of electric elbows. While this is an important characteristic, especially for persons with bilateral amputations, the elbows are primarily used to position the prehension device and then kept in place while performing some activity. As noted in Table 6C-3, the three elbows have maximum live lift capacities ("live lift" meaning lifting by powering the elbow) of between 3.4 N-m and 5.9 N-m (2.5 ft-lb and 4.5 ft-lb). At a distance of 30 cm (approximately 12 in.) from the elbow axis, the NY-Hosmer Electric Elbow can lift a maximum weight of 1.1 kg (2.5 lb), and the Boston Elbow can lift a maximum weight of 2.0 kg (4.4 lb). The maximum live lifting weight for the Utah Arm lies between these two values. Any weight due to the materials of the forearm, wrist component, and prehension device must be subtracted from these values to arrive at an estimate of the maximum weight of an object that can be held and lifted. An adult Electric Handlike prehensor weighs on the order of 0.45 kg, or about 1 lb. Assuming an elbow axis to palm distance of 30 cm, having this type of prehensor would reduce the maximum weight of an object that can be lifted to approximately 0.65 kg (1.4 lb) for the NY-Hosmer Electric Elbow and to 1.55 kg (3.4 lb) for the Boston Elbow. Weight of the forearm and wrist componentry would further reduce these values. In comparison, the lifting capacity of the physiologic elbow can exceed 25 kg (55 lb) for an adult male at low speeds of flexion and over 13 kg (29 lb) at flexion speeds of about 57 Therefore, one cannot expect to perform the same types of activities, degrees/sec. especially those involving the active lifting of moderate to heavy loads, with an electric elbow as one would expect to do with the physiologic elbow. Heavier loads can be lifted by a prosthesis with an electric elbow, but in a passive manner. This is done by locking the elbow in place after prepositioning it, using body movement and posture to orient the prehensor to grasp the object, and then straightening the body without actively moving the elbow joint. In this way, objects can be lifted that exceed the live lift capacity of the elbow. However, even this technique is limited by the breakaway device or slip clutches incorporated in the elbow mechanisms to protect them against mechanical overload. This overload protection also serves to protect the user, to a degree, from excessive forces transferred through the socket during accidents such as falls. The elbow would give way if the person fell upon the prosthesis. Both the Boston Elbow and the Utah Arm have passive lift capacities of 68 N-m (50 ft-lb), and the NY-Hosmer Electric Elbow has a capacity between 24.4 N-m and 27.1 N-m (18 to 20 ft-lb). By using the prosthesis configuration described earlier-with an electric prehensor and distance to the elbow axis of 30 cm (12 in.), the Boston Elbow and Utah Arm can passively lift an object weighing up to 23 kg (49 lb), and the NYHosmer Electric Elbow can passively lift 8.1 to 9.1 kg (17 to 19 1b). As with lift capacity, the speed of elbow motion is often used as a figure of significance when comparing prosthetic elbows. But here again, some perspective can be gained by considering speeds of electric elbows in comparison with physiologic performance. Averaged maximal speed of physiologic elbow flexion for adult males has been measured at about 600 degrees/sec for movements through a 120-degree range, with peak speeds in excess of Clearly the maximum speeds of adult electric elbows (see Table 6C-3 ) 900 degrees/sec. are far less than these values. However, maximum speeds of elbow flexion are probably rarely used in everyday functional activities. Peak physiologic elbow speeds more typical of those that might be used in common functional activities have been found to be correlated to the amplitude of the movement with the approximate relationship: speed (degrees/sec) = 2.9 For a movement over a 10-degree range, the degrees/sec/degrees x distance (degrees). peak velocity during the movement would be about 29 degrees/sec. For a greater angular movement of 90 degrees, the peak velocity would be about 261 degrees/sec. Therefore, it http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library would appear that all of the electric elbows can approach functional physiologic speeds over short distance movements but are significantly slower than the physiologic elbow over larger angular movements. Perhaps more important than an electric elbow's measured speed is how it is being controlled in relation to its speed of response. To use an extreme example, it would be difficult to position a fast elbow by using switch control that actuated the elbow at full speed in flexion and in extension. The user would have a tendency to overshoot the target position and would likely not be able to make small changes in position. Therefore, as electric elbows have become faster, there has been greater utilization of proportional velocity control. In this type of control, the magnitude of the input signal, which the user is presumed to be able to regulate, determines in direct proportion the speed of motion. By creating a higher-amplitude signal, the user directs the elbow to move faster (up to the limits of the mechanism), and by producing lower-level signals, the user drives the elbow at slower speed. The following sections elaborate on each of the adult electric-powered elbow systems. Liberty Mutual Boston Elbow The Boston Elbow had its origins in the 1960s in a cooperative research and development venture involving the Liberty Mutual Insurance Company and its Research Center, the Massachusetts Institute of Technology, the Harvard University Medical School, and Massachusetts General Hospital. The first prototypes were encouraging, but considerable development by the Liberty Mutual Research Center during the first 5 years of the 1970s was necessary to produce a version that could be commercialized. Robert Jerard redesigned the original prototype and proved that a commercial version was feasible, and T. Walley Williams III carried out the commercialization and directed subsequent design alterations. Trials with the commercial elbow were begun in 1975, and the elbow was made generally available in 1979. In its present form (see Fig 6C-7.), the Boston Elbow is available in one size and is configured with the motor and gearing within the elbow "cap" and the battery and electronics supported in a metal forearm frame. A prefabricated plastic and foam forearm shell (not shown in the figure) is custom-shaped and laminated to enclose and protect the forearm componentry when the prosthesis is finished. The elbow is typically controlled in one of two ways: by a two-site, two-function myoelectric The twocontroller or by integrated or separate two-function electromechanical switches. site myoelectric controller offers control of speed and torque in proportion to the magnitude of the myoelectric signal. Separate gain adjustments allow for tailoring the response of the elbow with respect to the condition of the myoelectric sources. An Evaluation Meter is available to monitor the myoelectric signals for evaluation and training and can be used with or without the elbow in operation. Control by electromechanical switches provides single-speed (or single-torque) operation in flexion and in extension. The additional circuit board required for switch control includes circuitry for limiting the flexion and extension speeds separately. Although the user cannot vary the speed of motion when using switches, the speed can be set to an acceptable level. These adjustments can be helpful during training, when the speeds might be reduced while the client becomes familiar with the operation of the elbow. The speed adjustments are also helpful in balancing the elbow's response to gravity, which (as with all elbow mechanisms) assists the elbow during extension and retards it during flexion, especially if an electric prehensor and electric wrist rotator are used. In operation, the Boston Elbow can be positioned anywhere within its 135-degree range of motion and is self-locking whenever the control signal ceases. A free-swing range of 30 degrees of flexion from the stopped position of the elbow can be engaged and disengaged by manual operation of a mechanical slide bar. The Boston Elbow can be used in conjunction with cable-actuated body-powered prehensors and with other electric components in a configuration with separate control sources for each component. Use of separate control sources is preferred, when feasible, because it can allow for simultaneous and coordinated operation of more than one component. However, if control sources are limited, Liberty Mutual offers a two-site, four-function proportional myoelectric controller configured for sequential operation of the elbow and an electric prehension device. A separate switch, such as a harness-type switch, is used to select the component to be http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library controlled. Although three control sources are needed-two myoelectric sites to control the movement of the component and a source to actuate the selection switch-this arrangement provides for proportional control of each of the two components. Other customized control configurations have been developed by the Liberty Mutual Research Center, and circuit diagrams for the elbow controller are readily available. NY-Hosmer Electric Elbow The NY-Hosmer Electric Elbow was designed by William Lembeck at New York University The prototype of this mechanism was originally under the direction of Sidney Fishman. conceived for use by children and was evaluated, as such, in the 1970s. Consequent modification to that prototype design and the involvement of the Hosmer Dorrance Corporation resulted in the commercialization of "large" and "medium"-sized versions introduced in 1983. The two sizes are equivalent to the E-400 and E-200 Hosmer Dorrance mechanical elbows, and the mechanical elbows can be alternatively fit to prostheses originally configured with the electric elbow. Hosmer Dorrance also introduced versions of the elbows for exoskeletal and endoskeletal applications ( Fig 6C-8 ). The same motor and drive mechanism, contained in the elbow cap, is used for all versions of the elbow; therefore, mechanical performance characteristics are the same for all models. External dimensions, the turntable, and the forearm saddle attachments vary from model to model. The absence of fixed componentry in the forearm and the use of a forearm saddle provides considerable freedom in the length and customized shaping of the forearm section. The elbow is powered by a separate battery pack, available in four-and five-AA cell configurations, that can be positioned within the prosthesis as appropriate. Placement within the humeral section is preferable to placement in the forearm because additional weight in the forearm will reduce the functional lift capacity- the maximum weight of a held object that can be lifted by the elbow. Two control options are available from Hosmer Dor-rance: switch control using two-function electromechanical switches and two-site, two-function myoswitch control. A variety of electromechanical switches are available from the manufacturer, including cable and harness pull switches and one-site and two-site push switches. Other switch configurations are also possible. Both the switch control and the myoswitch control operate the elbow at one speed, which cannot be adjusted but which is determined by the battery voltage, the load on the elbow, and the direction of movement. The variable-speed controller manufactured by Universal Artificial Limb Co. has been adapted to the NY-Hosmer Electric Elbow. This two-source controller can be set up to accept input from force-sensitive pads, displacement transducers, or Otto Bock electrodes to provide proportional control of the elbow's speed. A pawl-type locking mechanism placed in an early stage of the drive train locks the elbow virtually anywhere through its 130-degree range. Locking is automatic whenever the control signal ceases. The elbow can also be made to swing freely by driving it to its fully extended position, at which point the free swing automatically engages. Once engaged, the elbow can be swung or pushed unpowered anywhere within its full range of motion. Free swing is disengaged by activation of the flexion control. Elbows can be equipped with or without the free-swing feature, and elbows without free swing can be retrofit to incorporate it. Numerous configurations are possible when the electric elbow is used in conjunction with wrist and prehension components having control sources separate from the source (or sources) operating the elbow. Hosmer Dorrance does not offer methods for integrating control of the elbow with other electric components, with the exception of the NY-Hosmer Prehension Actuator (PA). In configuration with the PA (shown in Fig 6C-4.), the elbow can be operated by a three-function cable pull switch. The first two functions operate the elbow in flexion and extension, and the third function (with the switch control cable fully extended) operates the opening of the PA. Motion Control Utah Arm The Utah Artificial Arm is manufactured and distributed by Motion Control, a division of IOMED, Inc. The system was developed at the University of Utah in the latter half of the 1970s by a team directed by Stephen Jacobsen, Ph.D. The original Utah Arm, as first clinically fit in 1980, included the electric elbow mechanism and control electronics developed http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] 6C: Components for Adult Externally Powered Systems | O&P Virtual Library by the Utah team and a body-powered voluntary-opening split-hook prehensor. In 1982, Motion Control introduced a proportional myoelectric controller that allowed the elbow to be used in conjunction with an electric prehensor. As it is presently configured, the "arm" includes a motorized elbow mechanism, a friction-type humeral turntable, a forearm shell, and electronics for both the elbow and an optional electric prehension device (either an Otto Bock System Electric Hand or Grei-fer). The Utah Arm is available in one size and is shown in Fig 6C-9 . The battery pack and elbow electronics are contained within the stationary (with respect to the humeral section) enclosure distal to the turntable. The motor, mechanical transmission, and prehensor electronics are located in the forearm section. The forearm shell is a finished injection-molded plastic enclosure that can be cut to shorter length or lengthened by the addition of an extension. Elbow rotation occurs about an axis through the anterior aspect of the joint. This placement allows flexion to approximately 150 degrees, thus bringing the prehensor nearer to the face with less shoulder flexion than is possible with other elbow designs. Modularity of the electrical and mechanical assemblies is a hallmark of the Utah Arm, and this facilitates access for troubleshooting and replacement of subunits. A single control technique is used to operate the elbow mechanism: two-site proportional myoelectric control. Switch control is not feasible because of the relatively high speed of the elbow, over 100 degrees/sec with an electric prehension device. Nonlinear filtering of the myoelectric signals provides for quick response of the elbow to sudden high-amplitude changes in the control signals to achieve fast movements, but smoother response for the slower-changing lower-amplitude signals used in more precise movements. Motion Control offers the MYOLAB II-EMG Tester/ Trainer, which incorporates meters and auditory feedback of myoelectric signal amplitude for evaluation and training. The MYOLAB II can be used to monitor the myoelectric signals simultaneously with operation of the Utah Arm. Locking of the elbow is engaged whenever it is held stationary for a set period of time (the length of which can be adjusted) or whenever a momentary switch is actuated. The elbow has 22 locked positions throughout its range of motion. Unlocking can be effected in several ways: by rapid cocontraction of the controlling muscles, or "rate" control; by a slower contraction of at least one muscle, or "threshold" control; or by actuation of the same momentary switch that can be used for locking. Lock control by the switch is always available. "Rate" control and "threshold" control of unlocking are mutually exclusive and are determined by an adjustment in the electronics. When the elbow is unlocked and no myoelectric signals are present, the elbow is in a powered free-swing mode. The free swing is powered (unlike the free-swing modes of the Boston Elbow and the NY-Hosmer Electric Elbow) because the drive transmission of the Utah elbow remains engaged during free swing. Therefore, to overcome the electromechanical inertia of the drive mechanism, the motor actively flexes and extends the elbow, thus drawing battery current, as the arm is swung. The action of the motor is controlled by the response of a load cell transducer to the torque exerted on the forearm. The Utah elbow can be used in conjunction with other body-powered and electric components having separate control sources. In addition, options exist for integrated control. The electronics added in the Utah Arm version with electric prehensor converts the system from a two-site, two-function controller of elbow flexion and extension to a two-site, four-function sequential controller of elbow and prehensor. In this configuration, the myoelectric sources proportionally control the elbow when it is unlocked. Whenever the elbow is locked, the same myoelectric sources are automatically channeled to proportionally control opening and closing of the prehension device. Unlocking the elbow by "rate" control-rapid cocontraction of the controlling muscles-returns control to the elbow without inadvertent operation of the prehensor. An electric wrist rotator (Otto Bock) can also be added to the Utah Arm system if there is sufficient forearm length. The rotator can be controlled from a separate and independent source, such as a two-function harness switch actuated by scapular abduction. Alternatively, the movement of the rotator can be controlled by the same myoelectric sources as the elbow and prehensor. In this arrangement, a switch is still needed, but actuation of the switch when the elbow is locked channels the myoelectric signals to the wrist rotator. When the switch is not actuated and the elbow is locked, the myoelectric signals control the prehensor. Commentary on Electric Elbows http://www.oandplibrary.org/alp/chap06-03.asp[21/03/2013 21:53:42] This is the hope. all elbow controllers available through commercial manufacturers control the velocity of motion. control options. How rapidly this section is transformed from a state-of-the-art review to a historical footnote will be a measure not only of the technological advances in our culture but also of the vitality and earnestness of the community working to improve the capabilities of persons who use upper-limb prostheses. one should consider the many attributes of each of the elbows-including factors such as weight and size. and capacity for being finished in a cosmetically acceptable form-when choosing one for implementation in a fitting.asp[21/03/2013 21:53:42] . it will be necessary to adopt different control strategies (than are now used) to take advantage of the improved response. SW14 4LB England Liberty Mutual Research Center 71 Frankland Rd Hopkinton.6C: Components for Adult Externally Powered Systems | O&P Virtual Library At present. It is not. In a related study using tracking experiments. significant changes have occurred in the types and characteristics of electric-powered upperlimb components. Furthermore. There is greater difference between each of the prosthetic elbows and the physiologic elbow than there is among the elbow mechanisms. Other devices under development then are now commercial items accepted in clinical practice. Technological reviews are always in danger of becoming out of date. Ltd 237-239 Roehampton Lane London. Studies by Doubler and Childress indicate that improved control of currently available elbows may be achieved by the use of position servo controllers that directly link movement of a physiologic joint (such as shoulder elevation) to flexion of a it was also shown that prosthetic elbow. inevitable that new developments come into being. position control of a hypothetical prosthesis mechanism with nonlimited dynamic-response characteristics had greater potential for effective control of prosthetic joints than did velocitycontrol techniques. the devices and systems described here may no longer be available or may be eclipsed by improved versions. the work suggests that even present-day elbows could be controlled more effectively by position control. Consequently. MA 01748 http://www. Therefore. These types of controllers have been used experimentally on the NY-Hosmer Electric Elbow and on the Boston Elbow. integration into a complete prosthesis. it is not yet possible to truly restore elbow function with these prosthetic components. either with switches operating the elbow at some preset speed or with proportional controllers (such as myoelectric controllers) that enable the user to directly regulate the speed. No matter how well accepted or how adequately current devices and systems are thought to perform. CA 95008 Hugh Steeper (Roehampton). None of the available electric elbows approach physiologic performance. they fall far short of the physiologic systems they have been developed to replace. The implication for the future is that as elbow mechanisms become faster. In several years. Many factors beyond technological and conceptual breakthroughs must be brought together to create an environment that supports innovations and provides for the transfer of innovation into clinical practice. And still other items have been introduced in the intervening years that were not even conceived a decade ago.org/alp/chap06-03. Since that time. Several devices described in that edition have ceased to be available. however. CONCLUDING REMARKS The first edition of the Atlas of Limb Prosthetics was published in 1981. RESOURCE LIST Hosmer Dorrance Corporation 561 Division St PO Box 37 Campbell.oandplibrary. Inc 3000 Xenium Lane North Minneapolis. 1972. Yugoslav Committee for Electronics and Automation. Alpenfels EJ: The anthropology and social significance of the human hand. Grahn EC: Development of a powered prehensor. Hum Factors. Bankov S: Maximum strength of elbow flexors with pronated and http://www. 1969. Chan KM. Clin Prosthet Orthot 1986. Knutti DF. in Gavri-lovic M. and the elderly. 1972. 29:249-269. Northwestern University. Childress DS. 10. in Proceedings of the 38th Annual Conference on Engineering in Medicine and Biology. pp 159-167. 21:19-31. Childress DS: Artificial hand mechanisms. Houston. The Alliance for Engineering in Medicine and Biology. Inc Division of IOMED. in Proceedings of the Mechanisms Conference and International Symposium on Gearing and Transmissions. San Francisco American Society of Mechanical Engineers. Billock JN: Upper limb prosthetic terminal devices: Hands versus hooks. Suite A Salt Lake City. Doubler J A. 15. pp 1-11. Int Dis-abil Stud 1989. IEEE Trans Biomed Eng 1982. Doubler JA. 7. 10:57-65. 6. Wilson AB Jr (eds): Proceedings of the Fourth International Symposium on Advances in External Control of Human Extremities. 50. 8. Texas Institute for Rehabilitation and Research.asp[21/03/2013 21:53:42] . 13. 1989. Spencer WA: Development of Externally Powered Upper Extremity Orthotics. 11:167-170. 2. 4. Jacobsen SC. et al: A medical-social study of upper limb amputees in Hong Kong-a preliminary report. adults. report 72-Mech-55. Datta D. Inc 1290 West 2320 South. Columbia. Leung KK. et al: Development of the Utah artificial arm. Childress DS.6C: Components for Adult Externally Powered Systems | O&P Virtual Library Motion Control. Instrument Society of America. Yugoslavia. 1982. Chicago. 14. 1973. J Rehab Res Dev 1984. Jorgensen K. pp 65-67. Ronald J: Myoelectric prostheses for below-elbow amputees: The Trent experience. 9. Orthot Prosthet 1984. MN 55441 Universal Artificial Limb Co 938 Wayne Ave Silver Spring. 11. 21:5-18. Childress DS: An approach to powered grasp. Johnson RT. MD 20910 University of New Brunswick Prosthetics Research Centre Institute of Biomedical Engineering 180 Woodbridge St Fredericton. 12. in Proceedings of the 23rd Annual Rocky Mountain Bioengineering Symposium. 5. Childress DS: Design and evaluation of a prosthesis control system based on the concept of extended physiological proprioception. 31:689-701. Doubler JA: An analysis of extended physiological proprioception as a control technique for upper-extremity prostheses (dissertation). 2:4-21. Strysik JS: Controller for a high-performance prehensor. 1985. Evanston. 3. Ill.org/alp/chap06-03. New Brunswick E3B 4R3 Canada References: 1. Artif Limbs 1955. 1986. 37:43-48.oandplibrary. Final Report. Dubrovnik. Childress DS: An analysis of extended physiological proprioception as a prosthesis control technique. Missouri. p. Engen TJ. Kingston J. Imrhan SN: Trends in finger pinch strength in children. Lee SY. J Rehabil Res Dev 1984. UT 84119 Otto Bock Orthopedic Industry. Washington. Millstein SG. part 2. 10:118-155. Peizer E. J Bone Joint Surg [Am] 1981. in Medicine and Sport. Volland G. Berlin. vol 183. New York. National Research Council Canada. DC. Biomechanics II. 34. New York. Taylor CL.S.oandplibrary. Switzerland. 37. Askew LJ. London. Springer-Verlag NY Inc. 20. in Klopsteg PE. Andrew JT. Wright DW. Palmer AK. 1969. Clin Prosthet Orthot 1986. 29. Springer-Verlag. Nader. Los Angeles. in Klopsteg PE. Ottawa. 33. supinated forearm. Komi PV: Relationship between muscle tension. in Atkins DJ. Hunter G: The below-el-bow myo-electric prosthesis: A comparison of the Otto Bock myo-electric prosthesis with the hook and functional hand. 1989. Werner FW. Tanenbaum SJ: The Boston Elbow . Switzerland. 23. in Desmedt JE (ed): New Developments in Electromyography and Clinical Neurophysiology. 1973. the New York Prehension Actuator. in Proceedings http://www. 28. 1989. Keller AD. (eds): Comprehensive Management of the Upper-Limb Amputee. Northmore-Ball MD. pp 19. U. Taylor CL: The biomechanics of the normal and of the amputated upper extremity. 38. et al: Normal functional range of motion of upper limb joints during performance of three feeding activities. vol 1. 62:363-367. 40. 18. Canada. Murphy D. Andrew JT.119. Sears HH. 71:505-509. 1919. Wilson PD (eds): Human Limbs and Their Substitutes. M: The artificial substitution of missing hands with myoelectrical prostheses. Kashman N. 19. 24.org/alp/chap06-03. Meier RH. Pertuzon E. and the NU-VA Synergetic Prehen-sor. Ring ND. NY. in Proceedings of the First International Workshop on Robotic Applications in Medical and Health Care. 63:872-877. 25. McGraw-Hill International Book Co. Zahm V: Studies to Determine the Functional Requirements for Hand and Arm Prostheses. Safaee-Rad R. 1971. Schlesinger G: Der Mechanische Aufbau der kanstlichen Glieder.5. 39. J Bone Joint Surg [Br] 1980. Simpson DC: Functional requirements and systems of control for powered prostheses. 27. Basel. 31. Heger H. S Karger AG. Proceedings 1968-1969. Shwedyk E. Heckathorne CW. Congress. 26. 1984. McGraw-Hill International Book Co. et al: A biomechanical study of normal functional elbow motion. An KN. hand. Prout W: The New York Electric Elbow. S Karger AG. Office of Technology Assessment. 1954. Switzerland. Simpson DC: The functioning hand. Jacobsen SC: Experience with the Utah Arm. in Atkins DJ. Inc. Bouisset S: Maximum velocity of movement and maximum velocity of muscle shortening. et al: Four-function hybrid arm prosthesis incorporating an electric wrist rotator and prototype electric prehensor. 1984. et al: Functional wrist motion: A biomechanical study.6C: Components for Adult Externally Powered Systems | O&P Virtual Library 16. in The Basic Problems of Prehension. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. J Hand Surg [Am] 1985. Jacobsen SC: Clinical experience with the Utah artificial arm. Morrey BF. 66:69-74. in Medicine and Sport.asp[21/03/2013 21:53:42] . vol 6. Basel. 1:250-256. Mathiowetz V. 30. 1988. Hunter GA: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prostheses. in The Canadian Association of Prosthetists and Orthotists Yearbook. 258:9-17. 1971. Quanbury AO.Health Technology Case Study 29. Taylor CL: Control design and prosthetic adaptations to biceps and pectoral cineplasty. Krick H. 36. vol 6. EMG and velocity of contraction under concentric and eccentric work. 35. Arch Phys Med Rehahil 1985. Movement and Control of Artificial Limbs. 17. 22. Springer-Verlag. S Karger AG. Michael JW: Upper limb powered components and controls: Current concepts. et al: Grip and pinch strength: Normative data for adults. and terminal device. Wilson PD (eds): Human Limbs and Their Substitutes. Arch Phys Med Rehabil 1990. University of California Department of Engineering. 10:66-77. Mason C. The Institution of Mechanical Engineers. Basel. 1954. J R Coll Surg Edinb 1976. Welbourn DB: A self-adaptive gripping device: Its design and performance. 1947. Biomechanics II. 21. 32. et al: Guidelines for standards for externally powered hands. Kemp MC: Design and development of an electrically powered prosthetic gripper. 10:27-34. 10:39-46. Clin Orthop 1990. 21:329-340. Heger H. Uellendahl J. New York. Sears HH. the human advantage. Bull Prosthet Res 1969. Prosthet Orthot Int 1986. Biomed Eng 1966. in Ersatzglieder und Arbeitshilfen. pp 30-33. New York. Report OTAHCS-29. C.. pp 167-168.6C: Components for Adult Externally Powered Systems | O&P Virtual Library of the 13th Annual RESNA Conference. Exp Brain Res 1984. van Lunteren A. van Lunteren-Gerritsen GHM. et al: A field evaluation of arm prostheses for unilateral amputees. 43. 1990.org/alp/chap06-03. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 6C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Stassen HG.asp[21/03/2013 21:53:42] . Chapter 6C . Contact Us | Contribute http://www. Prosthet Orthot Int 1983. D. Johansson RS: Factors influencing the force control during precision grip. 41. Williams TW: The Boston Elbow. SOMA 1986.Atlas of Limb Prosthetics: Surgical. 7:141-151. Westling G. Resna Press. 42.oandplibrary. 53:277-284. Washington. Prosthetic. 1:29-33. any general discussion of control systems for arm amputees must include cable control from body movement inputs.D The material that follows in large part deals with control of externally powered prostheses. However. Also. as is the case with most control systems. reprinted 2002. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. With arm prosthesis systems. This concept is shown in Fig 6D-1. Hence. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Prostheses that are entirely cable actuated and body powered are dealt with in another section of the Atlas (see Chapter 6A and Chapter 6B). the most commonly prescribed lower-limb prosthesis. because lower-limb activity is highly repetitious and stylized (e. myoelectric. ©American Academy or Orthopedic Surgeons. If the input is. Prosthetic. the primary feedback method is visual feedback of output position to the prosthesis user. powered systems that emulate cable systems will play.org/alp/chap06-04. it is believed. control theory is a part of general systems theory-the part that has to do with how one goes about creating inputs to a mechanism or system in order to produce specified outputs or responses. As applied to prosthetics. IL.g.asp[21/03/2013 21:53:49] . This is particularly the case for high-level unilateral and bilateral amputees. Prosthetic.6D: Control of Limb Prostheses | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 6D Chapter 6D . This comes about because the lower limb must bear significant body loads. where the systems of choice often use hybrid control (cable. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists PLACEMENT OF PROSTHESIS CONTROL IN THE GENERAL CONTEXT OF CONTROL THEORY AND PRACTICE Control theory is a common topic in engineering and is even a topic of mathematics. or some combination of these or other methods) and hybrid power (electric and body power). edition 2. This section attempts to place prosthetics control in the wider context of general control applications. whereas the artificial foot is a passive mechanism. Rosemont. American Academy of Orthopedic Surgeons. switch. Childress. It is interesting that when we talk about lower-limb prostheses. cable-operated systems will also be considered in this discussion because they are an important form of prosthesis control. suspension. Consequently. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). However. Click for more information about this text. You can help expand the O&P Virtual Library with a tax-deductible contribution. a function of the systems output variables. Prosthetic. 1992. even when electric-powered components are used. http://www.. only for persons with amputations at the knee or higher do issues of control become apparent with lower-limb prostheses. Ph. alignment. etc. at least partially. Briefly. Instead. discussion is more prevalent about control of upper-limb prostheses than it is with lower-limb prostheses. we talk more about interface loads. and Rehabilitation Principles. The various control schemes of cableoperated prostheses are considered there. an important role in prosthesis control of the future. we seldom talk about control. Reproduced with permission from Bowker HK. Closed-loop control allows a system to adjust the inputs as the system outputs are changed by external disturbances or as the operator wants to change the output to a desired value. little will be found in engineering books regarding the control approaches that are currently used with limb prostheses and discussed here. A more complete view of feedback relationships in prostheses has been described by Childress. control concerns how to create inputs that will cause an artificial limb to behave in a desired way. with the transradial prosthesis. the attached prehensor needs to be controlled (unless a passive hand is used). for both electric-powered and body-powered prosthetics systems. If the inputs are generated independently of outputs.Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles Upper-Limb Prosthetics: Control of Limb Prostheses Dudley S. we call it "closed-loop" or "feedback" control. we call it "open-loop" control.oandplibrary. who is the input decision maker. walking) and because the intact knee joint acts as the natural controller for the transtibial prosthesis. Nevertheless. The transradial prosthesis for the upper-limb (the most common upper-limb prosthesis) is similar to the transtibial prosthesis in that it is an extension of the limb and because position and velocity are controlled by the elbow joint. as opposed to the so-called manual control systems.. Consequently. Robots Solutions to problems in robotics seldom have an impact on prosthesis design. Teleoperators that provide proportional force and position feedback to the site of control are often called "telechirs. and quiet in operation. arms. and other human-operated systems) have been extensively studied in the field of "human factors engineering. Prostheses. SOME COMMONLY EXPERIENCED CONTROL SYSTEMS THAT RELATE TO PROSTHESIS CONTROL http://www. solutions to manipulator problems often do not solve prosthesis problems. just as most arm prostheses have been cable controlled. at least partially. airplanes. because they must be carried about with the user. With these systems the human operator remotely controls manipulators that. Additional differences come from the engineering constraints that prostheses and manipulators are designed under. Murphy arms appear to be able to perform many tasks considerably quicker than what is typical with manipulators.org/alp/chap06-04. as it does in prostheses. Sheridan and Ferrell have written definitively on this topic. even though knowledge of manipulator and robot design is surely of assistance to designers of humanprosthesis systems (artificial arms). spacecraft. solutions to prosthetics problems may have points out that bilateral users of cable-actuated prosthetic manipulator applications. became available for prosthesis design. While in almost all human-machine systems the operator interacts with the machine with the hands or feet. to human-prosthesis systems. A main difference is that the controls of the manipulator are activated through movement and forces of the operator's hands. shape. Manipulators The class of complex human-machine systems used in industry and elsewhere. and/or feet. or appearance requirements. particularly from an engineering viewpoint. Some of these advances may be useful in limb prosthetics. prosthesis systems are a subset of human-machine systems that may be classified as having "nonmanual control" modalities. partially for the same reasons that manipulator designs have not had much impact.g. this is not the case with most humanprosthesis systems. such as in outer space or under the sea. shape. One aspect of prosthesis control that makes it unique when compared with typical human-machine systems is the modality of human control. that most nearly resemble complex human-artificial arm systems are master-slave manipulators (teleoperators)." and many of the ideas of that field relate. Human-machine systems (e. restricted in size. Robots are usually under the supervision of digital computers and so are less similar to human-prosthesis systems than manipulator systems. automobiles.6D: Control of Limb Prostheses | O&P Virtual Library Human-Machine Systems If we regard an upper-limb artificial arm as a machine that helps someone manipulate his environment. Another similarity of manipulators with prostheses is that the first master-slave manipulators that were designed were entirely cable controlled. As manipulators increasingly incorporated power into their designs. and these concepts should not be ignored. new control advances will be necessary if the operator is to have the advantages of "automatic assistance" and "feel" to help with control of the manipulator. manipulators are at least human-machine systems.asp[21/03/2013 21:53:49] . He attributes this to the basic design philosophy of arm prostheses. and their book deals with many of the issues of human-machine systems. Therefore. energy efficient so that they can operate all day on a relatively small battery." As tele-operator technology advances to more remote applications. the ways in which manipulators are designed to provide force and sensory and proprioceptive feedback to the operator in order to improve human-manipulator interaction are highly desirable in prosthetics. noise. then we can consider a human-prosthesis system as a human-machine system. Conversely.oandplibrary. and appearance (somewhat like a human hand/arm). However. handle radioactive materials or that work in hostile conditions like those in outer space. However. Direct cable control provides good proprioceptive and force feedback in manipulators. but the trend may now be in that direction. Manipulator design is usually not constrained nearly as much by power. for example. Consequently. Manipulator arms are somewhat similar to artificial arms and hands. attempts have been made to mimic the characteristics of the previously used This did not happen in prosthetics when power cable systems in the powered systems. even though they may not be applicable directly. weight. not many ideas can be translated directly between the fields without considerable modification. must be light in weight. . This is an automatic control adjustment that occurs without the knowledge of the operator but that helps with accurate control of the device. The upand-down operation of an electric-powered projection screen is another example of this kind of control. the operator can position the window in almost any desired vertical position. Pushing it the other way causes the window to elevate. Some lights have a proportional controller so that the position of a dial determines the level of light intensity.. This is a kind of position control input. the intensity may be set in the same way an electric car window is run up and down. the human operator is the feedback link for positioning the window." Powered drills. On-off control is a widely used approach to the control of prostheses. Lighting systems frequently use "on-off" control. It should be intuitively obvious that if a car's window moves very fast it would be difficult to position the window accurately with this kind of control. The window will stop whenever the switch is released. In proportional control. etc. rather simple systems. even when external loading is increased or decreased at the output. this is similar to the "velocity control" already described. owned a bicycle shop. Practical control systems for artificial limbs are. Cable controls have been used extensively in the bicycle and aircraft industry and also in the smaller field of limb prosthetics. In addition. effective positioning of an output such as a powered window is feasible for a human operator using "on-off control only if the velocity of the output is low enough to be commensurate with this control mode and with the limitations of the human operator. with the control ranging from mechanical switches to electronic switches operated by myoelectric signals. Some are so simple that when we experience them in daily life we often do not identify them as control systems. but which could be electronic and operated in a multitude of ways ranging from capacitive touch to breaking a light beam of a photodiode. Since intensity is related to the time the switch is activated.) as any systems that we commonly experience in our daily lives. Consequently. some of these devices have control mechanisms that automatically try to keep the output velocity constant for a given input setting. In prosthetics. Hence. pushing it the opposite direction causes the intensity to go down. intensity may be proportional to the position of a rotary resistor (transducer) that transduces rotational position into a signal that electronically sets the light intensity. and it is probably not by chance that the Wright brothers. The same is true in prosthetic systems that use "on-off" control. by and large. For example. They are self-contained and portable. In the bicycle brake example. Drills or screwdrivers with inexpensive control systems may use "on-off" switch control. It provides a kind of "velocity control" where position depends upon the time of activation of the switch and the velocity of the output (e.asp[21/03/2013 21:53:49] .org/alp/chap06-04. powered screwdrivers. Pushing the control switch down causes the window to be lowered. Pushing a switch one way causes the light intensity to go up. in a lighting system.oandplibrary. This allows a graded response in intensity. applying the brakes (gripping the rim of the wheel) is analogous to pulling the cable of a voluntaryclosing prehension mechanism to grip an object. Hand-operated bicycle brake systems are familiar cable-operated control systems that are similar to the cable control mechanisms of body-powered prostheses. are reversible. and have their own control systems. The Bowden cable was invented in 1885 by Bowden. and other portable powered tools are about as close to simple powered prosthesis systems and components (e. elbows. except that the prosthesis systems are not operated with the hands. prosthetic joint or car window). and the control systems used in these devices are often similar to those used in powered prostheses. By operating the switch and by watching the window as it moves. electric hands. the founder of the Raleigh bicycle company. contain rechargeable batteries.6D: Control of Limb Prostheses | O&P Virtual Library The use of powered mechanisms is a common experience of everyday life. use dc motors. Automobile powered steering is a kind of "boosted" power system in which the mechanism of http://www. More sophisticated devices may have proportional control in which the velocity of output rotation is proportional to position or pressure at the input. produce rotational velocity and torque. It is "on-off" switch control where the switch is often mechanical in construction. but it is not proportional control. the output intensity is proportional to an input setting. this method is sometimes called proportional-time control because the intensity is related to the time the switch has been activated.g. have interchangeable end components. but it should be noted that this is not conventional use for the term "proportional. Electric-powered automobile windows that are switch controlled for powered lowering or raising are an example of a commonly experienced system that is very similar to a switchcontrolled electric-powered prosthetic joint.g. the builders of the first airplane. In another kind of lighting system. Systems that fall short of these goals may be serviceable and practical. The ideas behind powered steering appear to have considerable application in control of upper-limb prostheses. used in combination with cable control. position servomechanisms are designed so that the output tracks or follows a time-varying input. The powered system works in the same way as its nonpow-ered equivalent. they need to be stated as goals in order to stimulate continued control system improvement and development. Home heating and cooling systems are in our common experience.g. Regulator-type control is not generally used in limb prosthetics. The fact that the antenna and the direction indicator box are only linked by an electrical position indicator means that the direction indicator on the control box can easily be moved to a new direction (there is no mechanical connection to the antenna) without a sense of "feel" of the antenna's actual position at the input.6D: Control of Limb Prostheses | O&P Virtual Library control is similar to the nonpowered case. This approach is closely related to the concepts of "extended physiologic proprioception" as proposed by D. In fact. in the discussion about manipulators and automobile powered steering. the development of cable-operated arm prostheses after World War II was considerably influenced by this cable technology through aircraft companies (e. an effort has been made to continue to give the pilot "feel" in the control stick.." In this control approach. if not impossible to achieve in practice. Some of these attributes may be difficult. Nevertheless. and forces on the wheels are reflected into the steering column. A position of the body is sensed and translated into a position of hand opening.C. outside temperature fluctuations. significant differences may exist between the input position indicator and the antenna while the antenna is powered to a new position.. connect the pilot to the control surfaces through electrical wire connections. This is a position control system (for a stationary car) in which the position of the front wheels is directly related to the position of the steering wheel. DESIRABLE ATTRIBUTES OF PROSTHESIS CONTROL (GOALS FOR LIMB PROSTHESIS CONTROL) There are several highly desirable attributes of control systems for limb prostheses. Velocity of turning of the wheels is directly related to steering wheel velocity. but we will know that they can be improved and made better. Airplane flight surface controls have traditionally been body powered through cables.asp[21/03/2013 21:53:49] . More recent advanced aircraft systems. Control systems of this kind are not too common in everyday experience. where a similar kind of "boosted" power. Cable-actuated systems give pilots a good "feel" for the plane just as cable-operated prostheses provide "feel" for the prosthesis. Nevertheless. Aircraft flight control systems for the control of wing and tail surfaces have taken a pathway of development that is similar to those taken with manipulators and automotive steering. Some of the important attributes are as follows: http://www. Such a system maintains the proprioceptive qualities of cable-actuated systems while also providing the benefits of powered components.) and by aeronautical engineers. The Steeper hand position controller is an example of this kind of system as applied to prosthetics. Consequently. inside temperature) in the face of external changes. the so-called "fly-by-wire" systems. however. They are a class of control systems that are called regulators and attempt to keep some variable constant (e. where the position of the front wheels is mechanically linked to the steering wheel so that error between the steering wheel and the front wheels is always minimal and so that a "feel" for the position of the wheels is provided through the steering column.oandplibrary. already discussed.org/alp/chap06-04. for example. The larger. a cable is used to "steer" a powered prosthesis joint through use of a position control system. new prosthesis controllers may follow this same trend. Simpson for the control of powered prostheses. The control system that orients a powered television antenna on top of a house by rotating the antenna until it matches a desired direction that has been set on a direction indicator box inside the house is one example that comes to mind. This is in contrast with automotive power steering. As noted already.g. Northrup Corp. except that with powered steering the required forces (torques) and excursions can be set to appropriately match the physical capabilities of a wide range of drivers. it is designed to maintain a fixed state that is set by a constant input. The author has called this "powered cable steering. Such systems are designed so that the output position responds quickly to input position changes. enables cable force and excursion to be matched to the physical abilities of the amputee using the system. The error between a new position of the direction indicator and the actual position of the antenna is used to drive the antenna's motor to reposition the antenna on the roof. On the other hand. faster planes that were developed after World War II often had "boosted" power for their cable controls. This kind of controller is automatic. This kind of control may require proprioceptive and sensory feedback of the right modality in order to be achieved. course. without excessive mental effort (attribute 1). the way people commonly use their limbs. Hence. A common example where independent action is not achieved is in typical cable-operated. muscular action and expenditure of energy are required from the arm. If possible. 6. If this is true. Prosthetic systems should respond immediately to inputs. should be directly accessible to the user and without time delay. In this document we have assumed that the prostheses to be controlled are basically "assistive tools. desirable for the "tool" to look and function somewhat like a human arm. of with activities of daily living. 7. it is often desirable to be able to control prehension force. Successful control systems enable the users to use their artificial limbs almost subconsciously.asp[21/03/2013 21:53:49] . then one may want to control joint compliance and other variables that may make the prosthetic limb have a number of characteristics of a human arm. it may be advantageous to lock specific joints. coordinated control of multiple functions. it is difficult to "replace" the human arm and/or hand system and probably always will be. the variables to be controlled in arm prostheses of the kind under discussion are as follows: http://www. if possible. The prosthesis should be used to supplement not subtract from available function.6D: Control of Limb Prostheses | O&P Virtual Library 1. at this stage of arm prosthesis development these concepts are still not clinically available. graceful movement) are important to prosthetic appearance." In other words. when a desirable position is reached. In general. if possible. the control system should be operated in ways that have a nice aesthetic appearance. just as are shape and color. The user should be able to think about other things. nonphysiologic control choices like mechanically locking the elbow have to be made. 4. For example. optional. For example. It may also be advantageous to control the rate of movement to the desired positions (the velocity). the mechanical response should be graceful. Operation of a function of one prosthesis should not cause any activity of the prosthesis on the opposite side. Independence in multifunctional control. it is not wise to sacrifice a useful body action for the control of a prosthesis.oandplibrary. It is. the clinical approach most often taken with arm prostheses is to design them as "tools" that the amputee can effectively use in assistance That is the direction taken by the author in this chapter. the hook tends to open during the lifting. It also implies attribute 3 in that it allows independent control of any function or any combination of functions. Control of any function should be able to be executed without activating or interfering with the other control systems of a multifunctional prosthesis. No sacrifice of human functional ability. the prosthesis should serve the user. All functions. The control system should not encumber any natural movement that an amputee can apply to useful purposes. when a person holds an object with the elbow bent at 90 degrees.g. It is advantageous for a prosthesis to move freely so that it can easily be put into the desired positions for operation. Therefore. prostheses are the machine parts of a human-machine system and not a part of the human systemeven though we want as much integration as possible. a person with prostheses on both arms should be able to use each limb independently. 5. the user should be able to learn to use the prosthesis quickly and easily. smooth. In other words. if possible. It means that learning to control the prosthesis should be intuitive and natural. This means that the prosthesis can be used without undue mental involvement. of course. Low mental loading or subconscious control. Since the energy stored in a battery of an artificial arm would be depleted rather quickly under this approach.. Practical issues often support the "tool" development approach to arm prosthetics. Likewise. the user should not be a servant to the prosthesis. Control methods that allow aesthetically pleasing action (e. In any case. Direct access and instantaneous response. Natural appearance. bodypowered transhumeral prostheses with a voluntary-opening hook. Movements that appear mechanical in nature may not be pleasing to the eye. even while using the prosthesis. flowing. 3. If the objective is to design an artificial arm that emulates a human arm as much as possible. Simultaneous. However. This feature is closely related to feature 1. User friendly or simple to learn to use. Likewise. WHAT SHOULD BE DESIGNED/WHAT SHOULD BE CONTROLLED? The question of what should be controlled by prosthetics control systems depends importantly upon the philosophy of artificial limb design. This is the ability to coordinate multiple functions simultaneously in effective and meaningful ways and. Once in position. 2.org/alp/chap06-04. If the user attempts to lift a heavy load. Biomechanical II. and when he wants the joint to remain fixed in position under load. even though they may complicate control since the locking state must be controllable. Although signals can be obtained from brain waves (electroencephalography [EEG]). It is not the intent here to discuss the many transducers that are available commercially. pushing) where it is advantageous for a prosthetic arm to be completely rigid (all joints positively locked).g. Most of the suppliers of control systems. tongue. Universal Artificial Limb Co. and changes in muscle mechanical/electrical impedance). http://www. When we think of control we usually think of grasping or of positioning and lifting.oandplibrary.asp[21/03/2013 21:53:49] . Practical inputs typically operate prostheses. It is difficult if not impossible to meet both of these needs with a single friction setting.6D: Control of Limb Prostheses | O&P Virtual Library 1. and other places. The ways in which biomechanical inputs can be used for control are. do not function well because when an amputee wants to position a joint. the ability to make joints rigid or free is also an important function to be controlled in practical arm prostheses.. to activate a cable attached to a switch or instrumented element. There are other instances where the joints should be free (e. Bioelectric/acoustic Biomechanical Input Biomechanical inputs of the kind described above have been used fairly extensively for the control of non-powered prostheses. Basically. However. only those transducers that are used in presently available prosthesis control systems will be discussed.. In fact. 3. or to otherwise operate some kind of position. Position Velocity Prehension force The joint state (locked/unlocked) There are many situations (e. with concentration on options that are currently in common or partial use and on those that appear to have some future potential for use with practical limb prostheses. Childress come from muscular activity (1) directly. the friction needs to be high. It is currently practical to control the "free" and "locked" conditions. 4. These same inputs can be used with some powered prostheses. 2. However.g.. SOURCES OF BODY INPUTS TO PROSTHESIS CONTROLLERS The human body can generate a variety of control signals that potentially could be used to has enumerated many of them. supply switch controllers and myocontrollers. A partial list of control options is included here. or touch/proximity transducer. that is not done in practical prostheses used by amputees today. (2) indirectly through joints. and excursion transducers that measure distance but with essentially no force required. intuitive and will not be discussed here in detail.g. force. increased flexibility can be obtained for these inputs with powered prostheses since force/excursion requirements can often be considerably relaxed when powered components are used. for the most part. In fact. I. the friction needs to be low. to push on a pressure-sensitive transducer. pressure-sensitive transducers that change their resistance with force applied but with essentially no excursion (isometric). as described in Chapter 6C. The options have been classified as two types: biomechanical and bioelectric/acoustic. locking/unlocking joints are often recommended. These are mechanical switches that require both force and excursion to turn on or off. In the future it may be advantageous to continuously control the impedance of joints from the free to the locked condition. myoacoustics. the force or movement of a body part (e. eyes. to activate an electronic switch. during walking).org/alp/chap06-04. feet. It should be pointed out that friction joints. these sources of control have not been shown to be practical for artificial limb control. the chin/head) is used to move a mechanical switch lever. and (3) indirectly from byproducts of muscular contraction (myo-electricity. Therefore. Transducers There are many kinds of transducers that can detect biomechanical signals (force or excursion) and turn them into electrical signals that can be used for control purposes. and it will not be discussed here. muscle bulge. particularly for high-level amputees. voice. and this kind of joint impedance control will be emphasized in this chapter. myoelectric control is the control of a prosthesis or other system through the use of "muscle electricity. In this way. just as mechanical noise is a by-product of an internal combustion engine.asp[21/03/2013 21:53:49] . Surface electrodes are currently the only practical way to pick up myoelectric signals for prosthesis control because in prosthetics applications the electrodes will be used daily for long periods of time each day. voltage polarity. Also. Unfortunately. hand or elbow). Switches also can provide more than one function from one source. Switch inputs can be arranged (with some electronics) so that multiple activations could be used to produce certain prosthetic functions. Myoelectric Control By definition. switch control is not always sufficient for good prosthesis control. this approach will probably never be able to attain the highest functional goals that may be possible. They are often called "dry" electrodes because of the absence of electrode paste (conductive gel). a frequently used pushbutton switch produces one function when pushed in a short distance and another function when pushed in a greater distance.g. questions must be asked. and electrical connections must often be observed when interconnecting transducers with control systems. Are they reliable and simple to incorporate into a system. do they offer some or many of the desirable attributes of prosthetics control that have already been discussed? The Integrated Nature of Prosthetics Systems Limb prosthetics systems suffer from the kind of "reductionist" approach being pursued in this chapter.. The modular approach has the advantage of providing great flexibility and novelty of system design. Hence. transducers. It is mentioned here only to hint at the wide variety of control schemes that are possible with simple switches and electronics. and to only talk about control in this chapter. which in turn drives the prosthetic system (e.6D: Control of Limb Prostheses | O&P Virtual Library supplies pressure transducers. they are not "dry" in the normal sense of the word because the body's own perspiration serves as a reasonably good electrolyte for the electrodes and makes conductive pastes unnecessary.g. in another sense this may not be a good way to think about how to design a well-functioning system. http://www. they must be benign to the skin and tissues. Muscle electricity is a by-product of muscular action. Care needs to be exercised when attempting to use transducers interchangeably (sometimes even switches) with control systems for which they were not designed or for which they are not specified as being compatible. A gel-type electrolyte is usually applied to the skin during ECG procedures to lower the electrical resistance of the skin. For example. Many kinds of control systems and transducers could be used with prosthetics systems. a simple code (like a few of the simple letters of the Morse code) could be input to produce a specified output. control systems. Consequently. For example. The surface method of detection of muscle activity is nicely illustrated in the standard electrocardiogram (ECG). With each system. the two functions of a powered prosthetic joint or prehensor can be controlled with the switch and activated by only one control source. their assembly into a whole prosthesis is fairly intuitive. and Hugh Steeper. electrical impedance. and more importantly. stainless steel) electrodes are usually used in myoelectric prostheses. This electrical potential is electronically processed and can be used to activate a switch controller or a proportional controller of power to an electric motor. Switches are easy to use. The electrical signal may be picked up with electrodes on the surface of the body as well as by internally dwelling wire/needle electrodes or telemetry implants. gel electrolyte is not recommended on the electrodes because of possible skin irritation with long-term usage. Correct voltage amplitude. the control source is a small electric potential from an active muscle.. and with a number of the control systems they can be used interchangeably." In this kind of control.oandplibrary. and inexpensive. inert metal (e. While it may be useful in one sense to break down upper-limb prosthetics systems into powered components. It is the author's opinion that the best operating system for a given task needs to be built as an integrated whole and not through a "modular" approach where different componentry is cobbled together to create a total system. Only systems that are designed from a more integrated standpoint may be able to accomplish this. simple. Ltd. However. with prosthesis control.. which is the electromyogram (EMG) of the heart muscle.. Actually. This is not done. However.org/alp/chap06-04. Switches are applicable to most systems. etc. supplies an excursion transducer. Bocker and push-button switches are commonly used switch types that can easily be operated by pressing against them with a body movement. some may consider this technique a result of "space age electronics. A myoelectrically controlled system will only work when the amputee wills it by voluntary muscle action. Collaboration between a German company. Similarly. Amplifiers or other circuitry at the electrode site are part of the electronic amplifying and processing system.. This kind of random-like electric wave can only be described statistically because its amplitude and frequency are constantly varying. Scott has written an elementary introduction to myoelectric prostheses. led to the first transradial myoelectric system that could be commercially purchased in the United States. Although myoelectric control will not be discussed here in great detail. The myoelectric signal itself is a rather random-shaped signal that comes from the spatial and temporal summation of the asynchronous firing of single motor units within the muscle. this voluntary control is one of the excellent attributes of myoelectric control. root mean square (RMS). To reduce electrical noise pickup. from a technical viewpoint it should be remembered that only the metal parts that interface with the user's skin are the actual electrodes. it seems appropriate to discuss this commonly used control method in a general way so as to give the reader a sense of what it is about." In reality. broadcast waves. The use of myoelectric control in arm prostheses has greatly increased in the United States and elsewhere during the last decade. It is impossible to cover myoelectric control comprehensively in this chapter. However. These potential interference signals may be many times larger than the myoelectric signal itself. The physical concept is therefore nearly 50 years old.g. are put into a single package with the metal electrodes on the outside.0001 V). the prosthesis should be free from influence by environmental electrical noise. which are more intuitive. etc.asp[21/03/2013 21:53:49] . Since there are no systems within our common daily experience that are analogous to myoelectric control. Consequently. British were instrumental in advancing the concepts of myoelectric control early on and scientists constructed some novel circuitry. The rule of thumb is to remember the number 100 for amplitude and for frequency. Good technical sources for information in this area may be found in a review of myoelectric control by Parker and Scott and in Bas-majian and DeLuca's discussion of myoelectric signals. as drawn diagram-matically. including control. When the electronic amplifier or the amplifier and processor electronics. or body position/motion. to see the electrodes. Viennatone.)-is often in the neighborhood of http://www. under moderate muscle action-which can be measured in a number of ways (peak to peak. The reader should refer to Fig 6D-2. The characteristics of myoelectric signals and the processing of myoelectric signals for use in prosthesis control have been described extensively in many places. filtering. In fact. for the most part. The electrical noise can be eliminated. Soviet scientists were the first to design a transistorized myoelectric system that could be carried on the body. by good electronic circuitry that features differential amplification. it seems appropriate to describe it more fully than was the case with biomechanical control approaches. Electricity from skeletal muscles can be created by voluntary muscle action. The early German system and an early British system were designed with vacuum tube electronic technology.oandplibrary. older than the solid-state electronics that made the method ultimately practical. Many other commercial myoelectric systems have followed (see the current listing in Chapter 6C). and Scott and have prepared a comprehensive bibliography concerning myoelectric control of Childress limb prostheses. A typical surface EMG amplitude on the forearm. whereas the noise signals may be a thousand times greater in magnitude. and an Austrian hearing aid company. the electronic amplifiers are often packaged together with the metal electrodes to make the connecting wires extremely short between the electrodes and the amplifiers. prosthesis location. one can use a "rule of thumb" to remember the general range of amplitude and the dominant frequency of a typical surface signal.org/alp/chap06-04. A typical surface EMG may have a peak-to-peak amplitude of around 100 µV (0.6D: Control of Limb Prostheses | O&P Virtual Library Just as with an ECG.100 |xV for amplitude and 100 Hz for frequency. the first myoelectric control system was built in Germany about 1944. even when a person is holding his muscular action as constant as possible.) that may cause the prosthesis to operate inadvertently. special care must be taken to negate the influence of interfering electrical signals from the environment (e. however. Otto Bock. It is a kind of electrical interference pattern resulting from the electrical depolarization of thousands of muscle fibers (perhaps several hundred per motor unit for typical forearm muscle action) when they are activated by neurons. and thresholding and by good electrode positioning and design techniques. etc. power lines. motor arcing. the whole package is often called an electrode. as shown. except for very exceptional cases. Such a system is immune to influence from external forces. fluorescent lights. Fig 6D-3. or 10. the power to the motor is turned off It should be noted that in myoelectric control it is the voltage and current from the battery that provide power to the motor. It is frequently desirable in electronic design to amplify the voltage of the surface EMG up to a level of from 1 to 10 V.0001) to accomplish this increase. Some can turn the motor on and also reverse its direction of action (polarity/rotation) while using only one myoelectric control site. Electronic logic circuitry can be designed such that if the dc potential is greater than some threshold voltage (e. In a myoelectric system. Therefore.0001. Frequencies below about 10 Hz are frequently not amplified to any extent so as not to amplify slow polarization voltage changes that may occur over time at the electrode-skin interface. All electrodes should remain in contact with the skin at all times during prosthesis usage. If electrodes lose contact with the skin.. Others use two or more myoelectric control sites to effect action of a motor or motors. Consequently.org/alp/chap06-04. a correct "tipping" response is a necessary but not a sufficient test to determine whether a myoelectric prosthesis is functioning properly. the electronics of myoelectric control systems from each manufacturer take on different forms and designs. an ac potential. amplification is followed by electronic processing that usually turns the myoelectric signal. Therefore. In actuality. However. Malfunctioning amplifiers may still respond to "tipping" even when they no longer function correctly as myoelectric amplifiers.. or it can be reduced all the way to zero when the muscle is inactive.000 is needed (1. There is very little energy in a surface EMG above about 400 Hz. "Tipping" the electrodes is often used as a way of demonstrating the general action of the prosthesis when it is not on the body. which may be of special importance with "dry" electrodes. The myoelectric signal is used only for activation or control purposes. Myoelectric control of a hand or other prehensor is particularly applicable to transradial amputation levels since people with acquired amputations usually have a "phantom http://www. The envelope of this dc potential goes up and down as the myoelectric signal increases or decreases in amplitude-as the muscular action increases or decreases. Consequently.oandplibrary.6D: Control of Limb Prostheses | O&P Virtual Library 100 µV. shows a typical transradial myoelectric prosthesis and a generic design for a two-site. touching the exposed electrodes with the fingers-so called "tipping"-introduces electrical noise through the fingers to the electrodes and into the electronics. Of course. not the electricity from muscles. it is not. a lack of control or interference may result.0/0. band-pass differential amplifiers are used so that voltages common to the two inputs (common-mode voltages) are rejected and so that amplification is most effective for frequencies around 100 Hz.0 V). For this reason it is important for the prosthetist to fabricate a diagnostic prosthesis with a clear plastic socket that permits the electrodes to be observed while the prosthesis is used in various positions and under various prosthesis loading conditions. The system illustrated in Fig 6D-2. two-function myoelectric control system for it. The body acts as an antenna and picks up electrical noise from the environment. up to 1000 Hz). It should also be noted that a myoelectrically controlled prosthesis can only function in its normal way when all the electrodes are positioned properly on the body. this response should not be interpreted to mean that the electrode is a touch sensor or a pressure sensor during regular use. It should be noted that additional bandwidth is necessary for instrumentation purposes (e. into a dc potential of a given polarity (positive in Fig 6D-2.g. The socket needs to be designed so that the electrodes maintain contact with the skin for all reasonable external load applications and for all reasonable prosthesis positions and movement velocities. this voltage can usually be made larger by increased muscle action.asp[21/03/2013 21:53:49] . then the circuit will turn on an electronic switch that allows electric power to flow to the prosthesis motor. There are no myoelectric signals in the fingertips. It merely means that when touched the myoelectric system responds to the stray electrical noise present on the fingertip. Some have circuits that enable the power to be applied to the motor in a manner proportional to the myoelectric signal amplitude.). it must be remembered that an expected response to touching the electrodes does not necessarily mean that the myoelectric system is completely functional.g. represents the essence of myoelectric control of a prosthesis motor-a kind of generic myoelectric control module. we can see by our "rule of thumb" that an amplification of 10. 1. the result of contracting a muscle to a certain level results in power delivery to the driving motor of the hand or arm.000 to 100. If the dc potential falls below the threshold. Also. or on the order of a million times less than the voltage of electrical wiring in American homes. No amplification is necessary above about 400 Hz for control purposes since the signal above this frequency is relatively low. To avoid noise amplification as much as possible. The frequency components of the EMG that have the most energy are in the neighborhood of 100 Hz (cycles/sec).0/0. When they think of moving their phantom hand. Therefore. Another surgical possibility with nerves is to surgically connect the cut ends of nerves to prepared muscle sites. this area of prosthetics is perhaps not emphasized as much as it http://www.asp[21/03/2013 21:53:49] . This technique has the benefit of not requiring implants. control requires indwelling components of some kind (e. Nervous tissue is rather sensitive to mechanical stresses. for example. is a landmark publication on prosthesis control and the proceedings of that meeting research. might be a good source of multiple myoelectric sites or other kinds of control sources for prosthesis control. This has been suggested by Hoffer and Loeb and experimentally The concept. telemetry implants) because neuroelectric signals are. remains a control possibility that may have future applications. THE ROLE OF SURGERY IN THE CREATION OF CONTROL SITES/SOURCES We know that amputation surgery is very important to the clinical outcome of prosthetics fittings. large mechanical vibrations can be created. how fast it is moving through space.org/alp/chap06-04. Neuroelectric Control Neuroelectric control. after reinnervation. to be any compelling reason to move from myoelectric control to myoacoustic control. and there does not appear. and what external forces are acting upon it. the original finger flexor muscles can be used (usually in conjunction with wrist flexor muscles) for the signal site to "close" the prosthetic hand. there can be a rather natural relationship between thinking about operating the phantom limb and actual operation of the hand prosthesis. That period of activity and research ferment was also marked by the excitement that resulted from the practical introduction of myoelectric control during the mid-1960s. transradial myoelectric prosthesis control is usually performed well. The method has the potential advantage of multiple-channel control and multiple-channel sensing because there are many motor and sensory neurons associated with each nerve. and so it may be difficult to maintain long-term neuroelectrodes.g. a phenomenon observed long ago but only recently reinvestigated in much depth. was stimulated by limb absences at birth that resulted from use of the drug thalidomide during pregnancy. in general. remove its normal innervation. Myoacoustic controls primary advantage over myoelectric control could be that the acoustic sensor does not have to be in direct contact with the skin. Myoacoustic Signals Myoacoustic signals (auditory sounds when muscles are active). Nevertheless. The decade from 1965 to 1975 was one of unprecedented research on the control of artificial limbs. Likewise. normal elbow control by the transradial amputee allows him to move the hand in space and to have proprioception concerning where it is with respect to the body. The elimination of this unwanted acoustic noise may be more difficult with myoacoustic control than it is with unwanted electrical noise reduction in myoelectric control systems. the muscles remaining in their limb are naturally activated. too weak to be picked up on the surface of the skin.oandplibrary. Nevertheless. particularly that conducted in Europe. The research. it is possible to relate original finger extensor muscles with "opening" of the prosthetic hand (often in conjunction with use of wrist extensor muscles) by placing electrodes on the skin near these muscles. Consequently. The Swedish Board for Technical Development sponsored a workshop on control of prostheses and orthoses in 1971. investigated in basic studies of animal preparations by Kuiken. When a prosthesis strikes an object in the environment or rubs against something in the environment. which may not be a functionally critical muscle for a shoulder disarticulation amputee. Also. Andrew (see Chapter 9B) has apparently fitted some transhumeral amputees with myoelectric control who had had successful nerve transfer following brachial plexus injury. Myoacoustic control systems are very similar in structure to myoelectric systems. would be to take a muscle like the latissimus dorsi. As a consequence. have been shown to have potential for the control of prostheses. The practicality and effectiveness of this kind of humanmachine interconnection will remain an open question until it can be tried extensively. Its main disadvantage concerns potential difficulty with elimination of extraneous mechanical noises. where microelectrodes interface directly with nerves and possibly with This method of neurons. and reinnervate it at multiple places with nerves that formerly went to the hand and forearm. at this time..6D: Control of Limb Prostheses | O&P Virtual Library sensation" of their missing hand. the method is experimental and only has "potential" for practical applications. The muscle. At present. Some partial-hand amputees who have no fingers or thumb decide that they want to have their limbs revised (shortened) to the wrist disarticulation level so that they can easily be fitted with standard electric hands and myoelectric control.g. have to be made on an individual basis. Unfortunately. but objectives of surgery in assisting with control sites and function are considered here. advancements in surgery and surgical techniques are as necessary as technical advancements.. if part of the deltoid muscle can be conserved after arm disarticulation. and neurosurgery have advanced rapidly over the last 20 years. Mar-quardt has used angle osteotomies of the distal end of the humerus to improve mechanical coupling between the humerus and the prosthesis so that the humeral rotation of the prosthesis is readily controlled by natural humeral rotation. Elbow disarticulations conserve humeral rotation. if all fingers have been amputated. Techniques in orthopedic surgery. and provide a force-tolerant distal end. In the future. HandiHook. plastic surgery. Surgical procedures in general are handled in other parts of the Atlas. Surgeons can play an important role in assisting with control of limb prostheses. somewhat natural working relationship. passive/cosmetic prosthesis. vascular surgery. With transradial amputations it is usually desirable to make the limb as long as possible. Myodesis is sometimes performed. it is often helpful to have the flail humerus fused with the scapula at the glenohumeral joint. unfortunately. if advanced finger components are available for the partial-hand amputee. the surgeon should try to save joints and bone length. by action of the scapula. Long transhumeral limbs often obtain good control of prosthetic elbow flexion by using glenohumeral flexion. the number of surgeons with an active interest in amputation and amputation issues seems relatively diminished today as compared with the years immediately following World War II.6D: Control of Limb Prostheses | O&P Virtual Library should be. can be used to aid prosthesis suspension. transhumeral amputations seem to follow guidelines similar to those for the transradial amputation. where it is practical.asp[21/03/2013 21:53:49] . For control of limb prostheses to advance along a broad front.oandplibrary. For example. From a control viewpoint. The elbow joint should always be saved. it may be useful to save the wrist because of the highly desirable movements it provides for positioning an artificial prehension component. technological advancements and surgical advancements in prosthetics should be integrated. Decisions concerning saving the wrist joint. http://www. in general. This procedure. Myoplasty procedures that connect antagonist-agonist muscle groups at the distal end of the amputation site are often used in order to keep the muscles in a dynamic. In fact. Single muscles that may have no functional purpose after amputation but that can be voluntarily activated should be attached to a reaction point and saved for possible use as a myoelectric control site. If amputation above the elbow is performed after brachial plexus injury. provide contours for prosthesis suspension. Soft-Tissue Conservation and Reconstruction Surgeons should conserve residual muscles that might be used for myoelectric sources if the conservation is consistent with good medical practice. many of the new techniques have not had as much impact on prosthesis control as they could have had if surgeons. synergistic activities. and create a force-tolerant distal end for the limb. its free end may be attached to the torso for possible use as a myoelectric control source for an arm prosthesis. and engineers had consistently worked together on limb control problems. It is felt that this promotes the possibility of good two-site myoelectric control from these muscles. Although tunnel cineplasties have not been used much in the United States since the 1950s. to some extent.org/alp/chap06-04. A control viewpoint suggests that the surgeon should attempt to save a short humerus if it will be voluntarily mobile because a mobile short humeral neck can be used to activate control switches or to push against pressure-sensitive pads. consistent with good medical practice. however. opposition post. Bones and Joints As a general rule. In this way the humeral section can be controlled. just as saving the knee enhances lower-limb prosthesis control. Muscles attached to it may also be used for myoelectric control purposes. if a disarticulation is not possible. since it greatly enhances prosthesis control. Wrist disarticulations are desirable since they conserve natural supination-pronation of the forearm. the length should usually be reduced enough to accommodate elbow mechanisms without compromising function. leads to improved prosthesis control. Robin-Aids Hand) because of size and length constraints. Bone lengthening might be considered for increasing the length of very short limbs. if possible. pros-thetists. the range of fitting options that can be achieved are limited at this amputation level (e. Finally. This is of particular importance for high-level bilateral amputations. the procedure may. Activation of pressure-sensitive transducers by the Krukenberg limb is one way to use it to control a hand. myoelectric control. Even though this procedure has normally been used primarily with blinded bilateral hand amputees. evaluation of the results of unilateral fittings may be more difficult than for bilateral cases. if normal. Some amputees may want it primarily for appearance purposes. It appears that the combination of powered prostheses and electronic position control systems. CONTROL OF PROSTHESES FOR SINGLE (UNILATERAL) LIMB LOSS While fittings of unilateral amputees are technically much more simple than bilateral fittings. The technique is being reconsidered in Europe. Powered prostheses make it possible for tunnel cineplasty control sources to be used even when they can develop only small forces or small excursions.oandplibrary.org/alp/chap06-04. or tunnel cineplasty control may all be possible applications for muscle transfers. In recent years Baumgartner. among others. Joint control.asp[21/03/2013 21:53:49] . Beasley exteriorization" procedure that shows much promise. Biederman. This is thought to be a particularly desirable feature for obtaining good control of multiple prosthetic functions without too much mental effort given over to the control process by the user. In the United States. It presents options. but they may prefer to use prostheses over their arms when they are in public venues. Myoelectric control is another option. This procedure demonstrates the possibility for surgical creation of a number of such control sources on the forearm that could. it should be mentioned that the Krukenberg procedure remains a viable method to allow direct prehension control and can also be used for control of powered transradial prostheses. Adherence of the skin to underlying muscle is a less direct method of using a muscle as a control source. the prosthesis at best serves only in an assistive mode. Direct muscle control through tunnel cineplasties is particularly attractive in both cases because of the proprioception they naturally provide to the user.. but this has not been done in large enough numbers for generalizations to be made about the utility and indications for muscle transfer procedures. it may be possible to use the concepts of extended physiologic proprioception with the Krukenberg limb in order to gain improved control of a powered prosthesis. Therefore. Surgical transfer of muscles to the amputated limb is possible for improvement of arm control. "tendon electronic prosthesis technology. enable amputees with long transradial limbs to gain coordinated control of individually powered prosthetic fingers. Many unilateral amputees decide not to http://www. Liicke et al. the surgical creation of a number of new tunnel cineplasty control sources on the torso may be particularly desirable for the high-level bilateral amputee who needs multifunctional control but who has limited control sites without such surgical intervention. Finally. New surgical techniques and the wide availability of powered prostheses may lead to a revival of this procedure. Krieghoff et al. It is important to remember that surgical procedures may need to go beyond just the original amputation in an attempt to create a limb that will be functional and easily fitted and that will not cause subsequent problems for the amputee. This method of control has been demonstrated by Seamone et al. in certain circumstances. while some may have only specific functions (jobs or sports activities) for it. have written about the utility of this control technique. can accomplish almost any task. Leal and Malone successfully fitted a transradial amputee who already had a standard biceps tunnel cineplasty with an electric hand that was switch-controlled from the cineplasty site. have applications with sighted and unilateral amputees. but often such surgical intervention will necessarily need to be done at a later date. Some users may choose to use the Krukenberg limbs in the privacy of their homes because of the good sensory and motor qualities. Sometimes the surgical procedures designed to assist with prosthesis control can be performed at the time of original amputation. but still vital ideas of tunnel cineplasty. Skin adherence brings about skin motion when muscular contraction causes movement. may open up a new era of control based on the older. in conjunction with new surgical techniques and procedures. This is because the unilateral amputee has a physiologic arm and hand that. Others may incorporate it extensively into their activities and body image. in the future.6D: Control of Limb Prostheses | O&P Virtual Library they offer a unique way for surgeons to create control sources. but may also be important for less difficult cases where a number of control sources are needed for multifunctional prostheses. have discussed the use of cineplasty in connection with modern introduced a new cineplasty-like. Surgery can be very beneficial in assisting with the control of prostheses. Tendon exteriorization does not traumatize the muscle itself and therefore is thought to have minimal influence on a muscle's circulation and neurologic mechanisms. Also. 0 radians/sec (-115 to 172 degrees/sec) normally will require proportional control. mechanical complexity). In general. If possible.. Professionals connected with prosthetics fitting need to support amputees' decisions about the use of prostheses.g.oandplibrary. then proportional control is not necessary for effective control. the muscle position would determine hand opening position. This is similar to the single-site. the conventional wisdom was that it might have more important usage with higher-level amputations and was not so important for transradial prostheses. as with the Steeper hand controller (see Fig 6C-2) or with some other kind of position control mechanism. an amputation often leads to job changes and other changes that require time to be sorted out. Likewise.. The prosthetics fitting of upper-limb amputees is partially an iterative process because amputees cannot know what problems they will face until they actually use a prosthesis and experience it in their natural environment.. and this makes initial prescription difficult. Rapidly moving prostheses that have maximum angular velocities greater than 2. the New Brunswick system) and with adults. two-function control is quite acceptable for amputees who do not have two good myoelectric sites. Electric switches in series with Bowden cables can be used to control powered hand prostheses. although cable-controlled mechanical hands are generally inefficient. In like manner. When myoelectric control first became available. In fact. on-off control is sufficient. then the muscle http://www. These factors suggests that diagnostic and temporary prostheses may be very useful for initial and early fittings. supination/pronation is not necessary for most unilateral amputees unless a particular vocation or avocation demands it. Nonetheless. At some operating velocity. the single-site. Anthony control circuit. The prosthesis takes its place amid many life changes. experience has shown that myoelectric control works admirably at this level. if powered prostheses have slow dynamic responses (e. In this situation. Control of Unilateral Transradial Prostheses Transradial prostheses may be controlled successfully in many ways. hands close or open at slow rates). Cable-controlled voluntary-opening and voluntary-closing prehensors (nonanthropomorphic) both work well with transradial amputees. it is preferable to use two myoelectric sites to control the two functions (closing/opening) of the hand because this gives the operator direct control of each function. battery. two-function controllers can be used to control four functions of powered hand opening/closing and powered pronation/supination for the short transradial limb. Also. Powered supination/pronation adds weight distally and also adds complexity. Single-site. accurate control of position becomes impossible for the human-operator using on-off velocity control (as noted previously in the discussion on control of electricpowered automobile windows). A myoelectrically controlled transradial prosthesis is shown in Fig 6D-3.org/alp/chap06-04. Sockets and apparatus that allow natural supination/pronation (body powered) from residual movements of the amputated limb are recommended. however. A possible exception would be when the switch is operated from a tunnel cineplasty. single-function myocontroller of hand opening with automatic powered closing (the St.0 to 3. this kind of control probably should be avoided if possible because a prosthesis controlled in this way by a transradial amputee has the disadvantages of cable control (harness and limited work envelope) along with the disadvantages of powered hands (weight. the prehensor can be various electric hands or various nonanthropomorphic electric prehensors as described in Chapter 6C. A pair of single-site. they also need to be able to inform the amputee concerning what kind of fitting can potentially serve him in the best way by taking into account the many factors involved. However. Of course. However.asp[21/03/2013 21:53:49] . although few devices with this speed are currently available. single-function myocontroller for voluntaryopening prehensors (Hosmer's Prehension Actuator). It has been used effectively with youngsters (e. the so-called "cookie crusher'' system) has been shown to be effective with very young children who are born with limb absences. This is intuitively understood. it has its greatest application with the transradial amputee. it seems likely that position control. when possible. This kind of control can become rather subconscious in nature for some amputees. however.6D: Control of Limb Prostheses | O&P Virtual Library wear a prosthesis. an amputee's true feelings and desires may take time to mature and to emerge. Proportional control has been shown to be effective by Sears and Shaperman.g. If muscle velocity could also be related to prosthesis velocity and muscle force to prosthesis gripping force. would be preferred for hand control through a tunnel cineplasty. which can be used to provide powered operation to a variety of voluntary-opening devices that traditionally have been controlled through cables and body power. asp[21/03/2013 21:53:49] . It can be answered subjectively by the prosthesis users. Billock has used this technique effectively with many people. If they have many of the attributes. 2. transhumeral amputees with relatively long limbs can function well with totally cable-operated. When the elbow is unlocked. which may be subject to change or may not. This may be difficult to quantify. The mechanical elbow has an electrical switch in it that is connected with the elbow locking mechanism. It avoids the problem of prehensor opening during forearm lifting against a load. there are many ways to fit amputees from a control viewpoint and from a component viewpoint. the question can only be answered quantitatively for particular criteria that are arbitrarily selected and through large-sample studies. everyone has his own opinions about what is best. How can the various options be evaluated? Of course. and the results may be equivocal. When the cable is pulled to operate the unlocked elbow. A theoretical construct proposed by the author is discussed later in this chapter. This allows a single cable to operate a servo-controlled hand and also the elbow. Such studies are difficult to fund and conduct. at best.org/alp/chap06-04. Their use of case studies and retrospective analysis of results suggests the need for studies of this kind to be performed by professionals in prosthetics who have reasonable caseloads of upper-limb amputees. It is a partial solution. Evaluation of the Effectiveness of Control Approaches As the reader can see from the transradial unilateral situation. has a body-powered elbow that is designed for a hybrid control approach to trans-humeral fittings. Control of Unilateral Transhumeral Prostheses It seems appropriate to present the most common control approaches currently used in prosthetics practice for powered transhumeral prostheses along with an emerging approach of interest to the author. The hybrid control/power approach has reasonable proprioceptive qualities and allows simultaneous coordinated control of elbow and prehensor function. they would rank higher than if they do not. This approach has been used effectively in Europe for almost 25 years. Another http://www. These ratings would be incorrect if the theory was incorrect. Which way is best? Is there a "best?" With higher-level amputations the question becomes even more important because the fitting options are multiplied. Several other approaches are common: 1. This kind of fitting is shown in Fig 6D-4. As with transradial amputees.oandplibrary. the switch is closed. to the evaluation of effectiveness of control techniques and methods. but if the theory was correct. When the elbow is locked.A. and simple examples of evaluations based on the construct are presented. which is a problem with a cable-operated elbow if the cable is also used to operate a voluntary-opening (spring return) prehensor. they would be valid. the electrical connection to the hand is turned off.. is somewhat natural because gripping objects strongly often involves the contraction of muscles quite distant from the hand. it just becomes very obvious in high-level fittings. and not everyone will agree upon the desirable attributes. Fittings with close correspondence to the theory would get higher ratings than other fittings. Surgeons have the same problem in evaluating many surgical procedures. Powered and nonpowered components at multiple joints coupled with various control schemes yield many possible fitting combinations. the electrical switch is open. without interaction. but again a large-sample study would be required. Another option is to base evaluation of control approaches on the basis of a theoretical construct. the hybrid approach of a cableoperated.6D: Control of Limb Prostheses | O&P Virtual Library might provide some proprioceptive sense to the user. It is a relatively simple approach-technically comparable to a transradial myoelectric fitting. the connection to the hand is on. but it may be a viable first approach to the problem. The author feels that myoelectric control of prehension. and when locked.. in this case from the biceps and triceps.) Unfortunately. The relationship between prehension and muscular contraction has been called the "myopre-hension" concept. and pulling on the cable operates the hand through the position servo control system. a combination of "rules of thumb" based on experience and clinical judgment usually determines the initial prosthetic approach. Ltd. body-powered elbow along with myoelectric control from the biceps (closing) and triceps (opening) of a powered pre-hensor (hand or nonhand) is a very functional fitting approach. (Note that although this question can be raised in all areas of prosthetics. body-powered prostheses. The author proposes that an alternative evaluation approach might be to measure control methods against the "Desirable Attributes of Prosthesis Control" presented in the first part of this chapter. At present. Hugh Steeper. For transhumeral amputees with long residual limbs. The approach is based on D. and shoulder position with his capable limb and would use the control system to position the elbow joint and operate the prehensor. and a body-powered system may be difficult to operate. the controls can be completely myoelectric. The prehensor can be cable controlled and body powered. is a kind of "boosted" cable control. This is a twosite myoelectric control system that can be used to control the elbow proportionally. 5. and this action transfers the myoelectric proportional control to the hand. It is an approach that has been promoted for use with the Liberty Mutual electric elbow. four-function control in which all functions are not directly accessible.C. Bodypowered prostheses are marginally effective at this level of amputation-when the contralateral limb is fully functional.B. as with the Utah arm fitting shown in Fig 6D-5. with electric elbow and electric hand or other powered prehensor) may also not be desirable at this level of amputation because. Light.oandplibrary. humeral rotation. When the elbow is unlocked. When the elbow is locked. Simpson's principles of extended physiologic proprioception. Heckathorne et al. holding a bottle while the other hand takes off the cap). Powered limbs also add undesirable weight.g. However. primarily with its prehensor acting as a conveniently located viselike holding mechanism (e.. A powered prosthesis (e.6D: Control of Limb Prostheses | O&P Virtual Library way to use this elbow design is to place a two-position switch in series with the cable that controls the elbow. Control can be alternated between the hand and the elbow. simultaneous control of both functions is impossible with this control approach. pulling the cable lightly will activate the first position of the switch and close the hand. Control of Unilateral Shoulder Disarticulation Prostheses Unilateral shoulder disarticulation amputees often choose not to wear a prosthesis. have reported on this technique for a clinical fitting. triceps-extension). then the structure can http://www. the functional gains provided are likely to be marginal when the opposite limb is fully capable.org/alp/chap06-04.. have trouble with the locking and unlocking function). If the elbow is held stationary at a position for a short period of time. This is a form of two-site. Some prefer to wear a lightweight passive prosthesis that is free to swing comfortably during walking and that can be easily positioned (passively) for placing its cosmetic hand in their lap when they sit.. cable operation is normal. 3. For transhumeral amputees who do not want to use the harness needed for cable control or who cannot tolerate a harness (e. The principles and details behind this particular control approach have been described by Doubler and Childress. An alternate but similar approach is to use a powered elbow in place of the bodypowered elbow but to control it in a similar way: using the cable to operate a position servomechanism controlling the elbow. the body's position cannot get ahead of the corresponding position of the elbow and forearm. This is thought to be an effective work prosthesis if a totally cable-driven system cannot be used.asp[21/03/2013 21:53:49] . An electric elbow and electric prehensor could be used in conjunction with friction or manually locking wrist rotation. For transhumeral amputees who cannot operate a body-powered elbow well (e. The advantages are that proprioception is maintained even while using a powered elbow and that the force and excursion necessary to operate the elbow can be matched to the amputees force and excursion capabilities.. a detrimental factor in this kind of fitting. passive holding by the cosmetic hand may provide some utility. mentioned earlier in this chapter. The user often has somewhat limited force and excursion when compared with amputees with mid to long transhumeral limbs.g.. In both cases the idea is to reduce the number of control sources needed.. The user would preset wrist rotation. a powered elbow can be used. and friction or a manually locking shoulder. it would likely be used mainly as an assist to the normal contralateral limb.g. friction or manually locking humeral rotation. again. shown in Fig 6D-4. 4. Therefore. it is a form of "unbeatable" position controller that is similar in operation to automobile powered steering. If a powered limb should be fitted for this amputation level. Pulling the cable with greater force will activate the second position on the switch and open the hand. If support for the arm can come from the torso. the elbow automatically locks. This approach. often myoelectrically controlled (biceps-flexion. A convenient control scheme for this situation would be movement or force from the shoulder on the amputated side. A quick cocontraction of the biceps and triceps muscles is used to transfer control back to the elbow.g. Since the cable is directly connected to the elbow's output position. because of skin grafts) or for amputees with a relatively short limb (weak glenohu-meral leverage). Body control with passive wrist flexion could be fitted on the dominant side with a voluntary-opening or -closing prehensor. There are many options. A variant of the complementary body-powered. We will consider only a few conditions of the many varieties of amputation conditions possible and will concentrate on general principles for the fittings rather than on specific details. the long limb would normally be fitted as the dominant limb. A transradial myoelectric hand prosthesis (or nonanthro-pomorphic prehensor. The two systems should complement each other. the number of variations can be large if several different amputation levels of each limb segment are considered and much larger if associated movement limitations or pathologies of each limb segment are also included. Attempts should be made to maintain the physiologic pronation-supination remaining-on both sides. The voluntary-closing prehensor would enable high prehension forces to be developed. transradial amputation condition. Another possibility is to use different kinds of prehensors and different control schemes on each side. If both arms have transradial amputations.g.g. passive rotation of the prehensor should be added (along with the wrist flexion) on the body-powered. externally powered system discussed in the previous paragraph may also be useful with this set of amputation levels. Passive (friction or locking) wrist flexion will be useful. particularly with most currently available electric elbows and prehensors..org/alp/chap06-04. Control of Bilateral Arm Prostheses The fitting problems become dramatically different when both arms are missing. It might be useful to use two kinds of prehensors. and the differences in overall performance of the unilateral amputee. although the author has not seen this done. dominant side. Therefore. as demonstrated by so many amputees who generally develop exceptional arm/prehensor skills. We will not address the fitting issues involved with all of the various combinations of bilateral limb loss. Again. e. Powered supination-pronation on the short.6D: Control of Limb Prostheses | O&P Virtual Library be contoured so that the shoulder is free to move up and down and back and forth.. and transhumeral-transradial). Greifer or Synergetic Prehensor) with socket provision to capture residual forearm rotation could be fitted on the nondominant side. as a whole. we have 16 possible combinations. If we add "long" and "short" to the classification of each amputation level. If we only consider transradial and transhumeral amputation combinations. short. with 10 different varieties (12 combinations have like equivalents. Amputees with bilateral long transradial limbs can effectively control a wide range of prostheses from cable-controlled voluntary-opening hooks to bilateral myoelectric hands. many other schemes would work effectively. However. However. a wide range of fitting possibilities are possible. powered. An all cable-controlled system with hooks can be very effective. at least on the dominant side. This would give the wearer the advantages of both kinds of systems-the precision prehension capabilities of many hook prehensors along with good proprioception from the cable-operated control system and the power prehension of an electric prehensor along with the large work envelope that is possible with a myoelectrically controlled prosthesis. within the prosthesis. pockets).g. unattended prehension. interfaced with up and down movement of the shoulder (up for elbow flexion). The author feels that position servo control of the elbow. nondominant side should be considered. Powered hand prostheses may be used bilaterally with aesthetic advantage but often with functional disadvantage because the hands are usually limited to one prehension pattern (palmar prehension) and because their bulk makes it difficult to use them in constricted spaces (e. but the prehensors would be complementary in function. and retraction movements against pressure-sensitive transducers would be a desirable control scheme. A person with a combination of transhumeral and transradial amputations can also be fitted http://www..oandplibrary. as before. to a limited degree. and the voluntary-opening prehensor would permit relaxed. and the one chosen will be highly dependent upon the needs and preferences of the user. would probably not be discernible with many other control approaches (e. This relatively free motion can be used effectively for control. This would provide body power on both sides. left and right) of amputation conditions. we have 4 combinations but only 3 different varieties (2 combinations are equivalent to each other. proportional force control of the prehensor mediated through shoulder protraction (the prehensor closes with a force proportional to the shoulder force). one voluntary closing and one voluntary opening. and the controls should be as independent as possible. bilateral transhumeral. one long and the other short. mechanical switches operated by the shoulder movements).asp[21/03/2013 21:53:49] . left and right) of amputation conditions (bilateral transradial. Similar control procedures are usable with the bilateral. James Cay-wood. Heckathorne et al.org/alp/chap06-04.6D: Control of Limb Prostheses | O&P Virtual Library well with body-powered. The wrist rotator and the powered prehensor are controlled by chin movement against rocker switches. The elbow is controlled by a two-position pull switch that is activated by shoulder elevation. the rotator can be unlocked. Nevertheless. Calif) and applied there currently by Mr. activating the primary control cable supi-nates the prehensor if all other joints are locked. body-powered. If both the wrist rotator and the wrist flexion unit are unlocked. The concept is to use the primary cable control to open the voluntary-opening prehensor (hook) and to flex or extend the elbow (when it is unlocked) as is the usual case. If the wrist rotation unit is unlocked by pushing a lever mechanism (e. on the right prosthesis. As in the previous case. (note the lever on the medial aspect of the forearm and the chin lever that is obscured under the shirt). the primary cable will pull the voluntary-opening hook prehensor open. body-powered elbow on the transhumeral side in conjunction with myoelectric control of an electric prehensor (as described for the long unilateral transhumeral amputation). Therefore. A body-powered elbow and myoelectrically controlled prehensor can be fitted to the nondominant side if the residual limb is fairly long. although totally body-powered. and wrist flexion units are all locked. If the primary cable is relaxed.oandplibrary. This kind of fitting is illustrated in Fig 6D-7. People fitted in this manner fly airplanesjust one way they manifest their excellent control capabilities. except that in this case one chin lever locks/ unlocks the elbow and the other lever locks/unlocks the wrist rotator. In other words. A rubber band causes it to move toward its extended position. When the transhumeral limb is short in this situation. and a powered wrist rotator. four-function control approach allows the bilateral transhumeral amputee to independently position joints of the arm and to lock them into position-an operation that is very helpful for the bilateral amputee. This kind of fitting is illustrated in Fig 6D-6. Using a totally body-powered system on one side with a totally electric system on the other allows the two systems to be effectively decoupled from a control standpoint. usually the side with the longest residual limb but possibly on the side of the individual's original dominance. wrist rotation. this cable controls flexion/extension. we like to use a four-function..g. have described the complementary function of bilateral hybrid prostheses of this nature. It may be locked at the desired position (in this case.. The amputee pushes a lever to unlock it (e. three positions). and then locked again. Their system has been redesigned somewhat to make it more modular and easier to apply. The single control cable. If the elbow is unlocked. a powered prehensor. lever on the forearm). This is a technique pioneered by Mr. a spring connected to the wrist rotator pronates the prehensor.g. An electric elbow with myoelectric or rocker-switch control may be useful if the limb is short. cable-controlled systems. . George Robinson at Robin Aids Prosthetics (Vallejo. A single cable control of four body-powered functions has been found to be very functional.. The functional dexterity possible at this level with this kind of control can be extraordinary. Short transhumeral and bilateral shoulder disarticulation amputations are cared for in our center with similar components as in the previous case. a powered elbow should be considered. http://www. would be to use cable control on the transradial side and a cablecontrolled. The prehensor will move to the extended and pronated position if the primary cable is relaxed. cable-controlled systems can be functional at this level.asp[21/03/2013 21:53:49] . The technique is also shown in Fig 6D-7. The nondominant side is fitted with a powered elbow. This technique is shown on the right prosthesis of Fig 6D-6. Pulling on the primary control cable flexes the wrist unit. if the residual limb length is adequate. Pulling this cable under this condition brings the prehensor to a flexed and supinated position. However. cablecontrolled system on one side. but the control methods may vary if a short transhumeral limb can be used as an EMG control site or if it can be used as a control source to push against pressure-sensitive transducers. cable-controlled system on the dominant side. if the transhumeral stump is reasonably long. chin-operated lever). The transradial side would normally be considered the dominant side fitting. they move together. Another scheme. with four-function control. The flexion wrist is unlocked by pushing the lever on its medial side in this case. two additional functions that can be locked (like the elbow) are added. The wrist flexor operates in a similar way. The user can don and doff the prosthesis independently and uses it effectively in activities of daily living. These are a locking/unlocking wrist rotator and a locking/unlocking wrist flexor. Two transhumeral amputations frequently lead to the use of external power on one side or the other. The group the author works with at Northwestern University and at the Rehabilitation Institute of Chicago believes that there is merit in fitting these amputees with a body-powered. he has found it useful to also modify his home environment to simplify function. As long as the elbow. positioned to a new rotation angle by the primary control cable. The three locking levers and two electric rocker switches shown in this figure are operated easily and unobtrusively by the amputee.Wash) that have positive locking/unlocking in flexionextension and friction in abduction-adduction. hand tools. This is one reason for putting forth a set of principles of this kind. The utility of a theoretical foundation is to give guidelines for control methods so that decisions do not all have to be made only on the basis of experience or subjective feelings. This automatic decoupling allows the amputee to concentrate on the prosthesis he is operating without having to consider both simultaneously. The output pathway and the input pathway for information flow are both embodied in the tool. refuted.6D: Control of Limb Prostheses | O&P Virtual Library forces and motions to activate the body-powered side do not activate the electric system on the opposite side. is for them to be able to manipulate their environment as well as the best foot users do who have similar arm amputation levels. plus the sensation that comes back to the body through the instrument they are operating. Another reason for suggesting an initial set of principles is so that they can then be argued. Collier. in a sense. Longview. Later the shoulder joints were converted to positive locking joints (MICA. (3) prostheses that are direct extensions of a limb (e. A reasonable medical engineering (human-prosthesis) goal. in the future. Initially. The shoulders had friction joints that were pre-positioned and set to high friction (see Fig 6D-7. the patellar tendon-bearing [PTB] leg prosthesis) are well controlled. validated. much as it is into a tennis racquet or into a hammer when a person uses them. without excessive "mental load. ease the effort now involved with locking and unlocking the joints of the body-powered prosthesis with the mechanical levers. seem to provide a natural kind of control that is intuitive and effective. extended into the prosthesis. all joints except at the shoulder had positive locks. poweredlocking mechanisms will. it would mean that we will have also been able to make similar or superior achievements at the less severe amputation levels. modified. Doubler and Childress provide some objective evidence that this kind of control is superior to "on-ofl" and http://www. which the author has called Simpsons theory. So behind the extended physiologic proprioception concept is the notion that the prosthesis is a kind of "tool" that the body can control very well when it is directly connected in some way to joints of the body. When Simpson implemented this concept for the control of prosthetic arms. if that goal can be achieved. This concept for control is the same as the one alluded to in the beginning of this chapter when powered steering of automobiles and cable control of remote manipulators and used tracking studies to airplane control surfaces were discussed." by children with high-level bilateral shortage. etc..asp[21/03/2013 21:53:49] . THEORETICAL FOUNDATIONS FOR PROSTHESIS CONTROL Childress has suggested that general principles for good control seem to come naturally out of observations of the control of various kinds of aids in rehabilitation. we think that future systems of this kind will be able to achieve better function through the use of position servos for based on the principles of Simpson and as adapted by Doubler and Childress positioning electric-powered joints in space. and (6) humans in general are very capable when using extensions of their limbs (e. We also believe that electric-actuated. These joints. Likewise. In all these observations the output is a position variable that is controlled by positions of the body's own joints. is based on the following observations: (1) cable-controlled.). .A).. body-powered arm prostheses-when they can be used-often seem to be controlled well by amputees.g. One of these is shown installed on the right shoulder in Fig 6D-7. for persons who require bilateral limbs at the shoulder disarticulation level. subconscious control of multifunctional limbs in meaningful and coordinated ways is one of the great challenges of the medical engineering field. he called it extended physiologic proprioception because the physiologic proprioception of the controlling body joints was. (5) persons with quadriplegia often control their environment well with a mouthstick. or added to. The author believes that provision for natural.org/alp/chap06-04. operation of the electric prosthesis does not activate the bodycontrolled system. from M. .B. (2) Simpson was able to demonstrate good multifunctional control of powered prostheses. The first and perhaps the most important concept. altered. (4) blind people are adept at understanding their physical environment with a long cane.oandplibrary. stilts. tested.g. Nevertheless. so the user does not have to worry about them slipping under loads. Chin control appears to be integrated nicely into control of a multifunctional prosthesis. and the reader is referred to the references for more extended discussion. racquets. Of course. This kind of system has inherent feedback. Not all the principles will be discussed in detail here. He has suggested that these principles may be useful in the formation of a theoretical foundation for control of upper-limb prostheses and has proposed a preliminary theoretical framework. these have been successful. if the place of stimulus on the prosthesis is represented by a particular place mapping on the body (position-to-position correspondence).asp[21/03/2013 21:53:49] . and muscle force corresponds to prosthesis force. which can be related to muscle effort. and if the velocity of movement of stimulus on the prosthesis corresponds to velocity of stimulus movement on the body (velocity-to-velocity correspondence). The myoprehension principle has been described as the natural relationship between muscular contractions and prehension. The extended physiologic proprioception control approach realizes feedback of important information in a form that is naturally received by the human operator. This Carlson. This is easily illustrated by gripping an object tightly. and on the basis that the cable-operated. As the prehension force is increased. For this reason. On the basis of these observations and others. and joint force corresponds to prosthesis force. The principles presented can be used as a guide to prescription.6D: Control of Limb Prostheses | O&P Virtual Library "proportional" velocity control. Childress The most natural and most subconscious control of a prosthesis can be achieved through use of the body's own joints as control inputs in which joint position corresponds (always in a one-to-one relationship) to prosthesis position. the principle suggests that myoelectric control can be somewhat naturally connected with the control of prehension. required force and excursion can be matched to the force and excursion available by the human operator. supplemental sensory feedback. This is intuitive if the muscles involved are in the forearm but not so obvious if the muscles are proximal to the elbow.B. We know that from a control standpoint. is a signal that the body can relate to the gripping function. To a great extent this principle suggests that powered prostheses should be controlled in much the same way that body-powered systems are controlled. New possibilities now exist for expanding the use of this kind of control input. an EMG signal. provides extended http://www. they suggest that myoelectric control is good for the transradially amputated limb because the intact elbow. body-powered systems as well as Simpson's powered systems were kinds of "existence proofs" of the validity of the approach for upper-limb formulated Simpson's theory of control as follows: systems. on the basis of the objective studies. muscle velocity corresponds to prosthesis velocity. This is in contrast to the many kinds of "supplementary sensory feedback" that have been experimented with A corollary theory for through the years and that the body does not seem to interpret well.org/alp/chap06-04. If we apply the principles outlined. The use of tunnel cineplasties (or variants) for control is an example of direct muscle action control. has speculated that direct muscle action can provide the same kind of control Childress that is available from joint position inputs. We know that good theories tend to fit what is known and can also be used for prediction of new kinds of control schemes. control method is relatively simple to implement and has been illustrated in Fig 6D-4. This kind of control may even make it possible in the future to control individual prosthetic fingers in coordinated and meaningful ways. Consequently. as we have already noted in this chapter. joint velocity corresponds to prosthesis velocity. it seems natural for the body to relate prehension with muscular effort to some extent regardless of where the muscle is located. and others have also worked on this kind of prosthesis control. Gow. provided that the components that are needed are available. This direct muscle action control conjecture is formulated as follows: Natural and subconscious control of a prosthesis can be achieved through the body's own muscles as direct control inputs to position controllers in which muscle position corresponds (in a one-to-one relationship) to prosthesis position. Therefore.. This has always been a hope of many hand amputees. As with powered steering on a car. with the prosthesis extension. muscles of the body that are quite distant from the hand are contracted in reaction to the holding forces being generated. is as follows: Supplementary feedback can be interpreted best if pressure on the prosthesis is interpreted as pressure on the body (force-to-force correspondence). as suggested by Childress.oandplibrary. if any. and this implies the need for locking/unlocking of joints. If it or some modification thereof is valid." In fact. which makes it potentially valuable in directing research and development efforts with regard to prosthesis control. Commercially available systems are not available to implement some of the approaches described in the theoretical construct. the theory suggests that using a body-powered elbow (extended physiologic proprioception) and a myoelectrically controlled prehensor (myoprehension from the biceps and triceps) is a favorable approach-a fitting principle that has a strong. In like manner. The concepts presented should also be applicable to the lower limb and to other rehabilitation situations where human-machine interactions occur. that would only be the case for a large number of fittings. Beasley and de Bese have said. the prosthetic control designs that require low conscious control effort by the amputee and that are naturally harmonious in human-machine interactions appear highly desirable and to be the ones that have the greatest potential for minimizing the handicap that may result from a disability due to arm amputation. Progress in science and technology is normally not a linearly increasing function of time. Theories have to be subservient to the wishes of the prosthesis wearer and user. The duty of professionals related to the field of prosthetics is to know what is a good (best. The theoretical framework that has been presented seems to be congruent with much that we know from previous experience. although theories can help guide our decision-making process. for the transhumeral stump. in the final analysis they cannot be the final arbiter for prosthesis control decisions. but they have taken on significant and practical roles in upper-limb prosthetic procedures.asp[21/03/2013 21:53:49] . and the term should be dropped from use as it is misleading. Many of the approaches presented in this chapter do not correspond to the theoretical ideas presented at its end. even when valid. It also appears predictive. and that demonstrates important progress." Nevertheless. In general." They suggest that "prostheses meet only very specific and limited objectives. Also.oandplibrary. "There is no such thing as an artificial hand.6D: Control of Limb Prostheses | O&P Virtual Library physiologic proprioception control of the artificial prehensor in space and the EMG signals independently control prehension (myoprehension). even when they are known to be valid. We have a long way to go before we can say that we have built an "artificial arm" or an "artificial hand. As a note of caution. in which case the theoretical construct would have to be questioned and re-examined. what holds on average may be quite different for a given individual. with a theoretical framework being only one factor." By extension of this idea we might say that the upper-limb prostheses currently in use are not worthy of the title "artificial arms. This. We seem to be learning how to integrate them appropriately into practical prosthesis systems. The principles suggest that there are many cases where limbs can be used effectively as rigid extensions of the body.org/alp/chap06-04. the framework proposed has been put forward as a "theory" and not as principles that have as yet gained any wide acceptance in the limb prosthetics field. or possibly a direct muscle input be used for control of prehension. if possible) control strategy under given conditions. it can become an effective guide for prescription. based on experience or upon theory. We must continue to seek insights that may result in "breakthroughs" that will yield very rapid improvement of the control of replacement limbs. However. must yield to the will of the individual in deciding the control method finally used. as already noted." we need to keep making the kind of incremental progress that has brought us to the present state of development. force control through pressure transducers. SUMMARY Although many factors need to be considered at the time of prosthesis prescription and during subsequent follow-up. If a control strategy based on a theory is in fact good-possibly best-it should also be successful in clinical practice. Theoretical constructs. we can see that progress has and is being made. Powered limbs have perhaps not brought the big advances originally envisioned. The final arbiter is the user. of course. Also. the principles suggest that the body's joints (or muscles) be used as inputs to position controllers (based on the Simpson principle) for control of prosthesis positions (prosthetic joint control) and that myoelectric control. As in statistics. Short of these "hoped-for breakthroughs. It was the author's intent to describe a number of the control approaches currently in clinical use and that are commercially available to the practicing clinician. http://www. does not diminish the usefulness of the theoretical construct unless it happens in a high percentage of cases. if not unanimous following as a good solution for this amputation condition. many complex factors are ultimately involved in prescriptions. 5:6-8. 15. http://www. 37:525-531. (eds): Progress in Bioengineering. Barry DT. Donovan R (eds): Amputation Surgery ir Lower Limb Prosthetics. 17. Battye CK.asp[21/03/2013 21:53:49] . of the Rehabilitation Institute of Chicago. 12. IEEE Trans Biomed Eng 1990. 9:2-13. Krick H. C. Proceedings of the 38th Annual Conference of Engineering in Medicine and Biology. 1983. 14. Beasley RW: The tendon exteriorization cineplasty. 8:293-303. 7. Biedermann WG: 1st der Sauerbrucharm noch aktuell? Orthop Technik 1981. Heckathorne CW. Gow GW. 20. vol 2. Nightingale A: Muscle substitutes and myoelectric control. Doubler JA. p. Baltimore. IEEE Trans Biomed Eng 1990.. 30:340-344. Carlson LE: Position control of powered prostheses. Bottomley AH. 11. 1985. Abul-Haj CJ. J Bone Joint Surg [Br] 1965. 9:23-25. in Paul JP. Uellendahl J. Chicago. In addition. J Bone Joint Surg [Br] 1955. Bottomley AH: Myo-electric control of powered prostheses. et al: The physiologically appropriate control of an electrically powered hand prosthesis. et al. Cole NM: Muscle sounds are emitted at the resonant frequencies of skeletal muscle. 208:1327-1335.org/alp/chap06-04. 37:506-510. Basmajian J. 1989. Presented at ISPO IV World Congress. 16. et al: Achieving complementary manipulative function with bilateral hybrid upper-limb prostheses (abstract). J Br Inst Radio Eng 1963. Evarts CM (ed): in Surgery of the Musculoskeletal System. 1989. 4. Childress DS: Closed-loop control in prosthetic systems: Historical perspective.P.O. Childress DS: Historical aspects of powered limb prostheses. 1988. Clin Prosthet Orthot 1985. Childress DS: Powered limb prostheses: Their clinical significance. 19. New York. Childress DS: Biological mechanisms as potential sources of feedback and control in prostheses: Possible applications. Churchill Livingstone Inc. Kinnier Wilson AB. Childress DS. Krick H. 22. 13. 9. Childress DS: Control philosophies for limb prostheses. DeLuca C: Muscles Alive. References: 1. 1985. Abul-Haj CJ. Edward Grahn. controls. de Bese GM: Prostheses for the hand. Billock J: Upper limb prosthetic management: Hybrid design approaches. Jack Uellen-dahl. 5. Draper ERC. London. 47:411-415. and man-machine interface for advanced teleoperation.oandplibrary. Baumgartner R: Moglichkeiten und Grenzen der Prothe-senversorgung der oberen Extremitat. Dick TD. 32:156161. 10. 6. Bejczy AK: Sensors. Presented at the 12th Annual RESNA Conference. He would also like to thank his associates Mr. pp 210-215. Nightingale A. Childress DS: Design & evaluation of a prosthesis control system based on the concept of extended physiological proprioception. Arch Phys Med Rehabil 1990. Craig Heckathorne and Mr. 21. 48. 3. Hogan N: Functional assessment of control systems for cybernetic elbow prostheses-Part I: Description of the technique. 23. pp 296-297. Biomed Technik 1985. In-ter-Clin Info Bull 1966. 2.6D: Control of Limb Prostheses | O&P Virtual Library Acknowledgement The author wishes to thank the Veterans Administration Rehabilitation Research and Development Service and the National Institute on Disability and Rehabilitation Research for their sustaining support that has made this paper possible. Hogan N: Functional assessment of control systems for cybernetic elbow prostheses-Part II: Application of the technique. Clin Prosthet Orthot 1985. 21:19-31. 26:439-448. 71:773. 20:200-207. Ann Biomed Eng 1981. 1990. Adam Higler. Beasley RW. ed 2. who have been open to use new upper-limb control concepts and who provided a rich clinical environment for this work. pp 197-203. et al: Positivelocking components and hybrid fitting concepts for persons with high level bilateral arm amputations. New York. J Rehabil Res Dev 1984. the author wants to acknowledge the clinical assistance of Dr. who assisted and influenced him significantly. 18. Science 1980. IEEE Trans Biomed Eng 1990. 37:1037-1047. IEEE Trans Biomed Eng 1973. in Murdoch G. Yeongchi Wu and Mr. 8. Whillis J: The use of myoelectric currents in the operation of prostheses. Blackwell Scientific Publications.37:1025-1036. Heckathorne CW. Williams & Wilkins. 10:52-56. 1983. 33. Prosthetic. Monographs on Myoelec. Monographs on Myoelectric Prostheses. Liicke R.N. Marquardt E: The operative treatment of congenital limb malformation-Part I. Can42. 32. Wilson AB Jr (eds): Proceedings of the Fourth International 44. in Herberts P.oandplibrary. Ill. Kovacs GT. Hoffer JA. Scott RN. 47:421-424. 43:689-691. Herberts P. 110:145-147. Kuiken T: The Hyper-Reinnervation of Rat Skeletal Muscle (dissertation). 40. 39. Prosthet Orthot Int 1980. Yugoslav Committee for Electronics and Automation. Ellis Horwood Ltd. Reiter R: Eine neue Elektrokunsthand. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 6D The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 30. Simpson DC: The choice of control system for the multi-movement prosthesis: Extended physiological proprioception. Chichester. Michael JW: Upper limb powered components and controls: Current concepts. Bruckner L. 70:20-28.Atlas of Limb Prosthetics: Surgical. 27. University of New Brunswick Bio-Engineering Institute. 1984. 1981. 36. et al (eds): The Control of UpperExtremity Prostheses and Orthoses. University of New Brunswick BioEngineering Institute. Scott RN: Myoelectric control of prostheses. Cambridge. 28. 26. 41. et al (eds): The Control of Upper-Extremity Prostheses and Orthoses. Murphy EF: In support of the hook. 13:283-310.6D: Control of Limb Prostheses | O&P Virtual Library 24. 29. Popov B: The bio-electrically controlled prosthesis. 34.asp[21/03/2013 21:53:49] . Contact Us | Contribute http://www. in U. Am J Occup Ther 1989. Marquardt E. Richter KW: Der aktuelle Stel-lenwert Sauerbruch-Prothese bei der Rehabilitation des Armamputierten. Mass. 10:78-81. Ann Biomed Eng 1980. Ill. Canada. England. ada. 42. Remote Manipulators. Carstens C: Kineplasty according to Sauerbruch-The fresh indication pectoralis canal in amputations in the region of the shoulder girdle (abstract). 1989. 1974. in Gavrilov M. Krieghoff R. 10:66-77. Hoshall H: A powered cable drive for prosthetic-orthotic systems. 38. Bull Prosthet Res. Med Orthop Technik 1990. Malone JM: VA/USMC Electric Hand with be-low-elbow cineplasty. Seamone W. Kadefors R. p 200. Scott RN: An introduction to myoelectric prostheses. 44. et al: Design and implementation of twodimensional neural interfaces. Magnusson R. Charles C Thomas Publishers. 1989. 4:135-144. Ferrell WR: Man-Machine Systems: Introductory Control and Decision Models of Human Performance. Leal JM. Grenzegebiete Med 1948. pp 1649-1650. Shaperman J: Proportional myoelectric hand control: An evaluation. Sheridan TB. tric Prostheses. Presented at the 10th Annual Conferences of the IEEE Engineering in Medicine and Biology Society. Clin Prosthet Orthot 1986.B. Yugoslavia. Springfield. Am J Phys Med Rehabil 1991. J Bone Joint Surg [Br] 1965. 1988. Springfield. 25. Childress DS: A bibliography on myelectric control of prostheses. Japan. Kobe. pp 146-150. Sears HH. Jemes B.N. Chapter 6D . pp 736-755. Crit Rev Biomed Eng 1986. Ill. Charles C Thomas Publishers. Parker PA. Thring MW: Robots and Telechirs: Manipulators With Memory. 1:133-135. Presented at the Sixth World Congress of ISPO. Evanston. Schmeisser G. Ryder RA: Occupational therapy for a patient with a bilateral Krukenberg amputation. New Orleans. 43. 31. 35. 1973. Loeb GE: Implantable electrical and mechanical interfaces with nerve and muscle. Northwestern University. 1974. in U. Dubrovnik. 37. Clin Prosthet Orthot 1986.B. MIT Press. 8:351-360.org/alp/chap06-04.1974. 1989.43. Symposium on Advances in External Control of Human Extremities. Machine Limb for the Handicapped. Storment CW. Prosthetic. Normal values for moving two-point discrimination are slightly lower (4 mm) than those for static two-point discrimination measured in the same individual ( Fig 7A-3. Point localization.). and Rehabilitation Principles Partial-Hand Amputations: Surgical Principles Elizabeth Anne Ouellette. in the case of precision grips. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Tip pinch is used in picking up objects such as paper clips. Prosthetic. M. and lateral-pinch grip. Functional capacity is assessed by observing a patient's ability to manipulate objects and use the hand. and two-point discrimination. The joint ranges of motion are important in assessing function.Atlas of Limb Prosthetics: Surgical. There are a number of standard tests now used to assess hand function.D.8-11 Prehensile activities involve power and precision grips. by a movement profile as well. temperature. and Rehabilitation Principles. while sensory function is evaluated through tactile sensitivity. The musculoskeletal components are evaluated by measuring muscle strength and joint range of motion. These evaluate the musculoskeletal components. McAuliffe. the primary goal is to restore the best function possible in the context of preservation of life. which are evaluated by grip strength The hand grip and. The primary goals of amputation surgery are preservation of length and useful sensibility. These grip measurements are also most accurate when an average of three trials is made. Evaluation of tactile sensitivity includes an examination of pressure thresholds. There are three types of precision grip: tip.). Reproduced with permission from Bowker HK.oandplibrary. Moving two-point discrimination can also be used to test fingertips is approximately 6 mm. ©American Academy or Orthopedic Surgeons. reprinted 2002. These involve the thumb and second and third fingers ( Fig 7A-2. An adequate method of evaluating function is necessary to assess the extent of the injury and the outcome of reconstructive efforts.D. and su-domotor function are also important in Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.). M. These are a Pressure sensitivity can be evaluated by Semmes-Weinstein monofilaments.org/alp/chap07-01. M. tactile object recognition. http://www. Rosemont. and functional capacity. Pressure sensation does not correlate with twopoint discrimination. Prosthetic. and prompt return of the patient to work or play. graduated series of nylon filaments of decreasing diameter that are calibrated so that the force required to bend the filament after skin contact is diminished with each test until the patient is unable to feel the pressure applied. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. 1992. the impairment as a result of lost motion is well outlined in the American Medical Association Guides to the Evaluation of Permanent Impairment. It is assessed by ( Fig 7A-1. and lateral pinch in holding a key. prevention of symptomatic neuromas and adjacent joint contracture. the three-jaw chuck in grasping objects more firmly. Ronaldo Carneiro. edition 2. John A. for a malignant tumor. It is therefore important that the basics of hand function and their evaluation be understood prior to repair or reconstruction. Click for more information about this text. dynamometer provides the most consistent measure of power grip strength.asp[21/03/2013 21:53:56] . Normal static two-point discrimination at the vibration. HAND FUNCTION The primary objective of hand surgery is the restoration of function to an injured hand. American Academy of Orthopedic Surgeons. IL.D. averaging three separate trials three-jaw chuck. early prosthetic fitting When the amputation is where applicable. the mechanoreceptors in the hand.7A: Surgical Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 7A Chapter 7A . and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). sensation. The referring physician must take care not to commit the replantation team to too much or too little in his discussions with the patient and family. usually working with a circular saw. or those through the palm or near the wrist. Generally accepted indications for replantation include the thumb. no defatting is done. In order to more fully evaluate functional activities of the hand.). The return of sudomotor function closely follows the return of tactile sensibility. there are no better instruments to evaluate hand function as a whole. The industrial worker. also known as tactile gnosis or stereognosis. At the level of the hand there is little or no muscle tissue to sustain anoxic damage.org/alp/chap07-01. particularly by Most patients report excellent levels of the young child. gets distracted. If an adult brings the part and it is clean. virtually any amputation in a digits. is the ability to recognize an object placed in the hand. it will not wrinkle. often the ultimate decision must be made in the operating room. These are fat advancement and splitor full-thickness skin grafting. Virtually every individual in the continental United States can therefore be considered to be within range of a microsurgical center and thus a potential candidate for replantation. a full-thickness graft can be taken from the amputated part to restore the nail matrix of the remaining digit. advances in microsurgical technique and increased experience have made replantation routinely possible in microsurgical centers. a number of tests have been devised that involve manipulating small objects or the performance of activities of daily living. and distant flaps. Children have their fingertips amputated in doors that are forcefully slammed on the digit. Tactile object recognition. The wrinkle test is performed by placing the hand in warm water (42° C) for 20 to 30 minutes. the best treatment is the application of a full-thickness defatted skin graft taken from the part. If the amputated part is not brought in or is dirty and therefore unusable. Significant stiffness at the interphalangeal and metacarpophalangeal joints does not hamper the thumb with an intact carpometacarpal Perhaps the most important reason for good function of the replanted thumb is articulation. These are well described in standard texts ( Fig 7A-4. Although the http://www. thus measuring the ability to execute certain tasks by the hand.7A: Surgical Principles | O&P Virtual Library evaluating sensory defects. that no completely satisfactory substitute for its function is available. Although the technical aspects of vascular repair are more difficult in children and success rates lower. amputations of multiple In addition.oandplibrary. child should be replanted. The time the patient takes to identify the object is also recorded. This fact not only guarantees its use but also tends to maximize restoration of motion during the usual activities of daily living. The only objective measurement in these tests is the time it takes to perform the tasks. satisfaction with replanted thumbs. the superior neurologic recovery exhibited. V-Y-plasty. and Fig 7A-5. and the saw amputates the finger at the midnail area. Although guidelines for consideration of replantation can be discussed preoperatively. REPLANTATION: INDICATIONS AND RESULTS Since the first report of successful reattachment of an amputated thumb by Komatsu and Tamai in 1968. There are basically four modes of reconstructing the fingertip to avoid amputation of the distal phalanx. and the skin becomes dry.asp[21/03/2013 21:53:56] . At present. These tests are important because they require a combination of functions measured by all the previous methods. and the clean amputated part is replaced in its proper position and sutured with as few sutures as possible in a circular manner so that revascularization may occur. If the skin is denervated. innervation to the sweat glands is lost. Su-domotor function is evaluated by the Ninhydriri sweat test or the wrinkle test. and successful replantation following cold ischemic times of over 30 hours has been reported. This test is performed by touching with a probe in one or two separate locations and asking the patient to identify those locations. one must proceed with reconstruction. cross-finger flaps. When a peripheral nerve is cut. In the case of the child. If there are losses in the nailbed on the remaining finger. FINGERTIP INJURIES Fingertip injuries are very common in industry and also in children. The action taken for treatment is different depending on whether the patient brings the amputated part or not. The same considerations also apply in the case of multiple digital replantations. makes this effort worthwhile. Point localization is the ability to accurately localize a point of stimulation of the skin. or excessive delay in treating the patient. Gelberman and colleagues have shown a correlation between the return of sensation and restoration of digital vascularity on a quantitative basis. Recovery of sensation following replantation is slightly poorer than that of digital neurorrhaphy in lacerations involving fingers. Once the decision for replantation has been made. Although the strictly medical issues involved in making such a decision are complex enough. the contribution of these fingers to overall hand function may be significant in the face of few Certainly each additional digit in or no remaining normal digits available for substitution.g. gross contamination. Other late complications include malunion or nonunion.oandplibrary. unless it is severely impaired. Causes of limited use may be decreased sensibility. Replantations distal to the flexor superficialis insertion. recommended for replantation.. while two thirds regain measurable two-point discrimination. The occurrence of postoperative hemorrhage reported in various series ranges from rare to nearly 50% of cases. It must be remembered that the functional results of digit salvage in the presence of injury to multiple tissues at the same level are not enhanced by our ability to re-establish circulation. a musician) or perhaps in Ring avulsion injuries are a specific subset of single-digit amputations whose care children. Digits replanted proximal to the flexor superficialis insertion have decidedly limited proximal interphalangeal found the total joint motion that averages approximately 35 degrees. Joint stiffness combined with limited sensibility may seriously limit the use of a replanted digit when three normal digits are available for substitution. Early complications requiring reoperation are related to vascular occlusion in up to 40% of cases. i. many authors no longer recommend proximal replantation of single digits. approximately 80 degrees of proximal interphalangeal joint motion. these cases. Approximately half will exhibit two-point discrimination of 10 mm or less. Postoperative heparinization seems to be associated with higher rates of hemorrhagic complications. may also make attempts at replantation inadvisable. the impaired function of the replanted finger may seriously jeopardize use of the entire hand. They exhibit significantly better range of motion. middle phalanx. Factors pertaining to the injury itself. Urbaniak states that most series. including severe crush or avulsion. and quadriga. Indications for replantation of a single digit.. and the incidence of bleeding significant enough to require reoperation is not reported. usually do well. are more controversial. Infection is a rare occurrence following replantation in the hand. although http://www. and the current tendency of most surgeons is to routinely heparinize only those patients with severe crush or avulsion injuries in whom the risk of thrombosis is greatest. Scott and associates active motion of replants through the proximal phalanx to be poor (averaging 120 degrees) in 84% of their patients.). Even worse. For these reasons. If nerve repair is delayed or requires the use of grafts. Somewhat fewer than half of the digits requiring early reoperation are salvageable. may add significantly to the width and strength of the hand. it has since been demonstrated that the level of experience of the surgical team and liberal use of vein grafts are of far greater significance than are mechanisms of injury in predicting success. this problem usually resolves spontaneously in the year or two following replantation. except in the occasional patient in whom a full complement of digits is a professional necessity (e. recovery of sensation is not as good as with primary repair. The ultimate question to be answered is whether the replanted part will function in a manner that will surpass amputation. Relative contraindications to replantation include associated life-threatening injury or the presence of systemic disease. The major factors influencing survival are age of the patient and experience of the surgeon. with an incidence of less than 5% in and the almost universal presence of cold intolerance. pain. Although complete amputations by this mechanism were not has been subject to debate.e.org/alp/chap07-01. cold intolerance. except the thumb.7A: Surgical Principles | O&P Virtual Library function of each individual digit may not be improved over that of a single digital replantation. particularly any that would affect the patient's vasculature or ability to withstand a prolonged surgical procedure. the physician must also consider and discuss with the patient the psychological and economic implications of the available options. than do replants at the metacarpal level. Leeches may also be of benefit if there is difficulty with venous drainage. The severity of this complication is difficult to quantify. the presence of injury at multiple levels. survival rates in most recent series approach 80% to 90% or greater at all levels.asp[21/03/2013 21:53:56] . The latter is a loss of full excursion in one profundus tendon that causes decreased motion in others due to their anatomic interconnections ( Fig 7A-6. virtually all patients develop protective sensation. In general. with few stating that they would have preferred amputation. which http://www. Very few patients require late secondary reamputation. the thumb must have at least protective sensation.asp[21/03/2013 21:53:56] . In order for function to occur. adequate length and sensation must be present as well as stability and the ability to oppose the other fingers. Amputation Through the Midproximal Phalanx and Mid-distal Phalanx of the Thumb At these levels of amputation. There are numerous techniques that will maintain length and provide sensation. with resultant loss of function. social. Early return to work should be considered a priority of rehabilitation. Data regarding return to work do give some indication of fairly normal functional use. If these do not provide adequate coverage. and neurovascular island flaps. disarticulation through the interphalangeal joint of the thumb is rated as a 20% impairment of the hand. For example. which serves as a post. Whatever the amputation level. and the ability to do so is of obvious economic. If this joint is destroyed or unstable. and personal significance to the patient. occupation. An appreciation of the patient's ability to integrate the function of the replanted digit or digits with that of the remainder of the hand is difficult to achieve and even more difficult to quantify. Thumb reconstruction requires assessment of the patient's age. Once adequate length has been achieved. The ability to oppose the thumb and index finger is necessary for grasping and pinching. it is difficult to recognize an object and localize its position in the hand. hand dominance. Secondary operations are performed on 15% to almost 50% of patients. with tenolysis and release of joint contracture being the most common procedures. cross-finger flaps. The thumb is involved in tactile perception and two-point stereognosis. the sensation of the thumb must be considered.7A: Surgical Principles | O&P Virtual Library it may remain indefinitely as a minor problem in colder climates. The level of amputation in the thumb determines which procedures should be considered. Virtually all patients express satisfaction regarding replantation. the patient must have an adequate residuum for pinch and grip to be restored. the functional impairment is caused by loss of length. documented. Restoration of thumb function by replantation has been reliable and well This should be the first consideration when examining a thumb amputation. These consist of palmar advancement flaps. In order to achieve this. sex. Replantation has become a reliable surgical procedure as microvascular surgical techniques have improved. controversy over exactly how much length must be lost before there is a significant impairment. Without adequate sensation. Loss of the thumb at the level of the metacarpophalangeal joint constitutes a 40% loss of There is still function of the hand and 36% loss of function of the entire upper limb. Amputation of the Distal Phalanx of the Thumb The functional impairment of amputation at this level is minimal.oandplibrary. then lateral triangular advancement flaps or pedicle flaps may be used to gain coverage. Only after replantation is not successful or found to be not feasible should other reconstructive procedures be considered.org/alp/chap07-01. When the soft-tissue loss is greater and there is digital nerve damage. THE THUMB The thumb is required for both power and precision grip. other procedures may be necessary to preserve length and maintain good sensation. Motion at the interphalangeal or metacarpophalangeal joint is not an absolute necessity for normal thumb function. and the remaining structure and functional status of the injured hand. This position enables the fingers to brace objects against the thumb. healing by secondary intention or skin graft is possible. Primary goals are skeletal stability and adequate pain-free skin coverage with good sensation. it can be fused with the thumb in full opposition. For losses of soft tissue dorsally but minimal loss from the distal phalanx. This motion occurs at the carpometacarpal joint of the thumb. infection. free flap. If the carpometacarpal joint is intact due to a residual portion of metacarpal. Amputation Through the Proximal Third of the First Metacarpal of the Thumb This injury represents a complete loss of the thumb and subtotal or total loss of the first metacarpal with resultant loss of mobility through the carpometacarpal joint. They are usually part of the reconstruction of a hand in which an amputation has occurred traumatically or in which an amputation is necessary for a tumor. Two thirds of the first metacarpal with good skin coverage must be present before contemplating metacarpal lengthening. The goals are to restore length and sensibility. toe-to-hand transfers. When there are contractures of the muscles and scarring with loss of mobility. and dorsal rotational or remote pedicle flaps. bone grafting with tubed pedicle flaps. unacceptable to the patient. the thumb is unable to perform any of its normal functions. Procedures that have been used to gain length and sensibility at this level are pollicization. Lengthening the residuum by 2 cm may improve function dramatically. This can be obtained by cross-arm flap. and mobility are required. there are other reconstructive procedures such as "phalangization" of the first metacarpal. sensation. then a pedicle from uninjured tissue must be utilized. stability. If function is severely impaired secondary to the injury and especially if the function of adjacent digits is impaired. RAY AMPUTATIONS These amputations are rarely performed emergently. Restoration of length.7A: Surgical Principles | O&P Virtual Library affects pinch and grip strength. Fig 7A-9. Each ray resection has its own special considerations for preventing complications such as painful neuromas. which results in a deepened first web space that can improve grip and pinch. the removal of the entire ray should be considered in an effort to improve function of the hand as a whole. When this is A free toe transfer satisfies all the requirements of reconstruction at this level. bone grafting with flap coverage is considered a less-satisfactory alternative. both simple and four flap. This http://www. The carpometacarpal joint is usually uninvolved.oandplibrary. the finger should be transferred with its metacarpophalangeal joint to preserve some motion. Toe-to-thumb transfer is best when there are other mutilated fingers. Disarticulation at the Metacarpophalangeal Joint of the Thumb At this level. transfer replantation of salvaged injured digits to the thumb position.. If the entire first metacarpal is absent. metacarpal lengthening. This is the only technique capable of restoring function when only metacarpals are remaining after amputation. ). These are best performed when the underlying soft tissues are minimally scarred and there is good joint mobility. Index ray resection has two complications associated with it that need attention ( Fig 7A-11. By deepening the web space and releasing contracted tissue. or reverse radial artery flap coverage into the web space.asp[21/03/2013 21:53:56] . Reconstructive options are essentially limited to pollicization and island or free digit transfers. a digit transfer to the thumb can be performed with minimal loss of mobility. thus giving the thumb good rotation and mobility. or failed replantation. and reoperation is not usually successful. Fig 7A-8.org/alp/chap07-01. ).). The second complication is an intrinsic-plus deformity of the long finger resulting from transfer of the first dorsal interosseous muscle to the second in an attempt to improve pinch strength of the long finger. For this reason. The web space procedures available include Z-plas-ties. This complication appears in the first 8 weeks following surgery. Pollicization and transfer of free tissue offer the best chances to restore thumb function ( Fig 7A-10. Sensation must be achieved for these techniques to restore useful function. and minimizing cosmetic deformities. the thumb is effectively lengthened ( Fig 7A-7. closing the gap created between rays. The first is debilitating pain occurring from excessive mobilization of the radial digital nerve when performing the amputation.. and composite radial forearm island flaps. disarticulation at the proximal interphalangeal joint is recommended. ). Tension of the unrestrained flexor digitorum profundus tendon is transmitted through the lumbrical to the dorsal hood mechanism to produce this effect. the involved finger's proximal phalangeal joint is seen to paradoxically extend.7A: Surgical Principles | O&P Virtual Library procedure is not necessary. Both the tendon and the digital nerves should be found and transected so that clean edges may retract proximally. Fifth-ray resections require that the base of the fifth metacarpal be left because of the insertion of the extensor carpi ulnaris ( Fig 7A-15. When performing a long-ray resection.asp[21/03/2013 21:53:56] . The condyles should be trimmed so that they are not prominent.oandplibrary. ). a ray resection should be considered in an effort to improve function. The fifth metacarpal can also be transposed to the base of the remaining fourth metacarpal after amputation. there may be difficulty in closing the space between the ring and index rays ( Fig 7A-12. The flexor and extensor tendons should not be sewn to each other because the excursion of these tendons would be limited. In addition. the lumbrical muscle is pulled into a more taut position. If there is difficulty in reducing the space. consideration has to be given to the space between them. attention is focused on reconstruction of the remaining hand so that a prosthesis can be worn. then bone trimming and primary wound closure can be performed ( Fig 7A-16. Flap coverage similar to those used in fingertip injuries may be used to preserve length. ). This is caused by the flexor digitorum profundus retracting proximally after transection. The space left in the center of the hand cannot be compensated for except by closing the gap with a ray resection or with a prosthesis (see Chapter 7C). depending on the anatomic situation. thus limiting range of motion of the amputated finger and adjacent fingers. It is not necessary to remove articular cartilage in amputations through the interphalangeal joints. As it retracts. The hypothenar muscles are used to provide padding over the base but are not reattached to the fourth interosseous muscle tendon because this too can cause an intrinsic-plus deformity and loss of function. When flexion at the metacarpophalangeal and proximal interphalangeal joints is attempted while making a fist. Ring-ray resections are similar to those of the long ray but usually close the remaining gap more easily ( Fig 7A-14. If this is unnecessary. An amputation through the middle phalanx distal to the flexor digitorum sublimis tendon insertion is a functional one. In fact. the fifth metacarpal base can be allowed to slide radially if the entire base of the fourth metacarpal is excised. but this is rarely necessary. This complication can be alleviated by releasing the lumbrical from its origin on the flexor digitorium profundus tendon in the palm. and Fig 7A-13. The proximal interphalangeal joint should be approached in a fashion similar to the distal interphalangeal joint. preservation of the general function of the hand has to be considered fundamental to reconstruction. When flexion control of the remaining middle phalanx is lost. there is evidence that the inflammatory response to amputation is less when the cartilage is left intact. Amputations Proximal to the Digital Tips These amputations by definition involve bone of the fingers. and the resultant deformity will further hinder hand function. When amputation through the proximal phalanx occurs in the long and ring fingers. A soft-tissue closure of the gap by using the deep intervolar plate ligaments can be performed with minimal rotational deformity of the fingers as a result. The most significant complication of amputation at the distal interphalangeal joint is the lumbrical-plus finger. Function can be preserved by shortening or maintaining length. RECONSTRUCTION Following single or multiple digital amputations in which replantation is not feasible.org/alp/chap07-01. Is that space adequate? Is there a painful neuroma in the midpalmar area that would inhibit function? Is http://www. ). In the case where the patient has retained a "basic" hand including the thumb and at least one of the digits. It is unnecessary to perform this at the time of the amputation since few fingers amputated at the distal interphalangeal joint develop this complication. Transfering the index metacarpal to the base of the long-finger metacarpal is another acceptable method of reducing the gap and gives an excellent functional and cosmetic result. preferably dorsal location seems to The most promising provide the most consistent and significant long-term relief of pain. The ideal timing for this procedure is at least 6 months from the original injury so that the patient has time to mature his scars and to develop significant contractures so that more skin can be included with the transferred toe if additional skin is needed for contracture release. The largest number of complications involve the presence of pain and is therefore at least partially subjective in nature. Transposition of the intact neuroma to a better-padded. The hooked nail resulting from the loss of distal http://www. A toe with its neurovascular bundle may be transferred from the foot to the hand to provide an opposing digit. When coverage must include subcutaneous tissue and sensation. The number of treatments proposed to prevent or manage a painful neuroma is large. new technique that may be considered when adequate local soft-tissue for transposition is not present is that of centrocentral nerve union. depending somewhat upon how diligently they are sought. but an established painful neuroma often requires a surgical solution.oandplibrary.org/alp/chap07-01. transcutaneous nerve stimulation. COMPLICATIONS Numerous complications can occur following amputation in the hand. The patient's attempt to come to terms with an amputation involves a complex and interrelated series of physical. where the superficial radial nerve can provide innervation. such residua seriously jeopardize function of the entire hand. whereby two proximal nerve ends are joined with intervening graft. Occasionally. Although maintenance of length is of concern. few authors have attempted to examine their true nature and incidence. soft piece of skin. Tension-free closure with appropriate shortening or tissue transposition should be performed initially. These flaps are capable of withstanding the use of a prosthesis very nicely. A review of surgeons with amputations involving the hand revealed few of these complications. poor padding. nonoperative methods such as desensitization. emotional. Other authors have had significantly less success with this technique. ideally a distant free flap with sensation. particularly the painful neuroma. If the patient presents with a thumb and no other digit. psychological. potential donor procedures are the free lateral arm flap and the radial artery fasciocutaneous flap. although occasionally local flap coverage may be considered for specific indications. ). Pain following amputation may be caused by inadequate soft-tissue coverage of the residuum or pain of neural origin due either to frank neuroma or pain syndromes such as reflex sympathetic dystrophy.asp[21/03/2013 21:53:56] . and almost universal return to preamputation activities. Although much has been written concerning solutions to these problems. however. Nail deformity following amputation at or near the level of the germinal matrix is generally best treated by ablation of the remaining perionychium and skin graft coverage.7A: Surgical Principles | O&P Virtual Library there adequate skin coverage? Is there good sensation? If a contracture exists. The incidence of painful neuroma following amputation in the hand has been reported to range from less than 1% to 25% or greater. Other donor sites are available but do not provide as good a sensory component as these flaps (see Fig 7A-10. or protuberant bone are much more common in the digits than at the metacarpal level. that area should be reconstructed with a long-lasting. This is also true for the radial artery flap. a high level of acceptance. but it is also quite true. or neural blockade may prove to be Tupper and curative. These are usually the result of an injudicious attempt to save length at all costs. economic. reconstruction with grafts of sterile or germinal matrix may be considered. The incidence of complications varies considerably in published reports. reconstruction of an opposing finger is a priority. The reported need for reoperation following amputation ranges from 2% to 25%. Deformity more distal in the nail may be treated similarly. Booth have reported a 71% overall success rate with simple excision of the neuroma when the nerve end was allowed to retract under cover of more proximal unscarred and wellpadded tissue. Late treatment of such a problem is usually best managed by more proximal amputation. aesthetic. To say that well-motivated amputees do better may be trite. and cultural adaptations. The free lateral arm flap has a very good cushion of fat and fascia and also has a sensory nerve that can be sutured to the recipient nerve. Painful amputations due to adherent or excessive scarring. Undblom U: Neurophysio-logical studies on patients with http://www. 73:293. Mosby-Year Book. 42:567-571. 6. 1984. Quadriga or profundus tendon blockage may limit motion of adjacent unaffected digits following amputation. 7:31. Barton NJ: Another cause of median nerve compression by a lumbrical muscle in the carpal tunnel. J Hand Surg 1982. 1984. pp 95-139. nonfunctional. Clinical evaluation of the quickly adapting fiber/receptor system. Gelberman RH.oandplibrary. et al (eds): Rehabilitation of the Hand. Bell J: Sensitivity evaluation. Brand PW: Clinical Mechanics of the Hand. Baltimore. Williams & Wilkins. References: 1. 3. 1981. Aust N ZJ S 1973. Conolly WB. 1988. Glas K. 33:841. state of the art. Interconnections of the profundus tendons in the palm and the relatively greater strength of the flexor system make this "lumbri-cal-plus" deformity uncommon. 16. Brown PW: Complications following amputations of parts of the hand. Gorkisch K. Biemer F. J Hand Surg [Am] 1978. McCormack RM: Functional hand testing: A profile evaluation. Scarring of these tendons within the amputated digit or in the palm may limit excursion of the adjacent digits. 9. division of the lumbrical tendon is curative. Duspiva KP. Gellis M. J Hand Surg 1979. Occasionally. Vaubel E: Treatment and prevention of amputation neuromas in hand surgery. Dellon LA: The moving two-point discrimination test: 10. Dellon LA: Evaluation of Sensitivity and Re-education of Sensation in the Hand. Median nerve compression following retraction of the profundus tendon and its lumbrical into the carpal tunnnel is another rare complication. 14. J Trauma 1983. Bright DS. 23:136. 3:474-481. 100:95. although long-term benefits are uncertain. et al: Digital sensibility following replantation. Arch Orthop Trauma Surg 1982. pp 20-21. Mosby-Year Book. Fess EE: The need for reliability and validity in hand assessment instruments. et al (eds): Rehabilitation of the Hand. 3:313. Paradoxical extension of the proximal interphalangeal joint during attempted flexion due to retraction of the divided profundus tendon and its associated lumbrical origin is rarely encountered clinically.asp[21/03/2013 21:53:56] . Philadelphia. Goulston E: Problems of digital amputations: A clinical review of 260 patients and 301 amputations. Plast Reconstr Surg 1968. J Hand Surg 1978. St Louis. Fisher GT. 19. ed 3. 20. ed 2. Wiesenfeld Z. Boese-Landgraf J. Schneider LH.7A: Surgical Principles | O&P Virtual Library phalangeal support is exceptionally difficult to treat. WB Saunders Co. pp 61191. St Louis. Grant GH: Methods of treatment of neuromata of the hand. 5. Once present. The three ulnar profundus tendons arise from a common muscle belly and are further interconnected in the palm by the bipennate origins of the ulnar two lumbricals. Pool R: Two-point discrimination distances in the normal hand and forearm. When encountered. ed 2. American Medical Association. 7. 8. Urbaniak JR. 11:621-623. Aulicino PL. DuPuy TE: Clinical examination of the hand. in Hunter JM. 15. 4. Cold intolerance following amputation is quite common. et al: Long-term follow-up results of 97 finger replantations. in Hunter JM. with resorption of distally located bone grafts and recurrence of deformity being the norm. 17. 1986. 18. 13. pp 101-132. Engleberg A: Guides to the Evaluation of Permanent Impairment. Brown PW: Less than ten-surgeons with amputated fingers. Boswick JA: Neuroma formation following digital amputations. Mackin EJ. pp 25-48. which is painful. is generally best treated by more proximal amputation. Early and full active motion of the intact fingers postoperatively usually prevents this complication. St Louis. 12. Plast Reconstr Surg 1977. Hallin RG. surgical correction by release of the adherent profundus tendon is quite successful. Mosby-Year Book. Schneider LH. Greenseid DZ. 2. J Hand Surg [Am] 1986. 43:118. 59:57-63. Chicago. although this usually resolves over time without treatment. pharmacologic treatment or local sympathectomy by excision of vessel adventitia may prove effective. 11. 4:189. J Bone Joint Surg [Am] 1951.org/alp/chap07-01. Plast Reconstr Surg 1984. in Boswick JA (ed): Complications in Hand Surgery. and prone to repeated trauma and ulceration. 1985. The dysvascular residuum. Mackin EJ. Orthop Clin North Am 1977. Tsai T: Results of surgical treatment of painful neuromas of the hand. MacKenzie JK: Profundus tendon blockage: Quadriga in finger amputations. 42:374. 25.oandplibrary. Philadelphia. in Green DP (ed): Operative Hand Surgery. Am J Occup Ther 1987. Spinner M (eds): Management of Peripheral Nerve Injuries. in Green DP (ed): Operative Hand Surgery. 1980. Komatsu S. Strickland J: Thumb reconstruction. 1988. Toews JV: Grip strength as measured by the James dynamometer. J Hand Surg 1979. Kevins S. O'Riain S: New and simple test of nerve function in the hand. Churchill Livingstone Inc. Onne L: Recovery of sensitivity and sudomotor activity in the hand after nerve suture. 73: 90-106. 52:321-327. Arch Phys Med Rehabil 1970. O'Brien BM. 1988. New York. Harvey FJ. Hashman N. WB Saunders Co. 41:158163. 21:204. Morrison WA. 52:71. 67:566. Macleod AM: Evaluation of digital replantation-a review of 100 cases. J Bone Joint Surg [Br] 1958. Rohrich R: Microvascular great toe-to-hand transfer for thumb reconstruction. 28. 22. Exp Neurol 1981. 6:157. in Green DP (ed): Operative Hand Surgery. ed 2. 7:190. Kalisman M. in Owen GE. 26. 58:369. 44. Arch Phys Med Rehabil 1969. Mass. pp 61-119. Trieschmann RB. 1986. Harvey PM: A critical review of the results of primary finger and thumb amputations. http://www. 52. Scott FA. Hand 1980. Boswick JA: Recovery of function following replantation and revascularization of amputated hand parts. 1988. J Hand Surg [Am] 1989. pp 3-80. Wolff TW: Ring avulsion injuries: Classification and prognosis. Jebsen RH. Moberg E: Objective methods for determining the functional value of sensitivity in the hand. Harvard University Press. 23. Howar JW. Smith JR. Taylor N. Br Med J 1973. Murray JF.org/alp/chap07-01. 32. 12:25. McCarroll HR. Semmes J. 40.7A: Surgical Principles | O&P Virtual Library 21. MacKenzie JK: Transmetacarpal amputation of the index finger: A clinical assessment of hand strength and complications. Murray JF. Mosby-Year Book. Werntz J. Jones L: The assessment of hand function: A critical review of techniques. Stei-chen JB (eds): Difficult Problems in Hand Surgery. Philadelphia. 43. New York. J Hand Surg [Am] 1982. et al: Replantation and revascularization surgery in children. et al: An objective and standardized test of hand function. ed 2. May J. et al: Somatosensory Changes After Penetrating Brain Wounds in Man. 8:295. 33. 66:69-74. Poppen NK. Am J Occup Ther 1973. May JW: Digit replantation with full survival after 28 hours of cold ischemia. J Hand Surg 1977. Volland G. ed 2. J Bone Joint Surg [Am] 1970. Eaton RG. 39. J Hand Surg [Am] 1985. 50:311-319. 2:471-481. Mutniowetz V. sutured median nerves: Faulty sensory localizations after nerve regeneration and its physiological correlates.asp[21/03/2013 21:53:56] . Leung PC: An analysis of complications in digital replantations. Ruderman RJ: Von Frey's method of measuring pressure sensitivity in the hand: An engineering analysis of the Weinstein-Semmes pressure aes-thesiometer. 300:1-69. Schmidt RT. 29. Ghent L. 42. 35. J Trauma 1981. 24. Gomez NH: Local injection therapy of neuromata of the hand with triamcinolone acetonide. 46. pp 4-11. 27:244-251. 12:12. J Bone Joint Surg [Am] 1976. 36. Smith HB: Hand function evaluation. 51. Owen JE: Sensitivity testing. Churchill Livingstone Inc. J Hand Surg [Am] 1989. pp 2175-2261. 1982. et al: Grip and pinch strength: Normative data for adults. Churchill Livingstone Inc. 27. Doyle JR. Franklin JD. Cambridge. Plast Reconstr Surg 1981. Pearsall G. 3:615616. Scott FA: Complications following replantation and revascularization. 41. Weinstein S. 45. New York. 14:204. 3:211-216. WB Saunders Co. 14: 221-228. Carman W. J Hand Surg 1978. McPhee SD: Functional hand evaluation: A review. Omer GE: The painful neuroma. Laborde KJ. 1960. Hand 1980. et al: Recovery of sensitivity after suture of digital nerves. Louis D: Amputations. St Louis. O'Brien BM. 40:454-476. Plast Reconstr Surg 1968. Neu BR. 30. 49. 53. 38. 4:212-226. Morrison WA. Littler JW: Management of painful neuromas in the hand. Tamai S: Successful replantation of a completely cut off thumb. 50. Kay S. 10:878. Arch Phys Med Rehabil 1985. 37. in Strickland JW. Acta Univ Scand Suppl 1962. 31. 47. 48. 34. Herndon JH. in Boswick JA (ed): Complications in Hand Surgery. Hand 1974. 58. Urbaniak JR. et al: The results after amputation of a single finger. 59. ed 2. 58. in Strickland JW.Wynn Parry CB: Peripheral nerve injuries: Sensation. and laterality. Tamai S: Digit replantation: Analysis of 163 replantations in an 11 year period. Urbaniak JR. 56. Ill. New York. 68:15-19. 62. 1988. pp 195-222. 6:25. J Bone Joint Surg [Br] 1986. Nunley JA. Prosthetic.Whipple RR. Roth JH. sex. Orthop Clin North Am 1988. Springfield. Booth DM: Treatment of painful neuromas of sensory nerves in the hand: A comparison of traditional and newer methods. Contact Us | Contribute http://www. 1982.oandplibrary. Evans JP. Strickland JW: A rationale for digital salvage. Churchill Livingstone Inc. in Green DP (ed): Operative Hand Surgery.asp[21/03/2013 21:53:56] . 67:611. 57. Unsell RS: Treatment of painful neuromas.7A: Surgical Principles | O&P Virtual Library 54. Clin Plast Surg 1978.org/alp/chap07-01. Charles C Thomas Publishers. 5:195. 59. 57.Weinstein S: Intensive and extensive aspects of tactile sensitivity as a function of body part. 60. 19:175. J Hand Surg 1981. St Louis.Atlas of Limb Prosthetics: Surgical. 61. 1:144. in Henshals DR (ed): The Skin Senses. Tupper JW. 55. Bright DS: Microvascular management of ring avulsion injuries. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 7A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Steichen JB (eds): Difficult Problems in Hand Surgery. 1968. J Hand Surg 1976. Urbaniak J: Other microvascular reconstruction of the thumb. Chapter 7A . J Bone Joint Surg [Am] 1985. Mosby-Year Book. and such devices Although it is true that covering the remnant are generally well accepted by the amputee. commented in 1986 that "partial hand amputees are more likely to reject their prostheses than any other upper limb amputee. Michael." As a result. PRESCRIPTION RATIONALE The dilemma facing physicians and prosthetists is to determine when our admittedly limited prosthetic armamentarium will add a measure of function to diminish the substantial loss faced by the partial-hand amputee. has sensation. Rejection stems from lack of tactile sensation. In 1944. it may well be necessary to prescribe more than one device to meet all of the amputee's needs. hand with a rubberized glove reduces sensory input and increases perspiration. M. if it is painless.7B: Prosthetic and Orthotic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 7B Chapter 7B . Beas-ley has noted that: Loss of a hand results in a major restriction of capabilities and the loss of a prime sensory perceptor and imposes a serious disfigurement that can be only incompletely disguised at very best. and Rehabilitation Principles Partial-Hand Amputations: Prosthetic and Orthotic Management John W.oandplibrary. and strong prehension. poor appearance. The loss of both hands creates a handicap that is exceeded only by serious brain or spinal cord injury.. Wedder-burn et al. edition 2. Chapter 7D discusses the aesthetic prosthesis in detail. treatment for partial-hand amputation has not changed significantly since those words were written. Prosthetic. Rosemont. Such devices are generally provided by highly specialized cosmetic restorationists who sculpt a detailed mirror-image replica of the contralateral hand from which to fabricate the device. and limited function. It should be noted that the degree of physical loss is not at all indicative of the degree of emotional loss. IL. reprinted 2002. and the foundation for successful prosthetic-orthotic design is therefore careful Although a variety of approaches assessment of the amputee's expectations and needs.org/alp/chap07-02. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. it is [not] far better than any prosthesis.P. ©American Academy or Orthopedic Surgeons. C. Aesthetic Loss One common concern of partial-hand amputees is the disfigurement that an anomalous hand presents. lack of ventilation in the prosthesis. Thus.asp[21/03/2013 21:54:02] . Prosthetic. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Despite numerous advances in the state of prosthetic art for other levels. Prosthetic. Due to the space constraints dictated by the remnant hand. Upper-limb loss can be far more catastrophic to the individual than the more common lowerlimb loss. are possible. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). neither factor is of great consequence for the unilateral amputee. Kirk aptly summarized the challenge that partial-hand amputation presents to the prosthetist-or-thotist: "No hand is so badly crippled that. Click for more information about this text. few devices can provide both a cosmetic appearance and strong prehension simultaneously. American Academy of Orthopedic Surgeons. which varies according to cultural and personal values. Those who elect to wear a prosthesis do so for specific reasons.Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles. Reproduced with permission from Bowker HK. the simplest device necessary to meet the identified needs will provide the greatest measure of acceptance and patient satisfaction.O. many partial-hand amputees choose to function without a prosthesis. 1992. Most prosthetists can also supply a polyvinylchloride (PVC) plastic cosmetic restoration that is fabricated by a specialty company (Realastic) from donor molds of hands that are similar (but http://www.Ed. Prescription of a prosthesis to restore the external appearance is common. and the like will differ significantly from the contours necessary to permit a chef to use cooking utensils. Protection Another indication for prosthetic use. It should be noted that passive restorations should not be considered to lack function. and the like..7B: Prosthetic and Orthotic Management | O&P Virtual Library not identical to) the patient's hand. play keyboard instruments. This permits the prosthetist to reconfigure the prosthesis to provide as many grasp patterns as possible prior to finishing the device. individually shaped to the anomalous hand. rakes. For example. Body power transmitted from biscapular abduction is generally used to open the device.). such protective devices may be required to permit a return to gainful employment ( Fig 7B-4. in addition to restoring a more normal appearance.B). ). STATIC DEVICES Most prosthetic devices used to restore grasp following partial-hand amputation have static configurations. they are not as durable nor as well matched in color or contours and are therefore satisfactory only in selected cases ( Fig 7B-1. many provide a source of opposition for mobile hand remnants. In some cases. Particularly for the manual laborer.). and covered with a pink-colored plastic (Plastisol) to increase the friction when gripping objects ( Fig 7B-6. The one exception is the limb without digits that retains carpal or carpal-metacarpal motion. Particularly for use under the rugged conditions of factory work or manual labor. Prehension The final justification for prosthetic-orthotic fitting is to improve prehension. Some are formed from stainless steel. Other devices are made of laminated plastic formed over balsa wood ( Fig 7B-7.org/alp/chap07-02. sensate. Some amputees choose to retain the simple utensil cuffs provided early in their rehabilitation training because they find this approach adequate for their needs. Although these latter prostheses are much less expensive than custom-sculpted restorations.). Prehension is not the only definition of function: persons who hide their disfigured hand in a pocket are as disabled as if the entire arm were ablated. articulated partial-hand prostheses usually offer a wider range of openings. grafted skin or hyperesthesias will require long-term protection by a prosthetic device ( Fig 7B-3. static designs have the advantage of durability. Once recovery is complete and vocational/avocational needs have been established. the patient may be referred to the prosthetist-orthotist for definitive prosthetic fitting ( Fig 7B-2. Preliminary devices are often provided by the occupational therapist and are fabricated from low-temperature plastics that can be easily reshaped as the partial-hand amputation matures ( Fig 7B-2. is to protect hypersensitive or fragile areas. Although technically much more difficult to fit than static designs. and partial-digit extensions frequently restore the ability to type.) or over lightweight aluminum armatures covered with polyurethane foam ( Fig 7B-8. The common denominator in all these prostheses is that they must be individualized carefully to perform the specific tasks desired by the amputee.A). Most allow a fixed grasp. This is frequently necessary during the early postoperative stages while healing is occurring. Most congenital deficiencies do not require any assistive devices to augment function because children naturally develop idiosyncratic grasp patterns that maximize the available body function. A mobile.).). The three-position design developed at the Child Amputee Prosthetics Program (CAPP) is particularly useful ( Fig 7B-5.oandplibrary.asp[21/03/2013 21:54:02] . ). the configuration to permit a landscape worker to handle shovels. sensate metacarpal "pad" to oppose. DYNAMIC DEVICES Articulated or dynamic devices powered by residual motions at the wrist or palm may also be developed to enhance grasp.. http://www. It is usually helpful to have the amputee bring examples of the objects he wishes to handle with the prosthesis to the initial fitting. thereby ( Fig 7B-10. although some prefer an aesthetic restoration. and prehension-capable limb deficiency will likely be encumbered by a prosthesis that attempts to augment grasp. It is also possible to use thermoplastics to form partial-hand devices ( Fig 7B-9.). It is sometimes useful to attach a facilitating grasp of more varied objects prosthetic hook mechanism to a hand remnant with no useful residual function ( Fig 7B11. An orthotic post may improve grasp by providing a platform for the mobile.). 38:64-67.Reconstruction vs. 15. 38:64-67. Mosby-Year Book. Cole DP. 14. In-ter-Clin Info Bull 1974.asp[21/03/2013 21:54:02] . ). Pillet J: The aesthetic hand prosthesis. 38:477-499. WF Prior Co Inc. Kapczynska A. Schottstaedt ER. pp 159-172. Artif Limbs 1957. 2. vol 3. 1944. Orthot Prosthet 1984. and augmentation of active grasp. protection of tender areas. Robinson GB: Functional bracing of the arm. Orthop Clin North Am 1981. 18. Am J Occup Ther 1975. partial-hand prostheses are highly individualized devices designed to meet such specific needs as cosmetic appearance. 17. 11. Dobner D: A simple cosmetic partial-hand prosthesis. ). Blair SJ. early provision of preparatory devices fabricated from lowtemperature plastics by the occupational therapist is believed to maintain two-handed functional patterns and facilitate definitive fitting by the prosthetist. 30:3-11. Malick MH: A preliminary prosthesis for the partially amputated hand. 12: 743-750. Rommerdale EH: Prosthetic finger retention: A new approach. 19. Orthop Clin North Am 1981. 2:8-11. 12:953-960. Konieczna D. 38:13-23.org/alp/chap07-02.7B: Prosthetic and Orthotic Management | O&P Virtual Library but wrist motion ( Fig 7B-12. It is sometimes possible to combine a wrist-driven orthosis with prosthetic fingers and thumb to result in a somewhat cosmetic hand prosthesis. Kramer S: Partial hand amputation. J Hand Ther 1988. Md. Brown RD: An alternative approach to fitting partial hand amputees. Kirk NT: Amputations. asensory hand. ) or other body motions may sometimes be used ( Fig 7B13. Orthopedics 1978. Researchers at Northwestern University have developed demonstration prototypes (see Chapter 12D). 13:7-14. Part 2. Orthop Clin North Am 1981. Orthop Clin North Am 1981. 12:929952. 13. http://www. Traunero JE: The Toledo tenodesis prosthesis-A case history utilizing a new concept in prosthetics for the partial hand amputee. Orthot Prosthet 1980. 12:961-970. 9. 6. Amputation and prosthetic fitting for treatment of the function-less. in Lewis DDL (ed): Practice of Surgery. 34:41-45. J Bone Joint Surg [Am] 1963. Tomaszewska J. although many barriers must be overcome before such technology can become clinically available. 1:314. 12:763-804.oandplibrary. 8. ). prosthesis. Baumgartner R: Active and carrier-tool prostheses for upper limb amputations. 7. Hagerstown. Swanson AB: Restoration of hand function by the use of partial or total prosthetic replacement. References: 1. in American Academy of Orthopaedic Surgeons (ed): Atlas of Limb Prosthetics: Surgical and Prosthetic Principles St Louis. This approach has been difficult to replicate due to numerous cosmetic glove technical constraints but is worthy of further investigation. SUMMARY In summary. 1981. Law HT: Engineering of upper limb prostheses. Beasley RW: General considerations in managing upper limb amputations. Orthop Clin North Am 1981. 16. particularly when covered with a modified ( Fig 7B-15. Koch RD: Meeting the challenge of partial hand amputations. 4. Devices to restore active grasp are best described as "tools" and are most readily accepted for manual tasks or factory occupations. 3. many individuals will choose to function without any devices at all. Myoelectric control of fingers driven by individual motors is the most advanced technique yet attempted. Kramer S: Partial hand amputation. Prosthet Orthot Int 1978. Since every prosthetic device reduces sensory feedback to some degree. Herring HW. Orthot Prosthet 1976. Davis GL. 4: 76-102. 12. 10. It is also possible to utilize a voluntary-closing terminal device ( Fig 7B-14. Beasley RW: Surgery of hand and finger amputations. 29:479-482. J Bone Joint Surg [Am] 1955. 5. Bender LF. Bender LF: Prostheses for partial hand amputations. Orthot Prosthet 1984. In traumatic cases. Many amputees prefer one device to provide cosmetic restoration and another for specific tasks where appearance is unimportant. Buckner HE: Cosmetic hand prosthesis-A case report. 1:209-212. Bunnell S: The management of the nonfunctional hand. Orthot Prosthet 1985. 45:284-288. 20. et al: Solving individual problems with partial hand prostheses. 21:42-45. Prosthetic. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 7B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .Atlas of Limb Prosthetics: Surgical. et al: A wrist-powered prosthesis for the partial hand.org/alp/chap07-02. J Assoc Child Prosthet Orthot Clin 1986. Wedderburn A. Contact Us | Contribute http://www.oandplibrary. Caldwell RR. Sanderson ER.7B: Prosthetic and Orthotic Management | O&P Virtual Library 21. Chapter 7B .asp[21/03/2013 21:54:02] . the majority of amputees get down to the business of leading a normal life. Prosthetic. However. They wear their functional prostheses but do not make use of them. it must be nonfunctional. as if the mere presence of the prostheses justified their behavior. by providing an opposition part for the remaining digits or thumb." It is often difficult to recognize that certain patients would benefit from an aesthetic device because the recent amputee commonly assumes that electronic prostheses will restore all previous functioning. the amputee experiences a major functional handicap. Once the limitations of active prostheses are understood. To more accurately reflect its dual benefits of aesthetics and function. However. They hide their stumps and refuse to use them. In addition. Evelyn J. In conjunction with the stump. Click for more information about this text. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). IL. and Rehabilitation Principles Partial-Hand Amputations: Aesthetic Restoration Jean Pillet. Mackin. It is a period mixed with hope and frustration. the author's 39 years of experience in the fitting of over 6. edition 2. and Rehabilitation Principles. we refer to it as a "passive functional prosthesis. M. Most patients finally grow accustomed to their physical impairments and learn to disregard them and even to forget about the function that has been lost. 1992.Atlas of Limb Prosthetics: Surgical. many prefer an aesthetic restoration. re-education. Prosthetic. and vocational rehabilitation. ©American Academy or Orthopedic Surgeons. the prosthesis can also provide some prehensile capability that can be very useful. the remaining hand becomes increasingly skillful to the amazement of not only immediate family members but also the amputee himself.T.000 amputees demonstrates that restoring near-normal appearance often improves the patient's function in a global sense by enabling him to better use what he has in the complex socioeconomic environment of today's mobile society. ATTITUDE OF THE UNILATERAL AMPUTEE After acquired amputation. and their attitude reflects a psychological need. The senior author's interest in aesthetic hand prostheses began in the 1950s with his recognition of how even the loss of a single digit could have a profound effect upon the amputees body image.7C: Aesthetic Restoration | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 7C Chapter 7C . even this group may feel for a long time. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. It is a period of illusions. but progressively the amputee adjusts to reality during the period of fitting.asp[21/03/2013 21:54:06] . during which doctors. American Academy of Orthopedic Surgeons. self-esteem.org/alp/chap07-03. and psychological status. UNILATERAL CONGENITAL ABSENCE Functional Needs http://www. Rosemont. Prosthetic. The common attitude at that time was that because the prosthesis was inert and insensitive. They reintegrate with their families and society and are able to do so because they have succeeded in making a realistic assessment of their disabilities.D. therapists. and psychologists all have important roles to play. Thus one may say that for certain amputees it is the unaesthetic aspect of the stump rather than the functional loss per se that is the most significant disability. Contrary to this small group. Others accept their amputations only too well-they are delighted to be helped and to be treated as children. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. aesthetic frustration about their altered appearance. P. prosthetists. Some amputees become invalids. He believes in the miracles of surgery and the possibilities of a prosthesis. never able to accept their amputations. Reproduced with permission from Bowker HK. and perhaps forever.oandplibrary. reprinted 2002. In fact.asp[21/03/2013 21:54:06] . Congenitally deformed persons themselves are astonished when people with more pronounced deformities than theirs are able to carry out the same tasks as they. and this varies from one person to another. The congenital amputee considers himself from the outset as being normal from a functional point of view. "Doctor. He sees himself as being complete and normal." Aesthetic Needs Unlike the traumatic amputee. They begin to fear medical checkups and gym. both equally misinformed.org/alp/chap07-03. this was the reaction of such a patient when I asked why he did not have a functional prosthesis. AESTHETIC IMPORTANCE OF THE HAND The aesthetic prosthesis fulfills a deep-rooted need: the wish to go unnoticed and have two hands like everybody else. the hurdle of adolescence is most important. attitudes have become attenuated. Finally. Whatever their ages. However. "what would you want with a third hand?" Congenital unilateral amputees are therefore disabled chiefly by our perceptions. It must be very similar to the digit or hand of the opposite limb. This mistaken reasoning whereby we imagine ourselves to have undergone an amputation as we try to "put ourselves in his shoes'' is not exclusive to normal people. the "father of French surgery. but he often suffers from feeling "different. One must understand that for some patients the hand not only is a functional tool but also possesses expressive beauty: the appearance of the stump may seriously inhibit adaptation. There is a strong desire for an aesthetic prosthesis in the Middle East. however perfect the prosthesis may be. but rather is a result of those around him. is tantamount to encumbering a normal person with a third hand." These patients may have the same aesthetic need felt by the amputee who has had a traumatic loss. The importance of aesthetics varies from one person to another and from one culture to another. In the 16th century. When one is treating a congenital amputee. The skin must http://www. They may use a technique that differs from ours. The realization is not spontaneous. giving them insensitive prostheses will not automatically make them any more dexterous. but they have never quite disappeared." reported seeing "an armless man do almost all the things anyone else could do with his hands. Many of our patients are of Latin origin. the prosthesis must be of high quality." he said. Generally speaking. and even just as quickly and just as well. A young person often tends to blame his malformation for all his teen-age troubles. awareness of their anomaly begins when they start their school days and new friends show their curiosity. and even fewer from Scandinavia. it is common to commit a dual error by considering him as a disabled person and by assuming that he must have a prosthesis. they typically manage all activities of daily living without any prostheses. In the very rare exceptions encountered. both technically and aesthetically. the gracefulness of a movement. To require fitting a prosthesis for a patient with unilateral agenesis. unilateral distal congenital amputees almost never ask spontaneously for a functional prosthesis. With the intermingling of ethnic groups over many generations. He has established his own perception of his body. an agenetic person is not subject to the initial emotional shock of losing a hand. Naturally they have some frustration from not being able to do certain things. This nearly universal desire demonstrates the importance of the beauty of the hand. it has been relatively easy to discern the influence of parents or family practitioners. He is not a true amputee but rather has an imperfect development because of a congenital deformity. which differs from our perception of it. while very few come from Britain or Germany. Ambroise Pare. where amputation is sometimes used as punishment for criminals. For such patients the hand emphasizes the beauty of gesture. ESSENTIAL CHARACTERISTICS OF THE PROSTHESIS To be of real and lasting benefit.7C: Aesthetic Restoration | O&P Virtual Library In the senior author's experience. Only gradually does he come to realize that he is not like other people.oandplibrary. if soiled.). attempts at removal create a negative pressure. translucency. When retraining is required. thin. the prosthesis may well improve overall function (Plates 1 and 2). The most beautiful result is achieved when the length of the prosthesis is extended over the proximal interphalangeal joint to the proximal phalanx.asp[21/03/2013 21:54:06] . must be easily cleaned by washing in water with a mild soap ( Fig 7C-2. It may lengthen a short thumb or become a stable thumb post against which the remaining mobile digits can work. By extending the digit to its normal length. It must not be stained by ordinary materials such as newsprint and. Amputations at this level require a thimble-like prosthesis extending to the middle phalanx. function will be improved just by the protective effect of covering a tender stump to free the injured person from fear of using it. By allowing the use of a stump that the amputee considers too repulsive to expose and use. flexible new materials with which good mobility and some skin sensibility can be preserved.7C: Aesthetic Restoration | O&P Virtual Library correspond to the normal skin in all details and match the color as precisely as possible.oandplibrary. the most common type of precision grip is http://www. The proximal edge of the prosthesis is feathered to a thin edge without pigmentation. fitting such a hand with the optimal prosthesis is most difficult and demands the greatest ingenuity but often is also the most rewarding. the man who finds himself unable to take his hand from his pocket. color. It must not irritate the skin. Since potential combinations are innumerable. the prosthesis is often the key to returning the patient to the employment for which he is already prepared. It should restore the appearance sufficiently close to normal to reduce the stigma associated with disfigurement. a replica of the hand is made. Fabrication of these prostheses is made possible by the availability of tough. Occasionally. FUNCTIONAL POTENTIAL OF PROSTHESES The first objective of the prosthesis is to eliminate the psychological consequences of amputation. The opposite hand of the amputee is cast in the silicone. flexible. Often the disfigurement is more pronounced in the mind of the amputee than others.org/alp/chap07-03. Fixation of the prosthesis must be secure. comfortable." may be as handicapped as if it were lost. Often the prosthesis can be useful for holding light objects that are placed in it. the prosthesis broadens the number of vocational possibilities that one can realistically consider. with the proximal interphalangeal joint left free. Sometimes covering a surgically reconstructed part with a thin. Fingernail details are especially important: consistency. It must not stiffen at low temperatures within the normal climatic range and must also be heat resistant ( Fig 7C-1. In the incompletely amputated hand the prosthesis can often provide an essential physical part for remaining parts to oppose. even though it is very "functional.). and this makes the skin juncture relatively inconspicuous. even though it is totally passive. strong. Polymers of dimethyl siloxane (silicones) allow copying of the natural hand in every detail. A lack of all these qualities has been the reason for dissatisfaction with the commonly used polyvinylchlo-ride (PVC) gloves. The material of the prosthesis must be strong and repairable if torn. thereby providing a suction suspension. PROSTHETIC CONSIDERATIONS Digital Amputations Partial or Total Amputation of the Distal Phalanx The loss of even part of the terminal phalanx may be of considerable aesthetic and functional concern to patients. even though some restriction of flexion results. high-quality prosthesis may prove essential to realizing the most from the reconstruction by giving it a socially acceptable appearance. both psychological improvements and improvements in physical capacity contribute to a better rehabilitation potential for the amputee. Obviously. When fixation is perfect. When a professional activity involving frequent contacts with the public has been interrupted. and from this design. and the nail and lunula length must be similar to the opposite side. and simple. However. both functionally and aesthetically. the missing part of the digit is filled with some supple plastic material to give the same pulp consistency. a small dorsal thermoplastic splint can be worn over the prosthesis during work for mechanical strength and stability. If the proximal interphalangeal joint of the fingers is present. and fixation is tenuous ( Fig 7C-3. It also provides a shaft and crotch so as to make it possible to hold objects too large for the fingers themselves to encircle. In multiple amputations of the digits. if a disguise of the juncture is desired. Otherwise. a thumb prosthesis will assist prehension. use of an ordinary ornamental ring perfectly disguises the juncture. Individual fitting of all four fingers is feasible if the stumps are of adequate length for secure individual fixation. Partial or Total Amputation of the Middle Phalanx The partial or total loss of a digit at the middle phalanx level interferes with lateral or key pinch. it is best achieved by wearing a small skin-colored plastic strip bandage as if covering an ordinary minor scratch. the prosthesis is firm and semicurved to oppose the thumb for purposes of prehension. When amputation occurs at the middle phalanx or just distal to the proximal interphalangeal joint. When amputation occurs at the interphalangeal joint or distal to the metacarpophalangeal joint. http://www. Partial Amputation of the Proximal Phalanx Amputation at the proximal phalanx level requires a minimum stump length of 1.org/alp/chap07-03. If amputation is through the proximal phalanx.e.5 cm requires surgical interdigital web recession. so that one of the opposing parts has good sensibility. It is made very flexible at the proximal interphalangeal joint level to allow motion. or has a spatulate appearance. The prostheses can also be used in typing and playing a musical instrument. adds stability to the fingers during lateral pinch. stiffens in a position of nonfunction. the prosthesis provides a buttress against which the pulp of the remaining thumb can hold light objects. Inside the prosthesis. as when picking up a pencil. Lack of support by a missing ring finger allows the long finger to deviate ulnarly (Plate 3). When a person's job requires that he uses his prosthesis hard. a glove is required.. strength is lost in key pinch. the prosthesis will provide proper opposition to the fingers. If the patient refuses further surgery. the result is complicated. In the latter case. The pulp of the thumb can now oppose the pulp of the prosthetic digit. If the distal interphalangeal joint develops a fixed flexion contracture from scar formation. The firmness and flexibility of the prosthesis depends on the functional needs. Partial or Total Amputation of the Thumb The thumb is essential for precision and power grip. usually with the thumb exposed if it is in good condition. and also prevents small objects from falling out of the hand when the remaining fingers are brought together (Plate 4). The patient with a stump shorter than 1. computer operator.. Loss of the necessary counterpressure to maintain a grip on objects diminishes power grip.A-C). Providing a prosthesis for the missing ring finger prevents deviation. to undergo amputation at the distal interphalangeal joint than to keep a longer but stiff stump in flexion.oandplibrary. i. By lengthening the thumb. the prosthesis is made flexible at this level to allow motion.5 cm measured from the metacarpophalangeal crease for adequate fixation of a digital prosthesis. When a single amputation of the long finger occurs. With the juncture lying near the metacarpophalangeal joint the use of an ornamental ring will disguise the transition perfectly.asp[21/03/2013 21:54:06] . however. except in the case of the thumb. Less thumb length decreases opposition proportionately. Experience has shown that it is much better. prosthetic fitting of the middle or ring finger can sometimes be achieved by suspension with ornamental rings worn on the involved digit and adjacent digit. Disarticulation of the thumb at the carpometacarpal joint requires a hand prosthesis with the fingers exposed. the prosthesis is extended to the proximal phalanx. The socket provides some flexibility for comfort. When the juncture lies over the proximal phalanx. surgical revision may be indicated.7C: Aesthetic Restoration | O&P Virtual Library improved. thereby enabling the patient to use it to push and as an assist in two-handed activities. Once locked into position. In the case of transverse amputations. it enables the amputee to use the prosthesis as a stabilizer as well as functional assist in bilateral activities. Short Stump Amputation at the forearm level requires a minimum stump length of 5 cm (measured from the elbow crease with the elbow at 90 degrees of flexion) for good fixation of a forearm prosthesis. the prosthesis is made thin over the palm area so that useful sensibility can be readily transmitted ( Fig 7C-4. or oblique. http://www. Amputation Through the Wrist Patients with amputations through the wrist require a total-hand prosthesis.oandplibrary. Flexibility of the prosthetic digits allows the amputee to hold light objects placed in the hand. The prosthesis is also useful for holding light objects that are placed in it due to the elastic memory of its components ( Fig 7C-4. but for most activities having a sensate thumb outside the glove is so functionally superior that it is generally recommended. one has the option of using a complete-glove prosthesis made very thin on the part covering the thumb or allowing the thumb to protrude freely through the glove. The small-finger juncture can be easily covered with an ordinary ring. When only a portion of the thumb remains.B). both the thumb and small finger are preserved. it is generally covered with a total-hand prosthesis that extends the length of the thumb and provides it with a natural-looking fingernail. This not only is more functional. the prosthesis is essentially a total hand terminating 2 to 4 cm proximal to the ulnar styloid. middle. When a metacarpal amputation is central and involves the index. The absence of any perfect solution gives rise to a great variety of possibilities that one must carefully consider. a punch press injury.. The latter method presents the problem of disguising the opening in the glove. By extending the hand to its normal length. In such cases the prosthesis is made very thin in appropriate areas to allow free motion of the thumb remnant and sensibility through the cover. it is best to leave both the thumb and small finger protruding from the prosthesis if they are normal. When a normal thumb has been preserved. central.. with the single finger having a better working relation to the thumb post. is very functional for the patient. To preserve these qualities it is necessary to make a hand prosthesis rather than a forearm prosthesis to avoid restricting forearm rotation. and potential solutions must be carefully weighed against the needs of the patient. A watchband or tennis bracelet in summer can be worn to cover the juncture between the prosthesis and natural skin. i. and the prosthetic problems chiefly involve the best socket arrangement. who uses it to push. When a useful small finger remains after an oblique metacarpal amputation in which all or most of the thumb is lost. The fingers are made firm in a semiflexed position to serve as opposition posts for the mobile thumb. the prosthesis increases the functional surface of the hand. but also allows the prosthesis to be fabricated to the exact size of the other hand.org/alp/chap07-03. which are almost as variable. Amputation at the Forearm Long Stump A long stump. Functionally.e. it is best that the second metacarpal be surgically resected and the small finger fitted into the ring finger of the prosthesis. and ring fingers. When amputation is through the carpus.A)..7C: Aesthetic Restoration | O&P Virtual Library Metacarpal Amputations Metacarpal amputations can be transverse. Fixation by suction eliminates the need for a complicated harness or suspension system. with preservation of sensitivity and pronation/supination. A rotational wrist unit attached to the forearm prosthesis permits manual positioning of the hand in almost any attitude of supination or pronation through a 360-degree range. The variety of physical problems encountered is enormous.asp[21/03/2013 21:54:06] . Prosthetic fitting of partial-hand amputations is a most difficult problem. In such cases. Benefits may be derived in the bilateral amputee by fitting one side with an aesthetic prosthesis. New materials and techniques now allow fabrication of prosthetic sockets that are light. but such a concern is in fact not diminished in these patients. If the stump does not have a pinch mechanism. The prosthesis is secured to the patient by means of webbing straps ( Fig 7C-5. and avocational needs can be determined. Children and teenagers usually manage to overcome the functional loss and in most cases perform all their http://www.asp[21/03/2013 21:54:06] . and to which an aesthetic forearm and wrist unit are attached. the prosthesis will be functionally more bothersome than useful in the daily activities of school and play.oandplibrary. but the need for sensibility of a part on at least one side very often precludes useful bilateral fitting. AESTHETIC PROSTHESES FOR BILATERAL AMPUTEES Physical impairment is so great for the bilateral amputee that it overshadows the aesthetic concern. The prosthesis for the shoulder disarticulation patient is very similar in design to that for the forequarter amputation. A child's physical appearance at birth is of primary importance to the parents. it is the parents we are treating through the child. fitting of a prosthesis may be carried out at a very early age-usually between 6 and 18 months. In these circumstances it is preferable to postpone fitting until the child has attained adolescence. the loss of one or more distal phalanges in a child or adolescent does not generally require a prosthesis. It is often difficult to fit and train these amputees in the use of a satisfactory active prosthesis. PREPROSTHETIC MANAGEMENT The considerations when applying a prosthesis are many and varied. Many patients prefer to use an aesthetic prosthesis with passive function consisting of a lightweight shoulder cap that has been made to match the contour of the involved shoulder ( Fig 7C-5. Short Stump Amputation of the proximal part of the humerus requires a stump length of 15 to 16 cm for satisfactory fixation and good muscle control. and secure. Shoulder Amputation Shoulder disarticulation is less disfiguring than the forequarter amputation since the contour of the shoulder remains. flexible. and it is sometimes necessary to fit a child with a prosthesis if the parents are suffering from psychological trauma. A stump that is too fat requires surgical revision prior to fitting of the prosthesis. If the tissues are soft.B) AESTHETIC PROSTHESES FOR CHILDREN The majority of children seen in consultation for prostheses are seen as the result of congenital abnormality.org/alp/chap07-03. soft. Those for amputation distal to the shoulder usually require no harnessing whatsoever.. thus improving the appearance of clothing. The stump should be conical in shape and firm. Although patients of all ages can be fitted with a prosthesis. with bone extending the full length.A). at which time his "selfimage" becomes preeminent and he will be more motivated to accept the inconveniences of a prosthesis. The fixation is similar to the forearm prosthesis. Fitting at this age accustoms the child to the presence of the prosthesis and encourages bimanual activity. a shoulder prosthesis will be required. except for the extent of the shoulder cap. If the stump has a useful pinch mechanism. social.7C: Aesthetic Restoration | O&P Virtual Library Upper-Arm Amputation Long Stump Amputation of the humerus at least 5 cm proximal to the normal elbow crease allows incorporation of a mechanical elbow to provide flexion and extension. Forequarter amputations leave a distressing aesthetic and functional defect.. These self-suspending sockets represent a major step in the advancement of prosthetics. vocational. Each case must therefore be evaluated individually so that psychological. Minn. or pianist who has lost the distal phalanx of any digit may find functional ability enhanced with a prosthesis. it is recommended that a ring or small plastic strip bandage be worn at the edge of the prosthesis. he is better prepared to accept the limitations of the prosthesis when he receives it. Coban [*Coban. DURABILITY OF THE PROSTHESIS We believe that each patient should have two prostheses. surgical revision should be considered. In the fingertip amputee. If no progress is made with desensitization techniques after 1 month. Having a second prosthesis also ensures that one is always available if the other needs repairs and/or adjustments if the morphology of the stump changes. typist. and it becomes an integral part of himself. If the patient is appropriately oriented to the realities of the prosthesis. When volumetric measurements of the stump have stabilized. all day long. Minnesota Mining and Manufacturing Co. The use of constant pressure such as elastomer caps secured with Coban wrapped in a figure-of-8 bandage in a distal to proximal manner can also help to diminish hypersensitivity. It is important to convey that the prosthesis may impede function and reduce sensation in an area.. this means that he considers it either a so-cioprofessional accessory or a part of his body image. Desen-sitization techniques reduce these paresthesias and help to prepare the stump for the prosthesis. He must understand that the color of the prosthesis will be the one that most matches the "average normal" color of the skin. This allows time for any necessary adjustments and to verify that the patient has become a good prosthetic wearer.] wrapping helps to reduce edema. The average life span of an aesthetic prosthesis varies from 2 to 4 years and depends on how well the patient takes care of it as well as whether it is worn everyday or just for special occasions.oandplibrary. but rather proof of the effectiveness of the prosthetic treatment that helped the patient through a difficult period of his life. It is generally recommended that the patient wear the initial prosthesis for approximately 6 months before beginning the second one. it is necessary that sound wound healing be completed and edema controlled. It is necessary to determine the patients motivation for obtaining a prosthesis and whether he has a realistic understanding of the advantages and disadvantages. This does not necessarily increase the total cost because two prostheses will wear twice as long as one. Paul." When the amputee uses his prosthesis all his life. Then he wears it every day. A secretary. Some patients wear their prostheses for years. Many patients who sustain distal amputations are engaged in occupations or hobbies where finger dexterity means the difference between success and failure.asp[21/03/2013 21:54:06] . A painful stump cannot tolerate a prosthesis. emotional status. and contour the stump for the prosthesis. and many other conditions that can change the blood flow. Also. a thimble-like prosthesis may provide the needed length to enable the flutist to play the flute again (Plates 5 and 6). A prosthesis might be functionally more awkward than useful.org/alp/chap07-03.7C: Aesthetic Restoration | O&P Virtual Library activities. the patient must realize that the color of his skin varies due to daylight or electric light. promote stump shrinkage. The prosthesis is then considered a temporary treatment discontinued because the amputee feels himself "cured. particularly in areas of wide variations in climate: one with the color adjusted to the average winter pigmentation and the other to summer. Medical Products Division. PHYSICAL ASSESSMENT Although patients are anxious to obtain their prostheses as soon as possible. some only for months. St. To make these differences less noticeable. Coban is applied firmly distally to proximally. CONTRAINDICATIONS TO AESTHETIC PROSTHESES An absolute contraindication to the provision of an aesthetic prosthesis is a patient without http://www. position of the hand. the patient is ready for fabrication of the prosthesis. We do not consider this a failure. with less tension over joints allowing free use. Each category was further subdivided into full-time and part-time wearers. as a support or to push objects. Pillet J: Possibilites actuelles de la prothese plas-tique. In the part-time group.7C: Aesthetic Restoration | O&P Virtual Library motivation or one with unrealistic expectations as to what the device is expected to accomplish. GEM Monographic 1978. 700 files of patients who had been wearing the passive functional prostheses for between 10 years and 38 years and had spontaneously consulted during the last 30 months (January 1988 to June 1990) were reviewed. 82:1-1767. result in significant functional loss. and be able to use them in public without embarrassment. Pillet J. BIBLIOGRAPHY Dautry P. Attempts at fixation on very short stumps can result in trophic skin changes that will make the prosthesis unbearable. et al: A la recherche d'une main perdue. pp 108-112. which enables him to better integrate into the complex socioeconomic environment of todays society. Dufourmentel C: La Substitution Prothetique de L'ongle. The prosthesis must conform to very high standards of quality to achieve these goals. It should also be remembered that in bilateral amputations an aesthetic prosthesis should be provided on only one side. vol 9.oandplibrary. Iselin M. The passive functional hand prosthesis has become a major component of the comprehensive professional and social rehabilitation program for patients with either a totalor partial-hand amputation. in two-handed grasping activities. with two hands. while congenital patients mostly belonged to the second group who wore them as clothing. the prosthesis also serves an important functional role by providing opposition to a remaining mobile finger or by lengthening a finger stump that is too short. or even achieve a poor aesthetic result. the prosthesis may be used functionally to hold light objects and. 21:603.org/alp/chap07-03. the prosthesis must cover the hand completely for adequate fixation. Apoil A. aesthetically pleasing prostheses may not be feasible without prior surgical revision. SUMMARY An aesthetic prosthesis can be equally helpful to the acquired amputee and to a patient whose malformation is attributable to agenesis. The full-time group included those who put on their prostheses each morning and removed them only for sleep. Presse Med 1953. In cases where the hand has been totally amputated. Finally. were divided into two categories: acquired and congenital amputees. Paris. Such a prosthesis may fulfill the psychological and functional needs of congenital or acquired amputees to look like everybody else. http://www. When there are bulky or badly aligned stumps. Although the primary aim and purpose of an aesthetic prosthesis is to provide an aspect of normality to a disfigured hand. thus making the device much a part of themselves. with disarticulation of several digits.asp[21/03/2013 21:54:06] . but frequently omitting them within the confines of the family circle. Relative contraindications include instances when such a device may be uncomfortable. Rev Practicien 1971. Multiple digital prostheses on the same hand can interfere with its sensibility as well as its gripping strength. the prosthesis encourages the amputee to use his stump for daily activities. Association a la chirurgie dans les mutilations de la main. the patients treated their prostheses much as clothing and wore them regularly when out of the home or on the job. The patients. For example. by being aesthetic. ACCEPTANCE AND UTILIZATION OF AESTHETIC PROSTHESES Long-Term Results In June 1990. Acquired amputees generally fell into the group integrating the prosthesis as a part of their body. all unilateral amputees. Toulouse. 1981. pp 217-220. 1990. Pillet J. 87:34213425. pp 212-213. Churchill Livingstone Inc. pp 123-127. p 141. Pillet J: La Chirurgie Secondaire Dans les Mutilations de la Main. 1983. Biteau O: La prothese plastique du membre superieur. Paris. Mackin E: Prosthetic contribution to distal amputations.asp[21/03/2013 21:54:06] . London.org/alp/chap07-03. Contact Us | Contribute http://www. Mosby-Year Book. Pillet J: La Prothese Dans les Amputations des Extremites Digitales. pp 46-50. Pillet J: La prothese plastique et restauratrice chez les amputés partiels du membre superieur. in Boswick J Jr (ed): Current Concepts in Hand Surgery. 1989. in Hunter JM. in Foucher G (ed): Fingertip and Nailbed Injuries.7C: Aesthetic Restoration | O&P Virtual Library Pillet J: Prosthetic requirements of the congenital unilateral amputee. ed 2. 1984. 1986. St Louis. Mackin EJ. Orthop Clin North Am 1981. Pillet J: The aesthetic hand prosthesis. Pillet J: The aesthetic and functional replacement. France.Atlas of Limb Prosthetics: Surgical. De Lucia S. pp 801-807. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 7C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Pillet J. Gaz Med Fr 1969. Acta Chir Belg 1958. Chapman & Hall Ltd. Pillet J. Le Gall CA: Protheses ungueales. G (eds): Reconstruction of the thumb. Pillet J: Digital and hand prosthetic fitting. Piccin Editore. Pillet J. GEM Monographic. in Urbaniak JR (ed): Microsurgery for Major Limb Reconstruction. 114:425-428. Chapter 7C . 1989. Prosthetic. 1987. Ann Dermatol Venereol 1987. Souquet Mansat. vol 9. Padova. Pillet J. Lea & Febiger. St Louis. 12:961. 57:319-322. New York. Desantis.oandplibrary. Mantero R: in Piccin (ed): Rivista di Chirugia Delia Mano. Guyaux MC. Mosby-Year Book. Philadelphia. et al (eds): Rehabilitation of the Hand. ed 2. Mackin E: Aesthetic hand prosthesis-its psychological and functional potential. Schneider LH. in Landi A. .oandplibrary. but primary amputation closure is contraindicated to prevent infection.org/alp/chap08-01.A-C). even without a prosthesis. Microvascular surgical techniques have also aided in the preservation of limbs after trauma. All other causes of amputation are less common. with males involved four times as frequently as females and the left side affected as often as the right. sensate. These flaps extend down to deep fascia. Prosthetic. The styloid processes need to be contoured enough to create a symmetrical limb for fitting of the prosthesis. The use of a tourniquet allows for clear identification of tissues and reduces blood loss. including peripheral vascular disease.. Click for more information about this text. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Rosemont. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). With the advent of limb salvage procedures. The movable. 1992. Amputation levels are now chosen not by the prosthesis. In these situations.8A: Surgical Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 8A Chapter 8A . Hemostasis should be achieved as these flaps are developed. IL. The ultimate goal of amputation surgery is to provide a pain-free residual limb that is functional. Prosthetic. Indications for elective shortening of residual limbs are rare.asp[21/03/2013 21:54:11] . Although functional. The dorsal and volar http://www. malignant tumors. is at the short transradial (below-elbow) level. and congenital deformities. Reproduced with permission from Bowker HK. reprinted 2002. contractures. by a specially designed wrist-driven prosthesis. Regional anesthesia is ideal. This occurs predominantly in the 20. Motor strength can be enhanced by attachment of the wrist flexors and extensors to the remaining carpal bones. and Rehabilitation Principles Surgical Principles Elizabeth Anne Ouellette. Passive restorations. The most common congenital infections. can be quite aesthetic. Grasp can be provided. American Academy of Orthopedic Surgeons. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. there must be adequate debridement of nonviable tissue. Despite these advances. ©American Academy or Orthopedic Surgeons. The triangular fibrocartilage complex must be preserved because it provides for stability and hence painless motion of the distal radioulnar joint. limb elevation alone is recommended. WRIST DISARTICULATION Full forearm length preserves pronation and supination and also provides a long lever arm with which to lift the terminal device and its load ( Fig 8A-1.Atlas of Limb Prosthetics: Surgical. there are still situations in which amputation is the final outcome. edition 2. however. well-padded carpal segment makes this amputation quite useful in "bimanual" activities. Exsanguination by an elastic bandage prior to elevating the tourniquet is indicated except in cases of tumor and infection. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.D. In the upper limb.A and B). The palmar-to-dorsal skin flap ratio should be 2:1 in order to provide coverage of the carpus with durable palmar skin. Palmar and dorsal flaps in a 2:1 ratio are developed to provide adequate tissue for closure ( Fig 8A-2. however. The surgical technique is similar to wrist disarticulation. a malignant tumor no longer automatically leads to an amputation. the etiology of 90% of amputations is trauma. this active prosthesis is not cosmetic. neurologic disorders. however. Prosthetic. M. but by the level of injury or involvement by the disease process.to 40-year-old age group. AMPUTATION THROUGH THE CARPUS The ability to amputate through the carpus allows for the preservation of wrist flexion and extension as well as forearm pronation and supination. amputation. If the cause is trauma. and Rehabilitation Principles. Length of the amputation can be preserved by coverage with split grafts over muscle or with free vascularized flaps. In order to fit this very short residuum with a prosthesis. Split grafts will require extra care from the patient until the grafts mature but should do well with time. If the amputation must be very proximal. Specifically. The bone edges are then carefully smoothed. which may be helpful in later myoelectric fitting. The sensation of the tips can approach normal finger sensibility when the operation is performed in children. The main vessel groups that must be identified are the ulnar. active pincer by using the ulna and radius.8 to 5 cm long is still adequate to preserve the elbow joint. may have difficulty tolerating the weight of a myoelectric prosthesis. The advantages of http://www.8A: Surgical Principles | O&P Virtual Library tendons are transected and stabilized under physiologic tension when the vascular supply permits. The prosthesis socket will be more cosmetic when the amputation ends no less than 2 cm proximal to the wrist because there is more room for the prosthetic components. Adults usually achieve protective sensation and the ability to identify objects. Rather than decrease prosthetic function by shortening the longer bone. To perform this operation. posterior interosseous. The same surgical principles apply to forearm amputations as to wrist disarticulation. the stronger the lever arm will be. radial. If skin coverage is a problem. Myodesis or myoplasty is performed to stabilize the muscle mass. A special situation arises when one forearm bone is considerally longer than the other and the longer bone can be covered with an adequate soft-tissue envelope. Very short residual limbs. A minor cosmetic drawback is that the active prosthesis for this level will result in a longer forearm on the prosthetic side. commensurate with the diagnosis. Skin coverage is best achieved by local flaps with care taken to avoid adherence to underlying bone. to preserve even a very short transradial level so long as active range of motion of the elbow will be preserved. The power of the pincer grip is usually 2 to 3 kg with the elbow extended and as high as 8 to 10 kg when the elbow is flexed. a split graft. then an ulna 3. POSTOPERATIVE IMMEDIATE PROSTHETIC FITTING Rigid postoperative dressings were initially used in lower-limb amputees. Transradial Amputation As long a residual limb as possible should be saved. and anterior and posterior interos-sei.oandplibrary.org/alp/chap08-01. something no prosthesis can offer. The longer it is. These should be cut under moderate tension and allowed to retract proximally into the soft tissues to avoid entrapment in the incisional scar.). so it is usually contraindicated in burn patients (see Chapter 36A). It is a valuable procedure in patients whose contralateral hand has been lost or severely damaged. ulnar. it can be easily fitted with a prosthesis if desired. and the more completely pronation and supination will be preserved ( Fig 8A-3. Blood vessels may be controlled by coagulation or ligation. The bone is transected after the periosteum has been incised. Because the appearance of the Krukenberg limb may be objectionable in some circumstances. as well as for those patients without access to prosthetic limbs. Revision surgery is necessary in approximately one third of transradial amputees. it may be helpful to detach the biceps and reattach it to the ulna. and passive cosmetic fittings are possible. it may be preferable to create a one-bone forearm. free flap. the transected end of the radial sensory nerve should lie beneath the brachioradialis muscle belly in order to protect its neuroma from mechanical trauma during prosthesis use. there must be good skin coverage and muscles in the forearm. Every effort should be made during revision surgery. KRUKENBERG OPERATION The purpose of this operation is to give an amputee a sensate. body-powered. as in some developing nations. It is particularly useful for the blind bilateral transradial amputee since it uses sensation to enhance grasp. and radial sensory. or abdominal flap can be used to obtain coverage and preserve length. however. however.asp[21/03/2013 21:54:11] . The nerves that must be identified are the median. Myoelectric. This will allow the amputee the option of using his Krukenberg limb or prosthesis as the situation dictates. Williams EM. Even pressure must be applied. 12:819-826. an original functional-cosmetic prosthesis. Millstein SG: The value of stump split grafting following amputation for trauma in the adult upper and lower amputees. with care taken to avoid flap necrosis.).oandplibrary. 1987. J Bone Joint Surg [Am] 1976. pp 597-637. Rees MJ. in Green DL (ed): Operative Hand Surgery. the patient can begin to use this temporary prosthesis within 1 or 2 days. Churchill Livingstone Inc. 11:71-74. thus preserving two-handed grasping patterns ( Fig 8A-4. 13:287-292. in Crenshaw A (ed): Campbell's Operative Orthopaedics. pp 61-119. ed 7. 6. Chapter 8A . Contact Us | Contribute http://www. J Hand Surg [Am] 1988. ed 2.asp[21/03/2013 21:54:11] . Mosby-Year Book. Artif Limbs 1968. Baumgartner RF: The surgery of arm and forearm amputations. 12:14-16. 4. early and immediate post surgical prosthetic fitting.org/alp/chap08-01. St Louis. 58:46-51. vol 1. 5. New York. Tooms RE: Amputations. Wood MR. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 8A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Bull Hosp Joint Dis Orthop Inst 1984. Prosthet Orthot Int 1987. 7.Atlas of Limb Prosthetics: Surgical. 1988. Orthop Clin North Am 1981. Mayfield G. 3. Hunter GA. Prosthetic. 8. Orthop Clin North Am 1981. 9. 12:805-817. 2. Sarmiento A.8A: Surgical Principles | O&P Virtual Library a rigid dressing include better control of postsurgical edema and protection of the wound from external trauma. Carmona LS: The upper extremity amputee. McCollough NC. DeSantolo A: A new approach to the use of the Krukenberg procedure in unilateral wrist amputations. UeGens JJ: Immediate amputation stump coverage with forearm free flaps from the same limb. et al: Immediate post surgical prosthetic fitting in the management of upper extremity amputees. References: 1. Burkhalter WE. Elastic bandages may be used if rigid techniques are not feasible. 44:177-187. With the addition of prosthetic prehension and suspension components to a rigid postoperative dressing. Louis D: Amputations. Tubiana R: Krukenberg's operation. until full healing had been achieved. i. especially if the amputee will alternate between wearing an electronic prosthesis and a mechanical body-powered prosthesis. Click for more information about this text. Listed in Table 8B-1. the use of traditional methods that would delay prosthetic fitting for 3 to 6 months. C.Atlas of Limb Prosthetics: Surgical. as is sometimes the case in weight-bearing lower-limb situations. A discussion of comprehensive prosthetic management would not be complete without some comment on the historical precedent to "save all length.e. COMPREHENSIVE PROSTHETIC MANAGEMENT A total of five distinctly different types of prostheses make up the armamentarium necessary to provide optimum and comprehensive management for the upper-limb amputee. Rosemont. However.8B: Prosthetic Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 8B Chapter 8B . and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). These five procedures include (1) immediate/early postoperative prostheses. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.P. and Rehabilitation Principles Prosthetic Principles Carl D. In this context. early intervention means the application of some form of upper-limb prosthesis within the first 30 days after amputation. This is particularly true in those instances where a quickdisconnect wrist is employed in order to provide easy interchangeability between an electronic hook terminal device and an electronic hand.O. Brenner. American Academy of Orthopedic Surgeons. In addition. The two major issues are limb length and residual pronation and supination. the application of a prosthesis within the first 4 weeks of amputation has dramatically improved the long-range outcomes. nothing has made as singular an impact as recognition of the need for early prosthetic intervention. Reproduced with permission from Bowker HK. The use of an immediate or early postoperative prosthesis has been demonstrated to be an effective way to achieve the goals of early intervention.. In the event that skin grafting is necessary in order to preserve the viability of a disarticulation surgical level. (2) preparatory/ training mechanical prostheses. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.oandplibrary. is the ideal fitting timetable for the utilization of these five prosthetic procedures. edition 2. In those cases where amputation is carried out at the wrist. it has remained underutilized in upper-limb applications despite the fact that it does not jeopardize wound healing. Prosthetic. had yielded a rejection rate of approximately 50%. THE NEED FOR EARLY INTERVENTION Of all the new developments that have occurred in the past decade as regards upper-limb amputee management.asp[21/03/2013 21:54:15] . with some centers reporting a success rate of prosthetic use and acceptance of 90% and higher. This improvement is believed to be due to the effective preservation of bimanual functional patterns resulting from early prosthetic training.org/alp/chap08-02. IL. (3) definitive mechanical prostheses. reprinted 2002. the absence of residual pronation and supination mitigates against disarticulation surgery if it is anticipated that the amputee will derive greater benefit from an electronically controlled wrist rotation module. (4) preparatory/training electronic prostheses. and Rehabilitation Principles. and (5) definitive electronic prostheses." Although the intrinsic advantages of disarticulation surgery through the wrist have been understood for decades. Although this procedure has been in widespread use for well over 20 years in lower-limb amputation. the use of a prosthesis will frequently result in an overall prosthetic length that is cosmetically unacceptable to the patient. Prosthetic. Prosthetic. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. ©American Academy or Orthopedic Surgeons. IMMEDIATE AND EARLY POSTSURGICAL PROSTHESES http://www. 1992. Historically. a higher-level amputation just proximal to the graft site may prove to be a better decision. the introduction of new electronic componentry necessitates careful scrutiny on the part of the surgeon prior to choosing the level of amputation. org/alp/chap08-02. and training objectives. It should be understood that to be successful. followed by distal padding that can be made of either lamb's wool. applied at the beginning. Once all the components have been taped to the cast/socket. The major differences between the preparatory/training prosthesis and the postoperative prosthesis are that (1) the preparatory socket is made over a plaster model of the patient's residual limb. while an early postoperative procedure is one that is performed anytime between surgery and suture removal. The primary purpose of the preparatory/ training prosthesis is threefold and consists of preparation.). It is important to note that no synthetic casting tape or plaster is used to attach the components to the inner socket. As an evaluation tool the preparatory prosthesis (1) helps the clinic team and the patient determine which components may prove to be of the greatest benefit. a preparatory/training prosthesis should be designed and fitted with the same care as a definitive system. that removal should only be done for very short periods of time so that edema control can be maintained. sterile fluffs. i. more typically. In terms of preparation. evaluation. and either a shoulder saddle harness or. and (3) the design of a preparatory prosthesis allows for the easy interchange-ability of various components during the evaluation process ( Fig 8B-5. and (3) help to condition tissues to accept the forces exerted by a prosthetic socket. which are connected to the triceps pad. The two stockinette socks.). (4) improved proprioceptive/prosthetic transfer.asp[21/03/2013 21:54:15] . which facilitates wound However.). Over this is applied a thin cast/socket fabricated of plaster or fiberglass casting tape ( Fig 8B-2. PREPARATORY/TRAINING MECHANICAL PROSTHESES The second type of prosthesis utilized in the comprehensive management of upper-limb amputees is the preparatory/training mechanical prosthesis. (2) the prosthesis is fabricated from materials that are more durable than those in a postoperative prosthesis. postoperative prostheses are as follows: (1) decreased edema.). and (3) aids the patient in identifying the functional value and limitations of a mechanical body-powered prosthesis. the preparatory prosthesis provides (1) continued edema control. or a reticulated urethane foam pad. the preparatory prosthesis helps the patient preserve two-handed function and allows the amputee to practice using a mechanical prosthesis for the normal activities of daily living (ADL). This is followed by a similar application of tape in order to affix the flexible elbow hinges. With regard to training. There appears to be no significant difference in the long-range outcomes between immediate and early postoperative application.e. This ensures easy removal of the components when it becomes necessary to change the cast/socket. A thermoplastic frame with a lightweight terminal device on the end is then taped in place by using a good-quality linen adhesive tape ( Fig 8B-3. However. (2) a reduction of the pain and anxiety that the patient experiences. If the two previous prostheses were used in the way intended. generally 10 to 14 days after surgery.. allow easy removal and application of the postoperative prosthesis. (2) assists the rehabilitation team in assessing the patient's level of motivation and compliance. even including the use of test sockets when necessary. Occupational therapy with this prosthesis can generally be started as soon as the The benefits of using immediate or early patient is alert enough to follow directions. a final covering of either Coban or Elastoplast can be applied in order to reinforce the fixation of the components ( Fig 8B-4. followed by a preparatory mechanical prosthesis for an additional 2 to 4 weeks. A standard Bowden cable assembly is applied. An immediate postoperative prosthesis is applied in surgery at the time of final closure. (2) decreased postoperative pain and phantom pain. both immediate and early procedures are done by utilizing the same technique. a figure-of-8 harness is employed for suspension and terminal device control. this prosthesis is applied at the time the sutures have been removed. it can be argued that an immediate application can provide additional psychological benefits to the patient and the patient's family. the formulation of definitive prosthetic prescription specifications is a relatively academic matter.oandplibrary. Ideally. which will come up to the level of the epicondyles but leave the elbow free. This begins with the application of two separate layers of stockinette directly over the dressing ( Fig 8B-1. to provide a diligent evaluation of the socket design and the harnessing system and also to determine which wrist and elbow components http://www. the patient and the nursing staff should be advised inspection and management.8B: Prosthetic Principles | O&P Virtual Library The first prosthesis to be considered when attempting to provide early intervention is either the immediate or early postoperative prosthesis. (3) increased prosthetic use. DEFINITIVE MECHANICAL PROSTHESES Once the patient has worn a postoperative prosthesis for 1 to 2 weeks. Essentially. and (5) improved patient psychological adaptation to amputation.). then the elements of an appropriate prescription become self-evident. Wrist Components The three most commonly used wrist units are the standard friction wrist. Among the advantages are the freedom to operate in a carefree manner within most physical environments and the ability to achieve a high level of accuracy and speed during functional performance. there are several things that should be considered when developing definitive specifications.8B: Prosthetic Principles | O&P Virtual Library prove most functional. PREPARATORY/TRAINING ELECTRONIC PROSTHESES In the last decade. In those cases where normal functional performance of the contralateral upper extremity has been compromised. the quickdisconnect/locking wrist. Although there are several self-suspended sockets that are now available for wrist disarticulation and long belowelbow (transradial) levels. electronic technology has made significant strides in the field of http://www. the figure-of-8. Advantages and Limitations When evaluating the benefits and disadvantages of the mechanical prosthesis. Elbow Joints The most common type of elbow joint to be employed for use with a wrist disarticulation or transradial amputation is the flexible elbow hinge. the use of step-up hinges may prove beneficial. a flexion wrist unit may add an additional measure of function to the prosthetic side and of course would be an appropriate choice for a bilateral amputee. socket. including the figure-of-9. However. Among these factors are socket configuration. In those rare instances where the patient has very limited elbow flexion. most of these designs cannot provide maximum benefit to the patient as long as some form of suspension/control harness is necessary. Harness Designs There are three basic harness designs. the shoulder saddle harness will frequently be rejected by a patient who prefers to wear an open V neck shirt or blouse that exposes the chest strap. Socket Designs For the mechanical prosthesis.oandplibrary.asp[21/03/2013 21:54:15] . The figure-of-9 harness is used primarily with a self-suspended socket that requires a harness only to provide terminal device operation. elbow joints. When the patient has a significant amount of natural pronation and supination available after surgery. several factors emerge. and the shoulder saddle harness with a chest strap. the quick-disconnect/locking wrist has proved to be the most useful for adult unilateral amputees.org/alp/chap08-02. The most popular type of self-suspended socket for midlength amputation is the Northwestern University-style while the Munster-style socket is the frequent choice for short transradial levels. which generates various degrees of negative attention. As a general rule. particularly in the case of the bilateral amputee. the use of single-axis elbow joints is the most effective measure to provide stability. the longer the residual limb. If the patient is to use more than one terminal device or is routinely performing activities that require the elimination of any unwanted wrist rotation during functional performance. The shoulder saddle harness is beneficial to those amputees who will be doing an unusual amount of heavy lifting. the proximal trim line of the socket should be cut low enough to preserve at least 50% of the active pronation and supination. and harness designs. wrist components. However. The primary disadvantages of the mechanical prosthesis are the discomfort caused by the shoulder harness and the cosmetic appearance of the hook terminal device. which can be made out of either triplethickness Dacron webbing ( Fig 8B-6. When socket rotation around the residual limb becomes a problem secondary to a very short bone length. and the flexion wrist unit.) or flexible metal cable. The most popular harness is the figure-of-8 design that can be fitted with either a sewn crosspoint or a ring to provide adjustable posterior fixation for all the straps. the choice of sockets lies either with a harness-suspended or self-suspended design. the lower the proximal trim line of the socket can be. It also provides relief from some of the axilla pressure exerted by a figure-of-9 or figure-of-8 harness. electronic switch controls. Once the socket has been fabricated. This ensures that the experience of the patient. Limb Banking and Lend-Leasing In recent years. Under such a scheme. while wearing the prosthesis.asp[21/03/2013 21:54:15] . The most common type of limb bank is a private limb bank. the fabrication process and the components used provide a very costeffective way of analyzing the patient's needs. over a period of time. It is very important that the patient receive preprosthetic signal training prior to the start of the prosthetic fitting and fabrication. generally organized and funded by an individual prosthetic laboratory. a hybrid combination may very definitely be indicated for a patient with marginal elbow function.oandplibrary. However. This involves the use of a temporatory electronic prosthesis that will allow the clinician and the patient the opportunity to respectively evaluate and experience many As such. or more electronic controls in addition to one or more mechanical controls. and this is used to both evaluate the suspension and stability of the socket design as well as establish electrode sites. of a variety of different kinds of electronic components. Although most electronic prostheses use myoelectric signals as the primary control format to command the prosthesis. batteries. and battery chargers. Rationale For Use As the fourth type of prosthesis used in the comprehensive management of the upper-limb http://www. Finally. both on and off the job. all of which can be loaned to the patient on a trial basis for a modest leasing charge. Following the fitting. it is very important that the same careful effort be taken in designing and fitting this temporatory prosthesis as would be for a permanent electronic prosthesis. The third type is an institutional limb bank. which is generally organized and supported by either a hospital or a charitable organization. the different design and component options before coming to a final conclusion. and It is not uncommon for a prosthesis to have a combination of one electronic touch controls.org/alp/chap08-02. it is then possible to attach a simple fitting frame ( Fig 8B-7. either rigid or semiflex-ible. This entire complex is then covered with some form of temporatory material. which may require a step-up mechanical hinge in conjunction with either a switch-controlled or myoelectrically controlled terminal device and/or wrist rotator. The same techniques are used for taking the negative plaster mold of the residual limb and subsequent modification as with a definitive fitting. The concept of a limb bank involves the collection. a standard protective outer glove is applied over the prosthesis to cover the inner shell of the electronic hand. there are three other electronic control modes that may also be utilized in a preparatory or a definitive electronic prosthesis. including electronic hands.) to provide a means by which the electronic components can be installed in the prosthesis. Although multiple combinations are seen primarily in amputation levels above the elbow and higher. What follows will be a brief description of the actual process involved in fitting and fabricating a preparatory/training electronic prosthesis. electrodes and electronic switching mechanisms. the formation of limb banks and corresponding lend-lease programs have made a favorable impact on the cost and complexities of providing sophisticated electronic limbs. These include electronic servo controls. As previously stated. the design of the prosthesis is designated as a hybrid system. This has led to increasing complexity and a much broader array of options to be considered when prescribing prostheses for the upper-limb amputee. Components and Technique Although a preparatory electronic prosthesis should be fitted with the same care as any definitive prosthesis. will compare very closely with a similar experience in a more costly definitive electronic limb. that provides protection to the wiring and various electronic components during the time that the patient will wear the prosthesis ( Fig 8B-8.). a practical method to simplify the decision-making process has slowly evolved throughout the past several years. preparatory/ training electronic prosthesis should be considered a separate and distinct procedure in the total evaluation process of the upper-limb amputee's needs. The advantage of this arrangement is that for a fraction of the purchase cost of new electronic hardware it is possible to provide the necessary electronics in a preparatory/training prosthesis on a very cost-effective basis. The test socket is then filled with plaster to create the final positive master model over which the preparatory electronic socket will be fabricated.8B: Prosthetic Principles | O&P Virtual Library prosthetics. the patient should continue with occupational therapy that stresses the specific activities that relate to that patient's daily routine. The second type is a commercial limb bank sponsored by a manufacturer of electronic limb components. A transparent test socket is then made over the modified plaster model. A limb bank can generally have one of three origins for its initial development. (3) providing the patient with the opportunity to determine the actual functional value of the electronic prosthesis when compared with other options. (2) sleeve suspensions that use either atmospheric pressure or skin traction to maintain suspension. midlength transradial amputations ( Fig 8B-9. Socket designs for the transradial level fall into three basic categories: (1) supracondylar brims that capture the humeral epicondyles and the posterior olecranon.oandplibrary. DEFINITIVE ELECTRONIC PROSTHESES After proceeding through the previous four types of prostheses. In today's world where health care costs seem to run toward the infinite and health care resources and funding most certainly have a finite nature. Under ideal circumstances. (3) the modified supracondylar brim with an olecranon cutout for long transradial amputations. and (3) elastic sleeves. Maintenance. and Downtime Among the concerns that come up when considering the viability of fitting electronic prostheses are the questions of funding. the preparatory electronic prosthesis provides for (1) the establishment of ideal definitive myoelectric signal sites. (2) neoprene sleeves. and (3) suprastyloid suspensions for wrist disarticulation amputees with prominent styloids. in the past decade it has been found that the majority of amputees have sufficient http://www.. (2) the opportunity to improve marginal myoelectric signals. Self-Suspended Socket Designs An important decision to be made regarding the definitive electronic prosthesis is choice of the socket design. which not only exposes the patient to the majority of prosthetic technology but also provides the opportunity to personally evaluate both simple and sophisticated systems. However. When the techniques described here are used. those involving suprastyloid purchase. which provide skin traction/suspension. it is essential that effective methods for evaluating high technology be utilized whenever possible. and (4) the floating-brim suspension for long transradial and wrist disarticulation amputations ( Fig 8B-10. the patient should have had the opportunity to try more than one type of socket suspension at the time that the test sockets were being evaluated. it has been documented that amputees treated by means of the aggressive methods presented have returned to work in five out of six cases reported. the four specific objectives to be addressed are (1) validation of the socket design and selected electronic components. and (3) the conditioning of the tissues contained within a self-suspended socket. (2) an assessment of the patients motivation and commitment to derive maximum benefit from an electronic prosthesis. the preparatory/training electronic prosthesis also adheres to the three general goals of preparation. This is particularly true of those patients who are wrist disarticulation or long transradial amputees. The issue of funding has long been one of the major obstacles in providing advanced technology to amputees.-benefit comparison between various alternatives. These are (1) the Miinster (2) the Northwestern supracondylar socket for socket for short transradial amputations.org/alp/chap08-02. ). which provide atmospheric pressure suspension. In terms of evaluation. The third category of suspension designs. The training objectives of a temporary electronic prosthesis include refinement of the patient's overall prosthetic control and the opportunity to practice ADL with an appropriate electronic limb. and training. the amputee and the clinic team are positioned at a unique vantage point from which to determine the prosthetic specifications for the long-term benefit of the patient. it has been found that by providing the amputee an opportunity to personally experience the actual benefits and limitations of each of these systems. Since there has been a significant amount of controversy over the past two decades regarding the respective advantages of mechanical and externally powered prostheses.asp[21/03/2013 21:54:15] . Since one of the prime sources of upper-limb loss occurs secondary to work-related injuries. By way of preparation. Among the supracondylar designs there are four basic types. Funding. (2) window/door suspension with elasticized closure. the final choice can be made with some assurance that no major oversights have occurred. and (3) soft removable inserts that grip the styloids. which provide a combination of atmospheric pressure and skin traction. the ability of amputees to return to work or their preinjury activities has proved to be a useful guide in measuring successful outcomes. maintenance. The sleeve suspension techniques include (1) latex rubber sleeves.8B: Prosthetic Principles | O&P Virtual Library amputee. evaluation. and (4) the development of clinical evidence to substantiate a cost-vs.). includes (1) silicone bladder suspension. and downtime. i.e. 26:16-23. it would be reasonable to say at this point in time that funding in the majority of cases no longer presents obstacles of any significant magnitude. Or-thot Prosthet 1972. Billock JN: Upper limb prosthetic management: Hybrid design approaches. In addition. 2. In recent years. For these amputees. Clin Prosthet Orthot 1985. August 1989. the use of electronic prostheses has increased.oandplibrary. dust. As a result. these same adult amputees who wear electronic prostheses have also come to realize that although the electronic terminal device generally provides a much stronger grip force. The solution that appears to be forthcoming is the development of regional specialty centers that can effectively deal with the complexities of providing uninterrupted service for electronic prostheses. Benefits and Disadvantages When evaluating the advantages and limitations of electronic prostheses. the use of two or three of these techniques is almost always possible and indicated. Billock JN: The Northwestern University supracondylar suspension technique for below elbow amputations. the advantages of an electronic prosthesis are in direct correlation to the disadvantages of a mechanical prosthesis. still be a major stumbling block unless the follow-up services are being provided by a specialty center that has developed a service delivery system that efficiently deals with the unique problems of repairing electronic prostheses. Brenner CD: Patient management experience with Myo-bock controls. depending on the situations in which they find themselves. CONCLUSIONS Each of the five prostheses described previously has proved to have a very specific role in assisting the rehabilitation team in providing comprehensive care for upper-limb amputees. grease. and it has been possible to evaluate and compare maintenance schedules among mechanical and electronic prostheses. and third-party payers can all rest assured that the highest quality and most cost-effective methods have been utilized to help these amputees reach their maximum rehabilitation potential. care givers. References: 1.org/alp/chap08-02. Brenner CD: Funding sources for electronic upper limb prostheses. this has been partially with the prosthesis has proved to be a major drawback. Although circumstances may not permit or necessitate the use of all five basic procedures in every case.8B: Prosthetic Principles | O&P Virtual Library health care insurance to cover the cost of these procedures. it has been recognized that many of the upper-limb losses occur in job-related situations and are covered by very adequate postinjury funding through the various workmen's compensation programs around the country. the patient. electronic prostheses appear to require maintenance at approximately the same level of However. 4. they generally find that the lack of freedom to use their electronic prosthesis in hostile environments where dirt. Other amputees find the ability to function with a prosthesis that has a close resemblance to a normal human hand to be of the highest level of importance.asp[21/03/2013 21:54:15] . many adult amputees have found that the best solution is to have the freedom to choose between both a mechanical and an electronic prosthesis at their discretion. Fredricton. In following the above model. the absence of a control/suspension harness through the use of a self-suspended socket has proved to be the biggest benefit and has provided them with a maximum degree of comfort. For the most part. remedied by the availability of electronic hook terminal devices such as the Otto Bock Greifer and the Steeper electronic hook. it may still prove to be somewhat slower in operation than a mechanical hook. New Brunswick. 3. Second. Each system can provide a unique perspective on the potential solution and eventual outcome for each individual amputee. On the converse side. 9:23-25. the patient's family. Presented at the Scientific Program of the American Orthotic and Prosthetic Association. water. clinicians. a mirrorlike image of the contrast between a mechanical and an electronic prosthesis appears. the issue of downtime for maintenance can frequency as mechanical prostheses. For most adult amputees. Quad http://www. Access to an electronic limb bank has proved to be the best solution to problems of downtime: a replacement component can be immediately installed in those cases when immediate repair of the prosthesis is not possible. A secondary concern involves the maintenance and corresponding downtime that may be associated with the continuous operation of a sophisticated electronic system. As a result. and solvents are in frequent contact However. Presented at the 1989 University of New Brunswick Myoelectric Controls Course and Symposium. Fleming LL. Orthot Prosthet 1973. 58:46-51. 18. Heger H.Atlas of Limb Prosthetics: Surgical. early. Malone JM. Malone JM. Hubbard S: Myoelectrics for the acheiria and partial hand amputee. J Bone Joint Surg [Am] 1976. 21:33. 14. 11:45-48. Prosthet Orthot Int 1986. October 1987. August 1989. 17. 8. Underwood J.8B: Prosthetic Principles | O&P Virtual Library Regional Meeting. 9:17-18. Michael JW: Upper limb powered components and controls: Current concepts. Clin Prosthet Orthot 1985. and late postsurgical management of upper limb amputation. British Columbia. Supan TJ: Transparent preparatory prostheses for upper limb amputation. deBear P: Myoelectric training for upper limb amputees. 23:60-61. et al: Immediate. Roberson J. Clin Prosthet Orthot 1986. 6. J Bone Joint Surg [Br] 1980. Presented at the Scientific Program of the 1987 Annual Meeting of the Association of Children's Prosthetic-Orthotic Clinics. Denver. Presented at the 1989 University of New Brunswick Myoelectric Controls Course and Symposium. Sauter W: Three-quarter-type Muenster socket. Burkhalter WE. 12. electric and myoelectric prosthesis. 10:66-77. Kritter AE: Current concepts review: Myoelectric prostheses. 35:1-9.1984. et al: Immediate postsurgical management of upper extremity amputation: Conventional. 20. Childers SJ. 20:34. Contact Us | Contribute http://www. Rehabilitation Institute.A. June 1989. LeBlanc MA: Patient population and other estimates of prosthetics and orthotics in the U. Hunter GA: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prostheses. 11. J Assoc Child Prosthet Orthot Clin 1985. 5. 7. 16. Northmore-Ball MD. J Assoc Child Prosthet Orthot Clin 1988. New Brunswick. Vancouver. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 8B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . June 1987. Carmona LS: The upper-extremity amputee: Early and immediate post-surgical prosthetic fitting. 9. 13. Morawa LG: Early intervention with immediate and early post-surgical prostheses. J Bone Joint Surg [Am] 1985. Orthot Prosthet 1981. Hunter GA: The below elbow myo electric prosthesis with the hook and functional hand. 27:38-44. Nichol WR: Electronic touch controls for prostheses. Clin Prosthet Orthot 1987. J Behabil Res Dev 1984. Detroit Medical Center. 10. Presented at the Seminar on Myoelectronic Upper Extremity Prosthetics. 10:27-34. 21:33-41.asp[21/03/2013 21:54:15] . 19. J Assoc Child Prosthet Orthot Clin 1986. Heger H. 15. Mayfield G. Epps CH: Externally powered prostheses for children. 67:654-657. Prosthetic. Millstein SG.org/alp/chap08-02. Chapter 8B .S. 62:363-367. deBear P: Functional use of myoelectric and cable-driven prostheses.oandplibrary. Fredricton. converting these patients to transradial (below-elbow) prosthetic wearers is significant. http://www. The caveat that such a procedure must result in a limb of more functional benefit than a prosthesis must always be borne in mind. the full humeral length in the case of disarticulation precludes the use of a myoelectric elbow. and Rehabilitation Principles Elbow Disarticulation and Transhumeral Amputation: Surgical Principles John A. Elbow disarticulation may be the level of choice for lesions of the forearm requiring radical surgical margins if the resultant cosmetic limitations are acceptable. as well as making Rigid dressings are. particularly those with shorter residual limbs. Prosthetic. with beneficial effects on wound management. residual-limb shrinkage. Elbow disarticulation remains controversial even though it provides improved suspension capabilities and rotational stability of the prosthesis because the adult amputee is limited to cable controls and relatively weak external hinges. 1992. within 30 days. M. Rigid postoperative dressings can be of value at these levels of amputation. Disarticulation is clearly the Reproduced with permission from Bowker HK. The vast majority of amputations through the humerus or elbow joint result from trauma.D. IL. McAuliffe. Many feel them to be an unnecessary complication and expense and cite frequently encountered difficulties with suspension. the reader is referred to Chapter 12A. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Replantation of traumatically amputated limbs is now a clinical reality. the inflammatory vasculitides. while return of While the functional gain of function to the wrist and hand is unusual and limited at best. and Rehabilitation Principles. not of immediate postoperative prosthetic fitting possible. Major limb replantation entails significant metabolic disturbance and risk and requires scrupulous medical management. with the decision regarding final prosthetic prescription made later. young males represent a major proportion of these amputees. An important subset of trauma patients in whom secondary amputation is frequently a consideration are those with unreconstructable brachial plexus injuries. Amputation should generally be performed at the most distal level compatible with the disease process that will allow for adequate padding and wound closure with healthy skin. vascular disorders account for fewer than 5% of upper limb amputations and are equally likely to occur in children and young adults due to entities such as fulminating purpura.Atlas of Limb Prosthetics: Surgical.org/alp/chap09-01. Prosthetic. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. however. remains the single most important variable affecting the success of prosthetic rehabilitation and seems to be as effective as immediate postsurgical fitting in producing this effect. which makes early functional rehabilitation critical. Early prosthetic fitting. American Academy of Orthopedic Surgeons. and particularly Buerger's disease. ©American Academy or Orthopedic Surgeons. although they are more costly and fragile. and pain control. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Tumor control remains the next most important reason for amputation at these levels despite recent advances in oncologic surgery favoring limb salvage procedures. As with other types of injury. Rosemont. In addition. Unlike the lower limb.asp[21/03/2013 21:54:20] .oandplibrary. Such "segmental replantation" is just one example of unconventional use of portions of an amputated limb that would otherwise be discarded in the form of microvascular free-tissue transfer. Useful elbow control in these patients seems fairly predictable. The superior potential for neurologic recovery in children makes them candidates for these procedures with injury at Reports of transhumeral replantation in adults are still relatively few in almost any level. Training is usually begun by using a conventional body-powered prosthesis. Click for more information about this text. The use of electrically powered prostheses. such proven benefit for upper-limb amputees to have gained the level of acceptance that they enjoy in the lower limb. the potential psychological turmoil inherent in suggesting transradial amputation following successful transhumeral replantation is very real. edition 2. Prosthetic. For a full discussion of this problem. is associated with increased prosthetic acceptance in the transhumeral (above-elbow) amputee. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). number.9A: Surgical Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 9A Chapter 9A . reprinted 2002. save for possible reinsertion of the deltoid at very proximal levels to enhance myoelectric control.org/alp/chap09-01. Blood Vessels Use of a pneumatic tourniquet greatly facilitates more distal amputations. therefore. Postoperative wound drainage is essential to prevent hematoma formation and delayed wound healing. remember that a bulbous or flabby stump produced by overzeal-ous preservation of soft tissues is a functional impediment in or out of a prosthesis. The ultimate position of the scar is not critical with modern total-contact sockets. for juvenile amputees. unconventional flaps should be used whenever necessary to preserve residual-limb length. and allowed to retract under cover of proximal soft tissue. Pectoralis cineplasty has in the past been performed to provide control of elbow locking mechanisms. It has been suggested that because of their close proximity. this is not of proven benefit and is to be avoided when attempting oncologic control of forearm lesions by radical margins. It must be recognized that the deltoid tuberosity is the most proximal level at which shoulder joint control is effective. however. however. this technique has been made obsolete by the development of practical myoelectric prostheses. Neuroma formation is the normal and expected consequence of nerve division. Bone and Joints http://www. Nerves should be gently withdrawn from the wound. Be aware that the skin in the region of the medial epicondyle is thin and wears poorly. however. Muscle and Tendon Myoplasty of the flexor and extensor musculotendinous units not only provides coverage and control of the stump but is also an important adjunct to maintaining shoulder control inasmuch as several of these motors cross this joint. TECHNICAL CONSIDERATIONS Skin Equal anterior and posterior flaps are the norm.oandplibrary. which can adversely affect early prosthetic training. Major vascular structures are doubly ligated proximally. and the goal is to locate the cut nerve end away from areas of contact and cicatrix so that it will be asymptomatic. Myodesis (suture of muscle to bone) is seldom necessary. Although preservation of length is important. although this is not of proven benefit. a long medial flap is the least desirable. which makes prosthetic suspension somewhat easier when compared with shoulder disarticulation.9A: Surgical Principles | O&P Virtual Library level of choice. High transhumeral amputations also provide more stable electromyographic sites for the myoelectric wearer and improved range of motion for body-powered function. and the tourniquet should always be deflated and careful hemostasis achieved prior to wound closure. however. The high incidence of bony overgrowth requiring stump revision in the case of transhumeral amputation in the child is avoided. It has been suggested that a portion of the forearm extensor musculature be reflected as a flap over the distal end of the humerus and affixed in the region of the medial epicondyle in the case of disarticulation. and cautery alone should not be relied upon to control larger collaterals. amputation through the surgical neck of the humerus has the significant cosmetic benefit of leaving shoulder width and axillary borders intact. that internal elbow mechanisms occupy approximately 4 to 6 cm of length. while it can be anticipated that slowed humeral growth will result in a humeral length at maturity Supracondylar amputations should take into account equivalent to a transhumeral level. Tourniquet deflation also allows for proper muscle tensioning.asp[21/03/2013 21:54:20] . sharply divided. exsanguination of the distal portion of the limb should not be performed in cases of tumor or infection. Nerves None of the myriad of physical and chemical techniques described to lessen the likelihood of symptomatic neuromas are particularly effective or to be recommended. Although functionally equivalent to shoulder disarticulation. As has often been emphasized. the median and ulnar nerves be divided in such fashion that their stumps do not come to lie at the same level. Neff G: The angulation osteotomy of above-elbow stumps. Abraham E.Atlas of Limb Prosthetics: Surgical. 10. et al: Immediate. 8. 13. Brown PW: The rational selection of treatment for upper extremity amputations. Transhumeral amputations should be performed with minimal periosteal stripping to prevent the occurrence of ring sequestra or bony spurs. Fleming L. Whipple RR. Unsell RS: Treatment of painful neuromas. 14. Marquardt E. 16. Orthop Clin North Am 1981. 11:682. A technique of angulation osteotomy of the humerus to provide rotational control for long transhumeral amputees is described in Chapter 36A and may be of value in selected patients. 2. Heger H. J Bone Joint Surg [Br] 1985.oandplibrary. Jaeger SH. 67:278. Clin Orthop 1986. Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation.org/alp/chap09-01. J Bone Joint Surg [Am] 1976. J Reconstr Microsurg 1987. although beveling of the bone is unnecessary. Burkhalter WE. Prosthetic. Malone J. 79:468. however. 19:175. 21:33. Mayfield G. 3. This must. References: 1.9A: Surgical Principles | O&P Virtual Library During elbow disarticulation. Orthop Clin North Am 1981. Millstein S. Hardesty RA. Schmidt R. care should be taken not to devitalize a large segment of bone. 6. 28:544. 58:46. 12:843. Robertson J. Carmona LS: The upper extremity amputee: Early and immediate post-surgical prosthetic fitting. Hunter G. 7. 209:202. 12. et al: Management of the upper limb deficient child with a powered prosthetic device. Tsai T. J Trauma 1988. Mosby-Year Book. Stevenson JH: Proximal upper limb replantation in children. Pellicore RJ. Rough edges should be removed with a file or rongeur. 15. 5.asp[21/03/2013 21:54:20] . J Hand Surg [Am] 1986. ed 7. (ed): Campbell's Operative Orthopaedics. Orthop Clin North Am 1981. et al: Upper limb salvage using a free radial forearm flap. 4. Zuker RM. 9. Clin Orthop 1974. J Pediatr Orthop 1986. early and late postsurgical management of upper limb amputation. Springfield D. Cooney WP: Above elbow limb replantation: Functional results. J Bone Joint Surg [Am] 1963. Goldstein SA. Contact Us | Contribute http://www. 6:66. 12:897. 104:232. Wood MB. epicondylar prominences may be reduced medially and laterally to prevent areas of pressure concentration within the socket. Glynn MK. Hamilton RC. Plast Reconstr Surg 1987. et al: Stump overgrowth in juvenile amputees. 45:1735. If myodesis is performed. Baumgartner RF: The surgery of arm and forearm amputations. Orthop Clin North Am 1988. be done conservatively to avoid negating the inherent suspension and rotational control value of elbow disarticulation. St Louis. Jones NF. Kleinert HE: Upper extremity replantation in children. Dell PC: Extended forearm flap. J Rehabil Res Dev 1984. Tooms RE: Amputations of upper extremity. The wound should be thoroughly irrigated following bone contouring. 11. Galway HR. 12:805. The articular cartilage is left undisturbed. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 9A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 1987. Chapter 9A . in Crenshaw AH. Aitken GT: Surgical amputation in children. 3:189. 2. Latissimus transfers seem Innervated pectoralis-to-biceps transfer has also resulted in a to be the most common. In these prostheses the anterior. In the transhumeral case. Length due to redundant tissue is functionally useless and serves only to complicate the prosthetic fitting.). Prosthetic. range of motion.). 4. The author has successfully fitted some individuals whose very short humeral stumps were lengthened by utilizing a vascularized fibular graft inserted into the remnant humerus. Prosthetic. and Rehabilitation Principles Elbow Disarticulation and Transhumeral Amputation: Prosthetic Principles J.org/alp/chap09-02.). and axillary surfaces of the residual limb are pressureand force-bearing areas. Any painful or severely scarred tissue in these areas will complicate prosthetic fitting. both component durability and cosmesis are reduced. Myoplasty helps to firm the residual limb. Sural nerve graft following brachial plexus injury has also resulted in sufficient muscle strength to prevent shoulder subluxation while allowing fitting with a myoelectric device ( Fig 9B-3. http://www. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. It is also preferred over the transhumeral level in children since the epiphysis is preserved and bony overgrowth is prevented. and stability of the proximal joints Reproduced with permission from Bowker HK.oandplibrary. Scar lines. including external power. IL. reprinted 2002. helps prevent redundancy. including the following: 1. lateral.P. Length of the bony lever arm Quality and nature of soft-tissue coverage Shape and muscle tone of the residual limb Flexibility. Click for more information about this text.) above the olecranon tip.asp[21/03/2013 21:54:25] . C. and skin grafts should be placed away from cut bones and away from the axilla whenever possible. if the adult humerus is transected 10 cm (4 in. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. on the other hand. optimization of these factors will significantly aid the amputee by facilitating his prosthetic rehabilitation and minimizing the need for revision surgery. and Rehabilitation Principles. will require the use of outside locking joints located on either side of the humeral epicondyles external to the socket. In this author's experience. who must use the residual limb for self-care. edition 2. Prosthetic. and provides improved electromyographic (EMG) potential for use in myoelectrically controlled prostheses. all available elbow options can be utilized successfully. Rosemont. Thomas Andrew. While severe trauma does not always leave the surgeon many options. Elbow disarticulation. muscle transfers have proved beneficial both as soft-tissue replacement and for providing a potential replacement EMG source for a myoelectric prosthesis when the natural muscle has been lost or denervated. very functional bicepslike EMG control site for use with a myoelectric prosthesis ( Fig 9B-2. There should be sufficient tissue to cover and cushion the distal portion of the bone without being redundant or creating a bulbous distal contour ( Fig 9B-1. Although this level may add active rotary control and the possibility of a self-suspending socket. Consideration should be given to what prosthetic components might be utilized so that elective amputation can be done at a level that will enhance the prosthetic result. drains. PHYSICAL FACTORS There are several factors that are crucial when designing and optimizing transhumeral and elbow disarticulation prostheses. The functional advantages of disarticulation make it especially valuable to the bilateral upper-limb amputee.Atlas of Limb Prosthetics: Surgical. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. American Academy of Orthopedic Surgeons.9B: Prosthetic Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 9B Chapter 9B . 3. 1992. ©American Academy or Orthopedic Surgeons. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Other important preprosthetic considerations include exercise to maintain strength and range of motion and careful determination of the amputee's vocational and avocational goals. Once this occurs. Several authors have discussed the "golden period" from 30 to 90 days postamputation when When prosthetic rehabilitation is delayed for many prosthetic fitting is most successful. He has also successfully fit patients with elbow disarticulation and very short transradial remnants with a unique "socketless" design.). supracondylar pads. 2. now has a long. This may be simply due to the infrequency of this level of amputation. While the supracondylar pads provide suspension. flexible socket is cooler than conventional rigid alternatives. after lengthening via a fibular graft. Advantages include control of edema and postamputation pain by containing the remnant limb in a snug dressing. In the case of elbow disarticulation. IMMEDIATE/EARLY MANAGEMENT Much has been written on the subject of immediate and early postsurgical prosthetic fitting. upper-limb immediate fittings have never enjoyed widespread popularity. 3. While such techniques are certainly not the answer for every short transhumeral stump. INFLUENCE OF HUMERAL LENGTH Leverage for prosthetic control varies directly with the length of the humerus. Circulation seems to be improved by the lack of edema. Flexible inner sockets with a rigid outer structural frame originally developed for transfemoral amputees have become increasingly common for upper-limb amputees as well and offer similar advantages. strong transhumeral residual limb capable of operating both an externally powered Utah Arm and a fully functional cable-powered prosthesis ( Fig 9B-4.asp[21/03/2013 21:54:25] . early fitting within a few weeks of amputation is strongly recommended. thereby increasing comfort and proprioception ( Fig 9B-8. intimate fitting at and above the condyles provides rotational control and suspension. The patient has an improved outlook since he has a usable replacement immediately following amputation and can maintain two-handed grasp patterns. thereby promoting quicker healing of the limb.9B: Prosthetic Principles | O&P Virtual Library Another somewhat successful alternative has been the use of progressive distraction and callus formation via an external fixator (the Ilizarov technique). It has been suggested that EMG signals seem to be improved when a limb is contained in a rigid dressing. The fact that there is no encompassing socket results in a lighter.).) Marquardt has described a clever approach for providing rotary control via humeral osteotomy.oandplibrary. months. Amputation through the distal third of the humerus provides functional control very similar to the elbow http://www. If immediate fitting has not been possible.org/alp/chap09-02. Amputees report that the thin. learning to use a prosthesis can become a much more frustrating and difficult experience. and circumferential straps placed superior and inferior to the biceps.) Flexible bladder variants for the less bulbous remnants "Screw-in"type sockets ( Fig 9B-6. Socket design alternatives are analogous to those for the knee disarticulation or Syme ankle disarticulation level and include the following : 1. Biofeedback training or muscle re-education using functional electrical stimulation has been shown to be an effective technique to enhance myoelectric control. 4. the potential benefits are significant. the combination of pads and straps allows humeral rotation control of the prosthesis. This technique utilizes an open mediolateral framework. Soft insert with an integral supracondylar wedge Fenestration with a cover plate ( Fig 9B-5. See Chapter 36A for more information on this technique. One of our patients. which is generally reserved for cases with bilateral upper-limb congenital absences. however.). The pliability of the inner socket also allows for contour and volume changes that occur with normal muscle expansion. cooler prosthetic interface as well as excellent tactile sense ( Fig 9B-7. Despite these potential benefits. SOCKET ALTERNATIVES Prosthetic socket design is largely determined by the physical characteristics of the residual limb. it appears that the amputee becomes more and more adept at one-handed work patterns. conventional cable-powered prosthetic control is severely limited. Guillotine amputations are difficult to fit either conventionally or myoelectrically due to the instability in the soft tissue from a lack of distal attachment. Dynamic load bearing is also a function of socket design. Conversely. ). ) is a modification of the standard Northwestern figure-of-8 ring type. The goal is to provide uniform and comfortable pressure along the humerus throughout the range of abduction and flexion of the prosthesis. This socket design is suitable for either myoelec-trically controlled or body-powered prostheses or for a hybrid prosthesis combining both options ( Fig 9B-14. Amputation in the proximal third of the humerus (proximal to the deltoid insertion) is particularly challenging prosthetically. The Utah inverted V harness ( Fig 9B-16.asp[21/03/2013 21:54:25] . As humeral length diminishes. and improves EMG consistency. the difficulty of donning a suction socket should be carefully considered ( Fig 9B-15. decreases loading in the contralateral axilla (which may reduce deleterious effects on the sound-side brachial plexus ). this hybrid approach is particularly useful for hand users. This preserves the inherent proprioceptive feedback of the force generated to use the terminal device and is particularly useful for the amputee who chooses to wear a hook. UTAH DYNAMIC SOCKET Over the past decade. The author has previously described the "Utah Dynamic Socket technique" for transhumeral socket design. Mediolateral stability is enhanced by casting the remnant limb in a special fashion ( Fig 9B12. Soft-tissue coverage also affects prosthetic function since painful. which is an outgrowth of the previous work of Pentland and Wasilieff. With myoelectrically controlled transhumeral fittings. experience in fitting significant numbers of externally powered transhumeral prostheses has led to refinements in socket design and harnessing techniques. enhances proprioception. of excursion when using biscapular abduction. ). . It is also quite possible to use body power for elbow flexion in combination with an electric terminal device ( Fig 9B-10. Since the socket design enhances rotary stability. Primary control is by scapular motion with assistance from the humerus. The properly fitted dynamic socket does not require socks for comfort or stability. Body-powered systems require up to 5 in. ). weight. suction suspension allows minimal harnessing. (Grafted amputations may eventually accept suction once they are well healed and mature. the harness may be totally eliminated. and fresh skin grafts. they can often be adapted for myoelectric elbow control as well ( Fig 9B-11. Careful shaping of the shoulder region adds rotational stability ( Fig 9B-13.) Although it is sometimes possible for the bilateral amputee to pull himself into the socket with an appropriately designed pull sock. This technique can also be adapted to provide suction suspension. both the lateral suspensor and the anterior suspensor straps http://www. Contraindications to suction socket transhumeral fittings are analogous to those for transfemoral cases and include remnant limbs with excessively bulbous distal ends.9B: Prosthetic Principles | O&P Virtual Library disarticulation except for the loss of humeral rotary control and condylar suspension. In selected fully myoelectric prostheses. 2½ to 3 in. reliability. In the transhumeral prosthesis. The precise component configurations must be individualized for each amputee and the relative importance of function. cosmesis. one variant works particularly well with the dynamic socket described above. of total excursion to open the terminal device with the elbow in the fully Since the average adult transhumeral amputee can achieve no more than flexed position. Numerous combinations of body-powered and externally powered components have proved successful. ).oandplibrary. these last two functions must be provided by the socket design and harnessing.). adherent scarring may limit the force that the amputee can comfortably generate. painfully adherent distal scarring. externally powered components are usually necessary for full function.AC). although they may be worn if desired. Primary control of the prosthesis is by the humerus with additional control offered by scapular motion.org/alp/chap09-02. While a thorough discussion of harnessing is included in Chapter 6B. Due to the obvious reduction in strength and leverage at this level. both leverage and power decrease significantly. Common examples include using an electric elbow with a body-powered terminal device ( Fig 9B-9. and cost weighed for each alternative. too much tissue makes donning the prosthesis more difficult and often compromises prosthetic humeral length and cosmesis. suitable sites for myoelectric hand control exist. Since myoelectric control can provide a very If precise yet powerful grip. ). Leal JM. Orthot Prosthet 1981. 10. pp 130-161. http://www. 1989. Prosthesen und bisherige Resultate (The Angulation Osteotomy in Above-Elbow Stumps: Indications. 13. pp 26-28. Grune & Stratten. et al: Brachial plexus injury management through upper extremity amputation with immediate post operative prosthesis. Operationstechnik.org/alp/chap09-02. Malone JM. Stuttgart. ed 3. et al: Immediate. Malone JM. Fla. New York. Boehniges Mannheim. and comfort despite limb volume changes 2. 1968. 5. electric and myoelectric prostheses. Underwood J. Marquardt E: Versuche des Ersatzes und der Ausnut-zung von Oberflachen-Sensibilitat bei Armprosthesen. 4:244-248. Marquardt E: Fitting with preserved epi-condyles. Three important tasks must occur during the period following prosthetic fitting: 1. The elastic "V" provides improved suspension by functioning as a shoulder saddle while also providing elastic recovery for the body-powered elbow locking cable. 63:89-91. early and late postsurgical management of upper extremity amputation. in Surgery of the Musculoskeletal System. Medizinisch-Orthopädische Technik. Marquardt VE: Die Winkelosteotomie an Oberarms-tiimpfen: Indikation. Orlando. Malone JM. Fleming LL. 53:64-71. and component selection based on amputee experience There are many aspects to upper-limb prosthetic rehabilitation that cannot be addressed until the patient has had reasonable time to assimilate the many new features of his life. Maintenance of socket fit. 8. 9. 1975. and prescription revisions based on the amputee's changing needs are the essential factors for successful prosthetic rehabilitation. 104:232-238. 11. Churchill Livingstone Inc. University of California Press. Ersdrienen in des Medizinhistorischen Schriffen-reihe. Mannheim. 1974. Operative Techniques. Marquardt E. Manson PN. vol 4. Childers SJ. Clin Orthop 1974. Maxwell GP. Re-evaluation of socket style. Arch Orthop Unfallchir 1961. harness design. Leal JM. 15. Rehabilitation 1972. Neff G: The angulation osteotomy of above-elbow stumps.oandplibrary. and function of the prosthesis must be maintained and optimized over time as the amputee alters and refines his initial goals and aspirations. Burgess EM: Postsurgical management. References: 1. 35:1-9. Hoopes JE: Experience with 13 latissimus dorsi free flaps. vol 2. 6. Marquardt E: Pneumatische und bioelektrische Prosthesen. 21:33. Arch Phys Med Rehabil 1982. Marquardt E: Steigerung der Effektivitat von Oberarm-prosthesen durch Winkelosteotomie. West Germany. Successful long-term use of an upper-limb prosthesis depends primarily on its comfort and its perceived value to the amputee. West Germany. J Rehabil Res Dev 1984. Bray JJ: Prosthetic Principles: Upper Extremity Amputations (Fabrication and Fitting Principles). Billock JN: Upper limb prosthetic terminal devices: Hands versus hooks: Clin Prosthet Orthot 1986.9B: Prosthetic Principles | O&P Virtual Library are eliminated. suspension. careful attention to follow-up adjustments. Ilizarov GA: Possibilities offered by our method for lengthening various segments in upper and lower limbs. 1983. 48:323-324. Monitoring to ensure that the patient fully understands and masters the functions of his prosthesis in his home and work environment 3. Innovative design and careful custom adaptation of socket and harness principles. AW Gentner Verlag. comfort. 10:57-65. Lister G: Personal communication. There are continuing questions to be answered and new skills to be mastered. 2. Prosthetics Orthotics Education Program. Underwood J. 7. The fit. et al: Immediate postsurgical managment of upper extremity amputation: Conventional. Jentschura G. 14. 12. in Malformations and Amputations of the Upper Extremity: Treatment and Prosthetic Replacement. Los Angles. FOLLOW-UP Follow-up could be considered to be the most important aspect of prosthetic rehabilitation and yet may be the most often neglected. 3. Prostheses and Results). Basic Life Sci 1988.asp[21/03/2013 21:54:25] . 4. Contact Us | Contribute http://www. West Germany. Reddy MP: Nerve entrapment syndromes in the upper extremity contralateral to amputation. 1976. 17. Pentland JA. New York. Jacobsen SC: Clinical experience with the Utah artificial arm. Schile & Schon. Zych G: Personal communication. Wasileif A: An above elbow suction socket. 1989. Springer-Verlag NY Inc. hand. 1984. Chapter 9B . Archives of Physical Med Rehabil 1984. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 9B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Toronto. and terminal device. Prosthetic. Andrew JT. Meier RH III (ed): Comprehensive Management of the Upper-Limb Amputee. in Atkins DJ.org/alp/chap09-02.Atlas of Limb Prosthetics: Surgical. 36:40. Andrew JT. 16. Sears HH.9B: Prosthetic Principles | O&P Virtual Library Surgery 1979. 65:24-26. 20. Otto Bock Prosthesen-Kompendium: Prosthesen fur die obere Extremitat. 21. Jacobsen SC: Experience with the Utah arm. 19. Biederstadt. Ontario. Sears HH. 18. Orthot Prosthet 1972. 1984.asp[21/03/2013 21:54:25] . in Yearbook of the Canadian Association of Prosthetists and Orthotists. 64:1.oandplibrary. Acceptance rates of conventional body-powered prostheses therefore fall considerably for shoulder-level amputees. and the reestablishment of structural con-.asp[21/03/2013 21:54:29] . reprinted 2002. of the caveats of major limb replantation concerning the patients overall injury status. tinuity is severely limited by the fact that most of these injuries occur through the scapulothoracic articulation rather than through the glenohumeral joint with its greater ligamentous integrity.10A: Shoulder Disarticulation and Forequarter Amputation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 10A Chapter 10A . early prosthetic fitting does encourage the retention of two-handed patterns of activity and may result in significantly higher rates of long-term prosthetic use even at these levels. Nonetheless. Tumor control remains the primary indication for amputation at this level despite efforts at limb salvage made possible by more accurate methods of preoperative localization. and Rehabilitation Principles. Congenital limb deficiencies do occur this far proximally. duration of ischemia.Atlas of Limb Prosthetics: Surgical. Click for more information about this text. albeit Rigid dressings are unnecessarily cumbersome and do not provide the at higher cost. Electrically powered prostheses. Advances in vascular surgery have made re-establishment of blood flow to severely Replantation of a limb amputated traumatized limbs commonplace. seldom feasible or indicated. All other causative factors are decidedly rare. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. American Academy of Orthopedic Surgeons. Prosthetic.org/alp/chap10-01. Preservation of the deltoid musculature also facilitates myoelectric control of a prosthesis.oandplibrary. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Serious injury is the next most common cause for limb loss about the shoulder. The available function from a prosthetic replacement decreases as the level of amputation progresses more proximally. The amputation stump itself is of no inherent functional value at these levels because even the ability to grasp or stabilize large objects between the residual limb and thorax will be eliminated. maintenance of shoulder width and axillary contour by the former procedure is a distinct cosmetic advantage. TECHNICAL CONSIDERATIONS It is imperative that any amputation be performed not as an end-stage surgical procedure but as a reconstructive undertaking that is viewed as the first step in the patient's rehabilitation. 1992. modern adjuvant therapy. can provide important function and increase levels of acceptance. Reproduced with permission from Bowker HK. Replantation may occasionally be considered when the skeletal and neural injuries allow repair or reconstruction. and the possibility of metabolic replantation toxemia must be carefully borne in mind when such a decision is made. safe. This is particularly true for the female patient in whom sacrifice of the pec-toralis major insertion disrupts breast contour and symmetry. however. the need for surgical revision is rare and usually best avoided. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). although fewer than 3% of traumatic amputations of the upper limb occur at these proximal levels. IL. through the shoulder girdle is. McAuliffe. When sound surgical judgement permits. The vast majority of traumatic amputations about the shoulder are due to avulsion forces. however.). but as at other levels. retention of the scapula is far less disfiguring ( Fig 10A-2. same beneficial effects on wound management and pain control as in amputees with longer stumps. Amputations through the glenohumeral and scapulotho-racic articulations are uncommon. The cosmetic deformity of forequarter amputation is significant ( Fig 10A-1. and effective. Prosthetic. Prosthetic. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. edition 2. ©American Academy or Orthopedic Surgeons. http://www. and probably then only in the All very young patient in whom some useful neurologic and functional recovery is possible. and Rehabilitation Principles Shoulder Disarticulation and Forequarter Amputation: Surgical Principles John A.D. Although amputation through the surgical neck of the humerus is functionally equivalent to shoulder disarticulation. M.) and of considerable psychological benefit to the patient. and advances in tissue banking. Rosemont. Microsurgical techniques enable the surgeon to make use of distal portions of the limb uninvolved with the disease process necessitating amputation to provide skin or muscle flaps to aid in reconstruction of the amputation site. http://www. Removal of acromial and cora-coid prominences is unnecessary and will further disrupt form as well as reduce leverage for body-powered prostheses. Muscle and Tendon In the case of forequarter amputation. and painless but shortened limb ready for early prosthetic prescription.oandplibrary. following which the deltoid is attached to the inferior glenoid and lateral scapular border to fill the subacromial space. Skin Sufficient sensate skin with adequate subcutaneous tissue for padding and normal vascularity is seldom a problem at this level. Bone and Joints During forequarter amputation. Blood Vessels Major arteries and veins should be dissected separately and doubly ligated proximally. split-thickness skin grafting of these areas can often be tolerated beneath a prosthetic socket. Vasa nervorum that are large enough to be evident are best controlled by gentle dissection from the surface of the nerve and bipolar electrocoagulation.10A: Shoulder Disarticulation and Forequarter Amputation | O&P Virtual Library With this in mind. should be sutured together to form additional padding and contour over the chest wall. and wound drainage should be used routinely. and Fig 10A-4. None of the various physical and chemical methods of treating the nerve stump seems to have an advantage over simple distal traction on the nerve. Excision of previous biopsy scars or skin involved with tumor can usually be accomplished by the design of unconventional flaps. save in the traumatic amputee. SURGICAL TECHNIQUES The details of surgical technique are well delineated in the standard textbooks and monographs on amputation. sharp division. Suggested skin incisions are depicted in Fig 10A-3. In cases of trauma.org/alp/chap10-01. osteotomy of the clavicle should be performed at the lateral margin of the sternocleidomastoid insertion whenever possible in order to preserve contour of the neck. Conventional technique for shoulder disarticulation suggests that the rotator cuff tendons be sutured together over the glenoid.. and its retraction under proximal cover away from the end of the residual limb and the cutaneous scar. none of amputation neuromas. strong. Such nonconventional use of otherwise discarded portions of the amputated limb should always be considered. Myodesis ensures consistent electromyographic localization that may improve functional control and particularly proportional grasp for wearers of electric prostheses. Overzealous distal traction may produce interstitial failure of the neural elements and formation of a more proximal symptomatic neuroma in continuity. All severed nerves form neuromas. Despite the superficial osseous structures of the shoulder girdle and chest wall. which in this region may be quite large. A postoperative compression dressing is carefully applied to stabilize the flaps and control shear without strangulation. Cautery should not be relied upon for their control. latissimus dorsi. them are uniformly successful. the lessons of military surgery must be well remembered and primary wound closure performed rarely. if at all. such as the pectoralis major. the ultimate location of the scar being of little consequence with modern socket construction. This includes collateral vessels. and the prime objective is to locate this normal neural reaction in an area where it will not be symptomatic. any remaining musculature. Skin and muscle flaps are large. There are two major techniques for performance of the forequarter amputation.asp[21/03/2013 21:54:29] . the surgeons goal should be a mobile. Nerves Literally dozens of methods have been described in attempts to alleviate the problems of As is usually the case when a plethora of techniques exist. and trapezius. In shoulder disarticulation the articular cartilage on the face of the glenoid is left undisturbed. Springfield D. Hardesty RA. Wood MB. 76:1241. et al: Management of the upper limb-deficient child with a powered prosthetic device. Bechtol CO: Modern amputation technique in the upper extremity. Chapter 10A . Ebskov B: Major upper extremity amputation in Denmark. including the trapezius. Fleming L. ed 7. 1957. Kleinert HE: Upper extremity replantation in children. Jaeger SH.). Philadelphia. Moore TJ: Amputations of the upper extremities. 79:468. 8. Br Med J 1922. JB Lippincott. Mosby-Year Book. J Bone Joint Surg [Am] 1976. Villela ER. Moseley HF: The Forequarter Amputation. Robertson J. 1987. Dell PC: Extended forearm flap. 2. levator scapulae. 1988. and serratus anterior. J Bone Joint Surg [Am] 1963. Clin Orthop 1986. 8:921. J Trauma 1980. 12:897. Burkhalter WE. 21:411. Division of the pectoralis major and minor muscles anteriorly then allows the limb to fall free. 12. Glynn MK. Baumgartner RF: The surgery of arm and forearm amputations.Atlas of Limb Prosthetics: Surgical. rhomboids. et al: Immediate. Unsell RS: Treatment of painful neuromas. and serratus anterior. Prosthetic. Goldstein SA. Following release of the pectoralis major from the humerus and the pectoralis minor from the coracoid process. 20:297. Hunter G. is found by many to be technically easier and to involve Littlewood's posterior approach less blood loss ( Fig 10A-4.oandplibrary.asp[21/03/2013 21:54:29] . Jones NF. 13. Marrangoni AG: Traumatic fore-quarter amputation. Tooms RE: Amputations of upper extremity. Layton TR. 59:321. Orthop Clin North Am 1981. the major neurovascular structures are exposed and controlled. Orthop Clin North Am 1981. 21. 20. clavicular osteotomy is performed at the outset. Anderson-Ranberg F. Whipple RR. J Bone Joint Surg [Br] 1985. et al: Amputations after vascular trauma in civilians. 6. 15. Schmidt R. 3:189. Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation. Orthop Clin North Am 1972. Tooms RE: Amputation surgery in the upper extremity. rhomboids. 3:383. Khodadadi J. Orthop Clin North Am 1988. 67:278. Dissection begins posteriorly with transection of the trapezius and latissimus dorsi muscles in line with the medial border of the scapula. Acta Orthop Scand 1988. 58:46. Millstein S. References: 1. JB Lippincott. The superior and medial borders of the scapula are then freed by division of the levator scapulae. 16. Plast Reconstr Surg 1987. Adinolfi MF. 209:202. The clavicle is exposed subperiosteally and divided. Anterior dissection is completed by release of the latissimus dorsi from its humeral insertion. which are thus placed under tension. St Louis.org/alp/chap10-01. 11. et al: Upper limb salvage using a free radial forearm flap. 1:381. 14. Galway HR. Pritchard DJ. Littlewood H: Amputations at the shoulder and at the hip. et al: Arterial combat injuries of the upper extremity. Adar R. in Chapman MW (ed): Operative Orthopaedics. Orthop Clin North Am 1977. 4. J Rehabil Res Dev 1984. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 10A http://www. Sim FH. Hardin WD. South Med J 1983. Philadelphia. 7. 18. The limb is then allowed to fall posteriorly and dissection completed by release of the periscapular musculature from the superior and medial borders of the bone. Heger H.). J Hand Surg 1986. Mayfield G. 5. 17. 21:33. Ivins JC: Forequarter amputation. 12:805.10A: Shoulder Disarticulation and Forequarter Amputation | O&P Virtual Library In the anterior technique of Berger ( Fig 10A-3. 9. Malone J. early and late postsurgical management of upper limb amputation. O'Connell RC. Cooney WP: Above elbow limb replantation: Functional results. 10. Hall CB. 45:1717. and the lateral portion of the clavicle may be removed from the field by disarticulating the acromioclavicular joint. The scapula and upper limb are rotated laterally and displaced anteriorly to allow for identification and control of the neurovascular structures. omohyoid. J Reconstr Microsurg 1987. 19. Schramek A. Tsai T. 3. J Trauma 1981. 11:682. 19:175. Carmona LS: The upper extremity amputee: Early and immediate post-surgical prosthetic fitting. in Crenshaw AH (ed): Campbell's Operative Orthopaedics. org/alp/chap10-01.oandplibrary.10A: Shoulder Disarticulation and Forequarter Amputation | O&P Virtual Library The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .asp[21/03/2013 21:54:29] . Contact Us | Contribute http://www. .) and those incorporating some type of perimeter frame ( Fig 10B-4. The major prosthetic problems are therefore prosthesis stability and cosmetic appearance. it should be noted that the clavicle and scapula are often misshapen. retention of a natural shoulder profile. the amputation site is likely to be rather elevated laterally. ©American Academy or Orthopedic Surgeons. it is sometimes difficult to decide whether or not a prosthetic shoulder joint should be included and. with surfaces that are capable of bearing some weight unless they are scarred by the trauma. Prosthetic. In addition. In addition.B. 1992. C. http://www. Click for more information about this text..). although some muscle bulk may have been lost during the trauma or surgery. edition 2. if so. when trying to provide for a functional device.). may be fused. For example. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. two factors must be taken into account: first. spur. Prosthetic. Alternatively.S. The shoulder profile drops away quite sharply from the bony point of the glenoid area. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. in particular. American Academy of Orthopedic Surgeons. but the lack of bony structures tends to make stability a problem.asp[21/03/2013 21:54:34] .T.oandplibrary. it is possible to make the whole socket interface from a soft material. It is unusual for the remnant shoulder musculature to be atrophied.org/alp/chap10-02. the two groups can be further subdivided to include cases in which other factors must be considered. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Each of these groups present a separate and quite distinct clinical picture that affects prosthetic management. In the congenital group one might wish to include individuals with digits at the shoulder or with similar longitudinal defi-cits. It is therefore important that the edges and surfaces of the socket that interface with the amputee be rounded and relieved very carefully. and Rehabilitation Principles. Rosemont.A. Prosthetic. it should be remembered that external forces that are transmitted to the shoulder from the hand will often be large because of the long moment arm involved.Atlas of Limb Prosthetics: Surgical. and are usually foreshortened with the lateral These features create a prominent and usually very mobile bony aspects swept upward.10B: Prosthetic Principles | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 10B Chapter 10B . reprinted 2002. For instance. in the acquired group one might wish to include those or discuss the treatment individuals who have received surgery for ablation of a neoplasm of the fragile stump in instances where the surface has been burned or grafted. it is good practice to make an allowance for relief over all bony prominences and provide additional flaring where the edge of the socket crosses protuberant bone. Reproduced with permission from Bowker HK. IL. In the acquired group ( Fig 10B-2. The remainder of the shoulder area is often fleshy and has the potential for weight support.P. SOCKET DESIGN In clinical practice two types of sockets are commonly fitted at this level. OVERVIEW It is important in any description of the through-shoulder level of upper-limb absence to distinguish between the appearance of an acquired amputation site and congenital absence of the upper limb. When providing an enclosed socket. F. and the incorporation of a prosthetic shoulder joint presents no great cosmetic or technical difficulty. When considering the congenital group ( Fig 10B-1.I. what type of component is appropriate. B. These can be classified as those that enclose the shoulder and are formed to its contours ( Fig 10B-3. and Rehabilitation Principles Shoulder Disarticulation and Forequarter Amputation: Prosthetic Principles Robin Cooper.) that encompasses the shoulder and provides structural mounting points for the prosthesis and location and reference points for a variety of controls. CASTING As with all prosthetic procedures the manufacturing process is built upon the foundation of accurate measurement. and passes over the shoulder near the neck. it is often convenient to manufacture a frame socket. This approach uses suitably padded metal strips brazed together to form a (e. information recording. on estimates of these dimensions related to general physique. in the case of a bilateral loss. The membrane that is applied to seal the cast during laminating will crush the edges of the foam as the vacuum is applied and will thus form a prerounded border to the socket. a more robust prosthesis can be supplied for manual workers following a traumatic loss.10B: Prosthetic Principles | O&P Virtual Library supported by stiffening where appropriate. A photographic record may also be helpful. This process starts by a determination of the dimensions of the prosthesis based either on the remaining limb or. lightweight passive arm ( Fig 10B-5. Care must be taken to estimate the amount of shoulder elevation remaining once the weight of the prosthesis is being carried. or it may be one of a number of soft thermoplastics such as certain forms of polyethylene that can be drape-formed. with care taken to mark the likely trim line of the socket and accentuate the bony contours. the prosthetist must take care to make. a high-stiffness laminate made. The shoulder should be depressed slightly to allow for the weight of the prosthesis. Although an intimate fit is necessary to provide optimal stability. Although it is commonly believed that prostheses fitted at this level are likely to be nonfunctional. it may be desirable to provide some form of ventilation or moisture-permeable surface next to the skin. casting.. Alternatively. COMPONENTS The hardware fitted from the humeral rotator downward can be selected from any of the major manufacturers. Where a user with a congenital deficiency is to be fitted.) is frequently supplied to individuals who have a sedentary life-style.asp[21/03/2013 21:54:34] . FABRICATION In preparing the positive cast. the foam technique is a useful way of making channels in which to lay up Kevlar or carbon fiber. While an endoskeletal. One must not be misled by the position of the axilla because surgery or scarring may distort the tissue in the axillary area. This may be a laminate using silicone or poly-urethane resins and a woven reinforcement. the socket is generally made of plastic. carbon fiber reinforcement) can be frame. extends down to about the fifth rib to within an inch or so of the anterior and posterior center lines. a hinge is provided to link the posterior frames. This may be done by extending the normal plaster cast over both shoulders.oandplibrary. It is useful to record both the amputation site and the contralateral contours so that a faithful copy of the shoulder profile can be created.org/alp/chap10-02. In the case of a bilateral fitting. and a mouth-positioned Velcro fastener is provided at the front. high up onto the neck. It will usually be necessary to remove material from the anterior and posterior aspects of the cast to eliminate gaping in these areas. they should be built up by using plaster or the appropriate thickness of closed-cell foam stapled to the cast.g. It is obviously important to provide a relevant prescription that will suit the planned life-style of the individual. With few exceptions. In these cases it may be necessary to custom-make special shoulder units http://www. A second cast of just the amputation site is then obtained. The area of the socket superior to the scapuloclavicular joint may have to be removed to allow the prosthetist to achieve a reasonable profile. If this is necessary. The frame covers very nearly half the torso. and over the upper part of the chest and back by using plaster of paris slabs. This technique may also be used to provide additional flare to areas where the edge of the socket and bony contours coincide and to delineate the boundary of the socket. this does not need to be the case. A second point to note is that with such a high-level loss the effects of perspiration may cause difficulties. after the outlined contours are smoothed and rectified. If a frame socket is to be constructed. and this should be taken into account when carrying out these procedures. A range of materials may be employed for this purpose. it may also be necessary to remove plaster from the subglenoid lateral aspect to accommodate any shoulder mechanism that is to be attached. an appropriate allowance on the positive model in addition to relief for bony structures. Active functions can be provided with the judicious addition of appropriate components. and modeling. the harness can provide control inputs with force. the shoulder can be used to activate simple push switches. First. For instance. provision of a powered elbow. but the cost must be assessed for the individual concerned. the harness must provide a medial force at two points. and displacement components. not only in financial terms but also with regard to the weight penalty and the likely difficulties in learning efficient control strategies. Harnessing and cabling present a difficult challenge in such cases. while control signals are linked to the position of the shoulder or some other small but independent motion. or alternately. There are no commercially available units that will survive such rigors. Mass) and modified with an interlock to allow single cable control of both elbow flexion and a Servo Electric hand. However. A frame socket is also used when it is desirable to leave the shoulders completely free. For instance. References: http://www. and a powered hand is appropriate.org/alp/chap10-02. more complex solutions are required. Campbell. and spread the weight of the prosthesis across the body. The control element also provides some sensory feedback if resistance to the motion is sufficiently large. It may be desirable. force/ power signals are taken from straps across the back. The first force is applied just inferior to the point at which the socket edge crosses the clavicle. the whole shoulder area may be shaped from Plastazote fitted at the transhumeral level into a lightweight socket with a manually controlled endoskeletal system attached. inferior to the spine of the scapula. possibly with the addition of an elastic element. When a very lightweight limb is required. These forces counterbalance the effects of gravity. and the second is applied to the posterior surface. With such prostheses. The simplest harness is a padded strap that passes under the contralateral axilla and connects these two points. Usually.asp[21/03/2013 21:54:34] . the author has provided prostheses that allowed one amputee to work as a welder under tanker trailers and another to work as a public parks employee who was required to shovel soil onto trucks and to plant and handle saplings ( Fig 10B-6. Activation of switch-controlled components is simply accomplished with a posterior ribbon fastened through a safety pin mounted vertically in the brassiere under the contralateral axilla. This provides complete freedom for the thoracic girdle. a Steeper switch-controlled electric lock can be provided at the elbow (Liberty Mutual Research Center. In some cases. For some individuals. If the user finds operation difficult or robotlike. by utilizing differential body motion. consistent with good cosmesis and practical fabrication for best results. HARNESSING The provision of harnessing for the through-shoulder prosthesis ( Fig 10B-7. all that is required are anterior and posterior ribbons fitted with clips that allow attachment to a brassiere. For very lightweight systems fitted to women.) has two objectives. The switch control elements of the harness are usually linked to the suspension components. Hopkins. The establishment of the connection points depends on the signal required. minimize slip and movement on the stump.oandplibrary. Externally powered components may be either switch controlled or myoelectric. and this makes one or more powered units a good option. to eliminate the chest strap and replace it with a figure-of-8 harness around the contralateral shoulder.). which takes advantage of biscapular abduction. This will provide function without exertion. To meet the first objective. dynamic forces occurring during operation and the forces generated by external loading. It is important to place the battery holder as high on the prosthesis as is possible. which should be suitably perspiration proof. the frame can be used as a fixed point against which force and displacement transducers may be operated to control actuators. Second. This provides fixed points against which force or displacement can be generated. this type of prosthesis may also be rejected as "useless" since it is purely passive. Calif) is a good addition to this prescription. it is designed to hold the prosthesis in place. on occasion. and it is likely that even with the best technical advice and training the device will be rejected. either to maximize the ability to operate controls or to minimize discomfort caused by perspiration.10B: Prosthetic Principles | O&P Virtual Library with locking functions that will enable tools to be positioned and operated in working environments. speed. the prosthesis may represent over gadgetization. A shoulder unit with variable friction in two planes such as the Hosmer Child Amputee Prosthetics Program (CAPP) device (Hosmer Dorrance Corp. a powered wrist. oandplibrary. Lamb DW: A system of powered prostheses for severe bilateral upper limb deficiency. Roehampton Disablement Services Centre. Inter-Clin Info Bull 1971. 2.asp[21/03/2013 21:54:34] . 37:53-60. pp 267-310. 4.Atlas of Limb Prosthetics: Surgical. Hall CB. 47:442-447. Williams & Wilkins. Lauko T: A myoelectrically controlled prosthesis using remote muscle sites. 450:1717-1722. Ring ND: The Chailey harness with carbon reinforced plastic. Clin Orthop 1964. 5. London. Contact Us | Contribute http://www. 7. Bechtol CO: Modern amputation technique in the upper extremity. Meier R: The Comprehensive Rehabilitation of Burns. 3. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 10B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Stern PH.org/alp/chap10-02. 1978. Aitkin GT: Management of severe bilateral upper limb deficiencies. Neff GG: Prosthetic principles in shoulder disarticulation for bilateral amelia. 47:425-434. Baltimore. Dennis JF: Shoulder disarticulation type prostheses for bilateral upper extremity amputees. J Bone Joint Surg [Br] 1965. Inter-Clin Info Bull 1963. 10. J Bone Joint Surg [Br] 1965. 12:1-4. Brooks MA. 6. Simpson DC. 2:1-7. Inter-Clinic Info Bull 1973. 2:143-147. Marquardt E: The Heidelburg pneumatic arm prosthesis. Chapter 10B . et al: Special projects group documentation (unpublished). 9. 8. Cooper RA. 1984.10B: Prosthetic Principles | O&P Virtual Library 1. Prosthetic. Prosthet Orthot Int 1978. 6:5-8. J Bone Joint Surg 1963. R. American Academy of Orthopedic Surgeons. and the reactions that the wearer gets from other people. 5. proprioceptive feedback. IL.asp[21/03/2013 21:54:40] . Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. nurse. a poorly made prosthesis. and (3) an electrically powered prosthesis controlled by myoelectric sensors or specialized switches. (2) a cable-controlled. Promote wound healing. Listening to and acknowledging the patient's psychological and functional needs will be critically important in determining the success or lack of success with prosthetic acceptance and function. The loss of fine. the unnatural look or profile of the prosthesis. reprinted 2002. The goals are as follows: 1. preprosthetic. and occupational or physical therapist. which removes the functional need for the prosthesis. http://www. An unusually high rejection rate of upper-limb prostheses can often be attributed to the following reasons: development of one-handedness. Rosemont. The impact of the sudden loss of a hand or arm upon a person cannot be overstated. In reality there are no perfect or ideal replacements that take the place of the exquisite mechanisms and function of the human hand. 3. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.oandplibrary. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists POSTOPERATIVE THERAPY PROGRAM Awareness of postoperative and subsequent preprosthetic principles of care is crucial to successful management of an individual who has just sustained traumatic limb loss. Prosthetic. poor comfort of the prosthesis. 4. Treatment goals of postoperative care can be addressed by any member of the rehabilitation team. edition 2. Explore the patient's and family's feelings about a change in body image. and Rehabilitation Principles Adult Upper Limb Prosthetic Training Diane Atkins. You can help expand the O&P Virtual Library with a tax-deductible contribution. Control incisional and phantom pain. Prosthetic. coordinated movements of the hand. and aesthetic appearance can only be compensated for to a limited extent by three types of prostheses that are currently available.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 11 Chapter 11 . Obtain adequate financial sponsorship for the prosthesis and training.org/alp/chap11-01. lack of sufficient training or skill in using the prosthesis. Reproduced with permission from Bowker HK. Maintain joint range of motion. which may include the physician. ©American Academy or Orthopedic Surgeons. the three prosthetic options include (1) a passive cosmetic arm and hand. This phase of care is one where the patient has little control over what is happening and must depend upon the health care team to provide the best treatment possible. body-powered prosthesis. As outlined in previous chapters. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Click for more information about this text. and prosthetic training principles. and Rehabilitation Principles. Prosthetic.Atlas of Limb Prosthetics: Surgical. O. 1992. tactile sensation.T. 2. It is felt that successful outcomes in rehabilitation for the unilateral and bilateral amputee can be attributed to the following reasons: Early post-traumatic intervention Experienced team approach Patient-directed prosthetic training Patient education Patient monitoring and follow-up The focus of this chapter is to stress the importance of postoperative. The program should be closely supervised and include active and ac-tive-assistive joint range of motion. Often the patient and his family are not ready to hear about or see prostheses until the acute postoperative phase has passed. These exercises can be started within 5 to 7 days following surgery. as well as offer encouragement and realistic optimism with respect to his future generally. Financial Sponsorship It is important to identify and explore third-party sponsorship at this time. Often there is a period of depersonalization that may occur during this time when other limbs and body systems may be involved following severe traumatic injury.asp[21/03/2013 21:54:40] .oandplibrary. Phantom limb pain may also be controlled by isometric exercise. All members of the team should respect the individual's dignity. The difference between a phantom limb and phantom pain should be clearly explained to the amputee. Transcutaneous electrical nerve stimulation (TENS) has also been used to decrease incisional and phantom pain in the amputated limb. The role of the nurse cannot be overemphasized since she is the member of the team having continuous contact with the patient during this stage of healing. Explore the Feelings of the Patient and Family The emotional impact of limb loss on the patient and his family is overwhelming. Residual wrist extensors and flexors as well as residual biceps and triceps are the muscles of choice to use in isometric exercise in transradial and transhumeral amputees. This modality can be used alone or in conjunction with oral analgesics. Gentle isometric contractions can begin on the fifth postoperative day. This can begin as early as the second postoperative day. The nurse will need to be active in the patient's rehabilitation program so that those activities taught to the patient by the occupational and physical therapists may be carried over successfully to the nursing unit situation. Full flexion and extension at the elbow combined with maintaining maximum pronation and supination of the forearm cannot be overemphasized. It is premature to discuss prosthetic component options at this time. An active exercise program should be initiated by the physical or occupational therapist. http://www. This is necessary for the first 3 to 4 postoperative days. respectively. and isotonic contractions can be encouraged 7 to 10 days postoperatively. and phantom pain is differentiated by the sensation of pain in the phantom limb. Sponsorship must be sought early.org/alp/chap11-01.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Promote Wound Healing Wound healing is generally monitored by the surgeon who performed the amputation and by the nurse. Additionally. Active exercise practiced several times daily can begin shortly thereafter and should be thoroughly reviewed with the patient. support the patient and family throughout the grief process. These motions are crucial for terminal device placement and subsequent function. Reassurance and support are vitally necessary not only at this time but throughout the rehabilitation process. scapulohumeral mobility must be maintained and strengthened. Maintain Joint Range of Motion Maintaining adequate range of motion in all joints of the upper limb is critical. This is particularly true in the burn patient. A phantom limb is the feeling or sensation that the limb is still present. These exercises should be performed every other hour for 10 to 20 repetitions. Control Incisional and Phantom Pain Acute incisional pain is generally managed by narcotic agents given intravenously or intramuscularly. and these devices must be adequately described to the payer so that a comprehensive rehabilitation program can be realistically pursued. Specialized prostheses are often costly. Full range of motion is frequently lost at the glenohumeral and elbow joints. Significant success in decreasing phantom pain has been achieved by using amitriptyline (Elavil) at doses of 50 to 150 mg daily at bedtime. Elavil is involved in serotonin production and is believed to modify pain perception. constant touch pressure. The elastic bandage should be worn all day and all night except when bathing. 8. Nursing is an important adjunct. The occupational therapist is the primary person who will be managing and monitoring this program for the upper-limb amputee. The wrap should be reapplied every few hours or more frequently if it slips or bunches. family.oandplibrary.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library PREPROSTHETIC THERAPY PROGRAM From the time the sutures are removed to the time the prosthetic prescription is being discussed there are many goals that are important to address. Washers and dryers decrease their longevity and ruin their elasticity. A figure-of-8 wrap is one that applies more pressure distally than proximally. Residual Limb Shrinkage and Shaping Shrinking and shaping of the residual limb is usually accomplished by compression from an elastic bandage. Healing has essentially occurred by the 21st postoperative day and should allow a vigorous program for prosthetic preparation. 3. 9.). The wrapping process begins with the end of the bandage placed diagonally at the distal end of the residual limb.asp[21/03/2013 21:54:40] . Maintenance of Joint Range of Motion When establishing an effective treatment program. scapular. 6. 7. He is aware of his tolerance and can become more "in touch" with his body by practicing this regularly. a compression bandage is generally preferred because it affords better monitoring of skin healing and points of pressure. 2. however. Residual limb shrinkage and shaping Residual limb desensitization Maintenance of normal joint range of motion Increasing muscle strength Instruction in proper hygiene of the limb Maximizing independence Myoelectric site testing (if myoelectric components are prescribed) Orientation to prosthetic options Exploration of patient goals regarding the future This phase generally occurs 2 to 3 weeks after surgery. 5. and nursing staff. Desensitization can also be accomplished by vibration. Bandages should not be twisted. with each pattern overlapping the previous one by approximately two thirds the width of the bandage ( Fig 11-1. and all shifts of the nursing staff should be thoroughly familiar with each of these areas. The wrap should encircle the limb from behind and wrap diagonally upward to cross over the end of the bandage. aggressive massage will prevent adhesions from occurring and provide additional sensory input. elastic bandaging should never be done in a circumferential manner. intermittent positive-pressure compression. The bandage is then secured with tape or special clasps.). It can be accomplished with gentle massage and tapping techniques ( Fig 11-2. As stated earlier. No elastic bandage should be used for more than 48 hours without being washed with mild soap and lukewarm water and thoroughly rinsed with clean water. The goals of the preprosthetic program are as follows: 1. or a tubular elastic bandage. but laid flat to dry. however. It should be explained that this will improve the patient's tolerance to the pressure that will be placed on the residual limb by the prosthetic socket. When healing has occurred. 4. or the input of various textures applied to the sensitive areas of the limb. it is important that the proper technique be taught to the patient. If an elastic bandage is used. glenohumeral. the maintenance of joint range of motion is essential. Residual Limb Desensitization An equally important yet often overlooked factor is desensitization of the residual limb. A preparatory prosthesis might also be applied early in the shaping process.org/alp/chap11-01. elbow. This figure-of-8 process should continue. The patient should be encouraged to do these techniques himself. and forearm range of motions are crucial to maintain in order to aid in the prosthetic control motions and to maximize the http://www. Active resistance applied by the therapist or cuff weights attached to the limb can be utilized. The bilateral acquired upper-limb amputation presents a unique challenge to the amputee team. The prosthetic prescription is based on a number of criteria that should be comprehensively addressed and recorded. An overview of the advantages and disadvantages of body-powered and electric components should be clearly explained. The myotester results should be discussed with a prosthe-tist. or pencil. DETERMINING THE PROSTHETIC PRESCRIPTION The discussion of the prosthetic prescription is ideally accomplished in the presence of the patient. toothbrush. and prosthetist should jointly determine the best positioning for the electrodes and discuss the issues of prosthetic socket design. support. particularly for the proximal levels of amputation. It is important to express reassurance. but being able to touch the device and understand how it operates is extremely helpful and informative for the amputee. Photographs or slides may be reasonable substitutions. A careful inventory of the patient's life-style. These criteria frequently include the following: http://www. Independence can be significantly enhanced by a simple device such as a universal cuff utilized with an adapted utensil. educational background. therapist. prosthetist. The occupational therapist. Instruction in change of dominance and teaching one-handed activities are often indicated when working with the unilateral amputee. and medical providers. Maximizing Independence Another important element in the preprosthetic phase of care is maximizing functional independence. physician. It should be rinsed thoroughly and patted dry with a towel. The amputee patient is an integral part of the decision-making process of this prosthetic prescription. family. this amputee is essentially dependent in all activities of daily living.asp[21/03/2013 21:54:40] . this is an appropriate time to utilize a myotester to gauge the electric potential generated by various muscles. physician. and third-party payer. and realistic optimism to these individuals during this time. The unique differences between body-powered and electric components should be comprehensively described. Instruction in Proper Hygiene of the Limb Education in proper hygiene and care of the residual limb is equally important at this time. Many amputees who have sustained work-related injuries have the unique advantage of having a rehabilitation insurance nurse or case manager assigned to their care. pen. insurance carrier. This provides additional sensory input into the residual limb as well as allows the patient to become more familiar with the changes in his body. Orientation to Prosthetic Options This is an important time to orient the amputee patient and his family to prosthetic options available to him. Involving the patient in decisions that affect his own health care will help to restore a sense of control over his life.org/alp/chap11-01. and future goals should be explored and discussed. The limb should be washed daily with mild soap and warm water. and this results in very real anxiety and frustration. support system. Increasing Muscle Strength Increasing upper-limb muscle strength can be accomplished in conjunction with the range-ofmotion program.oandplibrary. and examples of each should be shown and demonstrated if possible.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library functional potential of the prosthesis. Before receiving his prostheses. This individual is a valuable liaison between the patient. It is important to include these insurance representatives in the discussion of the prosthetic prescription because they have a direct influence on the financial approval of the prosthesis and the rehabilitation treatment plan. Myoelectric Site Testing If a myoelectric prosthesis is being considered. 4. he will be dissatisfied with the ultimate functioning of the prosthesis and may reject it altogether. If he "believes in" and understands the functional potential of the prosthesis. 3. success can be more realistically achieved. particularly if the patient lives out of town so that transportation can be arranged for prosthetic fitting and training.org/alp/chap11-01. 10. ADULT UPPER-LIMB PROSTHETIC TRAINING Before initiating a program of upper-limb prosthetic training. Several steps are required from the time the prosthesis is prescribed to the time it is delivered to the patient. http://www. Common reactions. It must be remembered that one amputee's experience does not directly parallel another's. Positive achievements should be stressed. These encounters should be followed by an opportunity for the amputee to discuss his feelings and reactions with an experienced psychosocial professional in amputee rehabilitation. If the individual has an unrealistic expectation about the usefulness of the prosthesis as a replacement arm. 7. This is also an appropriate time to discuss the options of outpatient vs.asp[21/03/2013 21:54:40] . 12. 2. Recommended and approximate training time schedules are as follows: Transradial. 11. These can be more closely monitored on an inpatient basis. all unilateral upper-limb amputee patients can be managed on an outpatient basis. then. with the family and patient becoming involved with the social worker or psychologist on the amputee team. one must realistically orient the patient to what the prosthesis can and cannot do. It is imperative. This is also an appropriate opportunity for the new amputee to meet others with similar levels of limb loss who have worn a prosthesis for a period of time. The bilateral upper-limb amputee has not only issues of functional independence to address but emotional issues as well. 8. Length of the residual limb Amount of soft-tissue coverage Presence of an adherent scar Movement of proximal joints Muscle strength in the residual limb Muscle strength in the opposite limb Adequate ability to learn and retain new information Adequate sensation in the residual limb Desire for function Desire for cosmesis Patient attitude and motivation Vocational interests Avocational interests Third-party payer considerations Family preferences Fabrication and Training Time The steps involved in fabricating the prosthesis should also be explained at this time. On the other hand. It is strongly recommended that all bilateral upper-limb amputees be trained on an inpatient basis. the following issues need to be discussed and documented if they have not already been accomplished. 6. if the expectations of the amputee are more realistic at the beginning of training. 15. 13. 12 hours Bilateral transhumeral. however. then the ultimate acceptance will be based upon the ability of the prosthesis to improve the individual's performance. 5. 20 hours Ideally this training should be managed on a daily basis for 1 to 2 hours a day. 14.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library 1. inpatient hospitalizations. 5 hours Transhumeral/shoulder disarticulation. Generally. that the therapist be honest and positive about the function of the prosthesis.oandplibrary. frustrations. This process should be thoroughly explained to the patient and third-party payer. 9. Initial Assessment During the therapist's first encounter with the amputee patient in therapy. and anxieties can be shared. 10 hours Bilateral transradial. he will probably be carrying the prosthesis in a bag or sack. This is particularly important for the amputee with insensate areas and adherent scar tissue.oandplibrary. It is important to understand this awkwardness and reluctance in putting it on with others "watching. the "coat" method may also be used ( Fig 11-3. Independence in Donning and Doffing the Prosthesis It is important that independence be established early in donning and doffing the prosthesis by the "pullover sweater" method. It is perceived as "artificial looking. Bilateral amputees most often use the "sweater" method. the upper-limb amputee should be wearing his prosthesis all day." heavy. uncomfortable. and care of the residual limb and prosthesis.). orientation to a wearing schedule.org/alp/chap11-01. how it looks and operates. terminal device.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Etiology and onset Age Dominance Other medical problems Level of independence Range of motion of all joints of the residual limb Muscle strength of the remaining musculature Shape and skin integrity of the residual limb Status of the opposite upper limb Phantom pain or residual limb pain Previous rehabilitation experience Revisions Viable muscle sites (for myoelectric control) Previous information regarding prostheses Background education and vocational goals Goals and expectations regarding the prosthesis Home environment and family support Although this list may appear unreasonably long and too lengthy to document." it is important that the patient learn to identify the major components of the prosthesis appropriately. acceptance of the limitations of the prosthesis are more readily achieved following delivery. If the patient is appropriately oriented to the realities of the prosthesis. wrist unit. If redness persists for more than 20 minutes after the prosthesis is removed. the patient should return to the prosthetist for socket modifications. cable. As an alternative. elbow unit or elbow hinge. The nature of patient-therapist rapport and subsequent success of therapy will be greatly enhanced if this information is gathered before therapy actually begins.asp[21/03/2013 21:54:40] . and awkward to operate. the finished prosthesis is often a disappointment for the patient. the assessment will make a significant difference in the therapist's awareness of the individual with whom he is working. Initial wearing periods should be no longer than 15 to 30 minutes. and hook or hand will suffice at this time. Unfortunately. Prosthetic Wearing Schedule Development of a wearing schedule is an extremely important aspect of this first visit. wearing periods may be increased in 30-minute increments three times a day. If no skin problems are present. During the first couple of visits the following goals should be addressed: orientation to prosthetic component terminology. Orientation to Prosthetic Component Terminology In view of the fact that the prosthesis has not become the patient's "arm. http://www. Initial Visit When the upper-limb amputee visits the occupational therapist for the first time. with frequent examination of the skin for excess pressure or poor socket fit. The period of time from casting until final fitting of the prosthesis is characterized by eager anticipation and hope that the artificial arm will enable the individual to function as before the amputation. nondistract-ing room with a mirror plus an atmosphere of acceptance and understanding is preferable." A quiet. By the end of a week. Any orientation to identifying such basic aspects as the figure-of-8 harness. independence in donning and doffing the prosthesis. It is advisable to have the amputee practice this motion by cupping one's hand under the residual limb and instructing the patient to press down into the palm. shoulder disarticulation. followed by the sock being thoroughly rinsed.-Spreading the shoulder blades apart in combination with humeral flexion. The socket can be left to dry through the night or dried thoroughly with a towel inside if one plans to continue to wear the prosthesis immediately. 1. Scapular abduction and humeral flexion are the basic motions to review with the transradial amputee. or alone. This is best done before the prosthesis is actually applied. Chest expansion. which may irritate the skin. The amputee should be encouraged to inspect his skin daily. the skin of the residual limb is subject to irritation and sometimes to further injury and infection. will provide tension on the figure-of-8 harness in order to open the terminal device. Allow the sock to dry slowly to avoid shrinkage.org/alp/chap11-01. internal-locking elbow of the trans-humeral prosthesis. Elbow flexion/extension. It should be rinsed thoroughly with clean water. Shoulder depression. If soap is left to dry on the skin. 5. it may be preferred to the figure-of-8 harness.oandplibrary. and moisturizers should not be applied to the limb unless specific orders are given by the physician or therapist. 3. 6. The socket should be cleaned often. creams. Harnessing this motion with a cross-chest strap is determined by the prosthetic design. The residual limb should be bathed daily. If possible. This will enable the amputee to position the terminal device where he chooses without manually preposition-ing the wrist unit. Lotions. Body Control Motions Prior to allowing the upper-limb amputee to practice prosthetic controls training. and abduction. Chest expansion may be utilized in a variety of ways for the transhum-eral.This is the combined movement necessary to operate the body-powered. This range will enable him to reach many areas of his body without undue strain or special modifications to the prosthesis.asp[21/03/2013 21:54:40] . and then relaxing slowly. 2. If stump socks are worn. some degree of forearm pronation and supination is maintained. It will probably be necessary to adjust the prosthesis. several motions need to be reviewed. before the perspiration dries on it. Humeral flexion. Avoid brisk rubbing. If skin disorders develop. A minor disorder may become disabling if incorrect treatment is used. expanding the chest as much as possible. Scapular abduction. the physician should be called promptly. Forearm pronation/supination. extension.-This motion should be practiced by deeply inhaling. Appropriate care of the skin is therefore a vital part of rehabilitation. -The amputee is instructed to raise his residual limb forward to shoulder level and to push his arm forward while sliding the shoulder blades apart as far as possible. Strong disinfectants such as iodine should never be used on the skin of the stump. it is equally important to maintain as much forearm pronation and supination as possible. In warm weather the socket may require cleaning at least once or twice daily. It is advisable to not wash the residual limb in the morning unless a stump sock is worn. The socket should be washed with warm water and mild soap. The limb should be washed with mild soap and lukewarm water. It should be thoroughly wiped out inside with a cloth dampened in clean warm water. the sock should be washed as soon as it is taken off. 4. Damp skin may swell and stick to the prosthesis and may be irritated by rubbing. in some instances of extensive axillary scarring. preferably in the evening. or forequarter amputee. -It is critical to instruct the transradial amputee to maintain full elbow range of motion. Mild soap and warm water should be used.. several changes may be necessary during warm weather owing to perspiration. and therefore the prosthetist is generally involved at this time as well.-In the long transradial amputee. This will prolong the life of the stump socks. This motion applies pressure on the cable and allows the terminal device to open. If the amputee has retained more than 50% of his forearm. http://www. particularly if the individual perspires heavily.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Care of the Residual Limb and Prosthesis Following amputation. This will simulate the motion required to lock and unlock the elbow in the individual with transhum-eral amputation. After rinsing. the skin should be dried thoroughly by using patting motions. it may be irritating. The therapist is encouraged to communicate openly with the prosthetist on a frequent basis not only initially but whenever concerns regarding fit or operation arise. 4. biscapular abduction and/or humeral flexion causes the conventional terminal device to open. Close attention must be paid to the individual's awkward or compensatory body motions when he approaches an object. It is often necessary to remind him to maintain an upright posture and to avoid extraneous body movements. http://www. As described previously. This pattern not only locks but unlocks the elbow in an audible "twoclick cycle. The pattern of "down.). and out" is often stated to the amputee in an effort for him to repeat the shoulder depression.). 5. it is important to ensure that the prosthesis fits comfortably and that the components function in a satisfactory manner. a force against an object in the environment or between the individual's knees is necessary to accomplish this positioning. Ideally this is accomplished with the occupational therapist and prosthetist together. in the proper position. one is able to position and lock the elbow where desired. By depressing this button with the chin. and abduction pattern. 2. 3. for the bilateral amputee. before one is able to operate the terminal device.org/alp/chap11-01. the mechanism to lock and unlock the elbow is often a nudge control "button" attached to the thoracic shell. Often the amputee will "adjust" his body rather than repositioning the elbow and wrist unit positions. Elbow extension is accomplished by gravity if the elbow unit is unlocked. In all proximal levels of upper-limb loss.asp[21/03/2013 21:54:40] . The friction shoulder joint is manually adjusted with the sound hand or by applying pressure against an object or the arm of a chair. Prepositioning involves both manual and active controls to place the prosthesis in the most optimal position for a specific activity. 2.oandplibrary. Controls Practice A form board is frequently utilized to perfect prepo-sitioning as well as tension control of the terminal device ( Fig 11-5. In the bilateral upper-limb amputee. Elbow lock/unlock is perhaps one of the most difficult tasks to learn in the operation of a transhumeral prosthesis. Prosthetic Controls Training Manual controls are important to review after the prosthesis is applied. back. nondistracting room where one can hear the clicks without difficulty. It is helpful to instruct the patient to "think" how his own arm would have been positioned to approach the object. This pattern may need to be exaggerated at first. Before approaching terminal device operations. 3. It is important to clearly explain that the elbow must be locked first. Positioning the terminal device in the wrist unit is accomplished by manual rotation with the sound hand. A mirror can be effective in assisting the amputee to see the way his body is positioned. this can be manually controlled by applying pressure on the button or. The upper-limb amputee incorporates the body-control motions he learned previously while wearing the prosthesis. extension. It is essential that the harness be adjusted properly before initiating these exercises: 1. body-powered elbow flexion is facilitated by a forearm lift assist that counterbalances the weight of the forearm. while relaxing allows it to close ( Fig 11-4. by applying pressure against a stationary object. Active controls are equally important to review prior to functional training. A formal prosthetic checkout form for this purpose is available from Northwestern University. Rotation at the elbow turntable is manually adjusted or controlled by leaning the prosthesis against an object. it is important for the amputee to practice locking and unlocking the elbow in several positions. One control should be taught at a time and then combined with others: 1. If the prosthesis has a wrist flexion unit." Practicing this task should occur in a quiet. but soon it will be barely observable. 4.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Prosthetic Evaluation Before beginning functional training. In the shoulder disarticulation and forequarter amputee. density. http://www. may help in reinforcing this pattern. grasp. Functional Use Training Functional use training is the most difficult and prolonged stage of the prosthetic training process. This applies to all amputees fitted with body-powered or electric components. to fit the unilateral amputee within 1 to 2 months of the amputation. Realistic situations should be pursued so that the individual will automatically use the prosthesis when he encounters the same activity in his daily routine. 7. 4. The knife is held by the sound hand.oandplibrary. Cutting Food It is easiest to cut food by holding the fork in the hook. (2) the comprehensiveness and quality of the tasks and activities practiced. such as a rule. if possible. Passing an object back and forth. prior to approaching these tasks. Flat objects can be moved to the edge of the table and then grasped with the terminal device in a horizontal position. which can be added as tolerated. These individuals definitely show a greater propensity for wearing and successfully using their prostheses. 6. Winston M. 1958 (Santschi W. Prehension force is generally controlled by rubber bands. the experience and enthusiasm of the occupational therapist. weight. move. Prehension control can be practiced with a sponge or paper cup. The prosthetic terminal device is most useful for gross prehension activities and to hold and stabilize objects. ed. The amputee is instructed to maintain constant tension of the terminal device control cable so as not to crush the object being held. Springs may be used as an alternative. The individua'ls acceptance and usage of the prosthesis is dependent upon (1) the motivation of the patient. most difficulties in use are a result of improper positioning. and release. and release objects differing in shape." Unilateral patterns of independence occur quickly in the amputee who has lost an arm or hand. The training experience is most effective if the same therapist remains with the patient throughout the entire process. Cutting food Using scissors Dressing Opening a jar or bottle Washing dishes Hammering a nail and using tools Driving a car The importance of prepositioning. cannot be overemphasized. It is therefore essential. 2. To learn to separate the controls motion of two prostheses is a complex and coordinated motor process that may need to be practiced frequently. with the hook fingers grasping the flat surface of the fork handle and the upper handle of the fork resting on the dorsal surface of the thumb of the hook.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library The five motion elements that are primarily used in hand manipulation are reach. while the sound limb performs fine motor prehension activities. 2. The amputee should be instructed to orient the components of the prosthesis in space to a position that resembles that of a normal limb engaged in the same task. 5. It is extremely important to reinforce to the unilateral amputee that his prosthesis will play a nondomi-nant functional role.org/alp/chap11-01. 3. eds. A form board can be used in training to orient the individual to approach.). and (3). As a rule. Controls training for the bilateral upper-limb amputee is an aspect of therapy that may require a period of time to perfect. The sound hand will always be dominant for all activities performed. position. A valuable and comprehensive guide in orienting the therapist to the specifics of training the amputee is the Manual of Upper Extremity Prosthetics. Approach to an object should be such that the stationary hook finger makes contact with the object and the movable finger actually "grasps" it. It is appropriate to practice activities of daily living that are useful and purposeful. The therapist must be realistic and convince the patient to view the prosthesis as a "helper. and size. grasp. This is a publication of the Engineering Artificial Limbs Research Project at the University of California at Los Angeles. of critical importance. It is unreasonable to expect the prosthesis to assume any more than 30% of the total function of the task in unilateral upper-limb activities.asp[21/03/2013 21:54:40] . Examples include the following: 1. The terminal device can "pinch" the fabric at the bottom of the zipper to facilitate zipping with the sound hand.). performance can be improved by using the prosthesis to assist the sound arm. All tension should be removed from the cable to ensure maximum grasp on the container. The hook should be pronated to 90 degrees so that the nail is perpendicular to the wood. (TRS. Opening a Jar or Bottle When opening a jar or bottle. An alternative design in terminal devices is illustrated by the voluntary-closing Grip II ( Fig 1110. A driving ring is available from most prosthetic suppliers. The sound limb always becomes the dominant and active limb ( Fig 11-9. When drying dishes. When correctly positioned. To avoid "flopping.org/alp/chap11-01. CO 80803). Boulder. the tip of the nail should just contact the wood. or special attachment of the no. http://www. the cuff can be buttoned rapidly and reliably. Driving a Car Driving a car is an important goal for the individual who has lost an arm. A list of activities and a rating guide designed by Northwestern University are helpful adjuncts to the therapy plan in determining which activities are important for the unilateral amputee to accomplish ( Fig 11-11. 2860 Pennsylvania Ave.asp[21/03/2013 21:54:40] . the sound hand holds the dish while the terminal device grasps the towel. Periodic cleaning and oiling of the stud threads and bearings may be necessary for the amputee who engages in frequent dishwashing activities. ). and the sound hand unscrews the lid.). the amputee may need to be reminded that the prosthesis and terminal device are merely "functional assists" to aid in stabilization. the material to be cut should be placed in the terminal device. the middle of the container is grasped by the terminal device. Buttonhooks are particularly helpful for the transhum-eral and shoulder disarticulation amputee.). the head of a large bolt may be secured in the hook terminal device while the wrench is held in the sound hand to tighten or loosen the bolt. to hold and manipulate objects by using body power to close rather than to open the hook. With the proper preposi-tioning." the area to be cut should be as close to the area grasped as possible. This device is specifically designed by Therapeutic Recreation Systems. The scissors are held by the sound hand.oandplibrary. 3 or no. Again. ). or button. snap. 7 Hosmer-Dorrance work hook. As demonstrated ( Fig 11-8. Inc. If the prosthesis has sufficient function. A buttonhook may be used to assist in buttoning cuffs on the sound side ( Fig 11-7. the dish should be held in the sound hand. rubber band guard.). a dishcloth or sponge is held and manipulated by the terminal device. Hammering a Nail and Using Tools Hammering nails is accomplished by holding the nail in the hook fingers. Washing Dishes To achieve the greatest security of grasp while washing dishes.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Using Scissors When using scissors. Submerging the hook in water should be avoided because detergents dissolve the lubricating oils in the hook and wrist units. Depending on the individuals preference. The fingers of the hook are secure in the ring for turning but can easily slip out in emergencies. The actual turning of the steering wheel should be done by the sound limb. Dressing Dressing activities such as fastening trousers are accomplished by the terminal device holding the waistband or belt loop while the sound hand tucks in the shirt and fastens the waist hook. The material should be repositioned as cutting angles are changed ( Fig 11-6. 5. shoe polish. Never reach for a moving object with the hook. 10. 1. tobacco tar. incorporating well in the body http://www. 100%-Wearing all day. An example of how effective prosthetic hooks can be for drafting is illustrated in Fig 11-12. When a rubber band wears out from use. 8. 3. and other petroleum products. and care instructions should be reviewed with the amputee and his family. The following substances cannot be removed unless immediately washed with water or alcohol: ball point ink. When an amputee washes dishes frequently. Rubber band applicators are obtained from the prosthetist. and lipstick. however. and an explanation of what to expect during this visit is helpful in making the transition from the rehabilitation center to the home environment. Follow-Up Issues Following discharge from the therapy program. The neoprene is resistant to gasoline.org/alp/chap11-01. Never use the terminal device as a hammer. If the therapist can do an on-the-job site evaluation. . The services of the prosthetist are available for consultation as well as for any repairs and modifications to the prosthesis that may be required. 11. cut it off with scissors. Take the prosthesis to the prosthetist as soon as damage occurs. It should. 9. and patterns of prosthetic use and emotional well-being must be carefully re-evaluated at each visit. be protected from hot objects. or injury. the amputee is regularly monitored and reviewed in an outpatient clinic by the rehabilitation team. Care and Maintenance of the Prosthesis The following points are important to review with the amputee who has been fitted with a body-powered upper-limb prosthesis. This is a crucial time for the upper-limb amputee. This is an appropriate time to discuss the amputee's present status and successes as well as problems that may have been encountered. Unfortunately. Although not everyone can return to the exact job held prior to the injury. A follow-up appointment should be arranged. carbon paper. The neoprene lining of the hook may need to be periodically relined for a firmer grip. Each rubber band is equivalent to approximately 1 lb of pinch force. the stud threads and bearings of the hook should be cleaned and oiled regularly. a review of job responsibilities and expectations can be explored with the therapist. 6. The cosmetic glove of a mechanical or myoelectric hand is easily stained.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Vocational Activities Discussing vocational needs and expectations with the amputee is very important. In an attempt to define prosthetic function in a quantitative manner. the author has designed the following use rating scale. functional use. using well in bilateral tasks. oil. mustard/ketchup. or lever. 12. The harness should be washed when soiled because perspiration stains permanently mark the straps. Do not iron the Velcro closures on straps. A household cleaner with ammonia works well. colored lacquers. egg yolk. The prosthesis should be hung up by the harness rather than by the cable or cable strap. brightly dyed fabric.asp[21/03/2013 21:54:40] . 2. 4. grease. it would be a valuable addition to the amputee's comprehensive rehabilitation. Several of these have been noted in the guide "Helpful Hints for the Upper Extremity Amputee" from the Occupational Therapy Department at the University of Florida. fresh newsprint. It may be possible to break down the tasks of a job into a step-by-step process that can be practiced and reinforced in therapy. Home Instructions At the conclusion of training. a home program of wearing. wedge. The elbow lock should be cleaned frequently and kept free from abrasive materials.oandplibrary. The cable should be examined frequently for cut or worn areas. This discussion should occur later in the training continuum when the individual begins to acknowledge and accept his disability. Detergents should be avoided since they tend to dissolve the lubricating oils in the hook and wrist unit mechanism. this is an area that is often overlooked or given only brief attention during the rehabilitation process. 7. Specific instructions regarding which team member to contact when a problem arises should also be provided. and replace it with a new band. indeed.Controls Training. or of therapy. Prosthetic-Orthotic Center. and eventually an annual visit. using in grossand fine-motor tasks. For the more complex amputee with specific skin. Maintain a regular periodic follow-up with rehabilitation professionals. Re-enter the family and community environment. It is the responsibility of all rehabilitation professionals involved to create a conducive environment that will not only encourage this process to occur but enhance it as well. Motivation and the desire of the patient to be independent are perhaps the most important ingredients to cultivate and reinforce. 1958. bone.oandplibrary.e. University of California. 50%-Wearing all day (primarily for cosmetic reasons). J Hillis Miller Health Center. Ill. The first follow-up visit is scheduled approximately 4 weeks after discharge from training. Colorado.. 4. Rehabilitation should not be considered complete until a stable. University of Florida. as well as additional information.g. i. Springer Publishing Co Inc. The amputee's potential is limitless. 3. 2. a long one.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library scheme. the following goals are equally important to address during the follow-up visit. Resume avocational interests. 6. is published in two chapters entitled "Postoperative and Preprosthetic Therapy Programs" and "Adult Upper Limb Prosthetic Training" in the following: Atkins DJ. Boulder. Occupational Therapy Department: Helpful Hints for the Upper Extremity Amputee. Surgeons and Therapists. 3 months. CONCLUSION The complete rehabilitation process for an amputee is. independent life-style has been achieved and the individual's social and occupational niches have been re-established. incorporating in gross activities (used as a leaning surface. pp 233A-238C. Follow-up visits are then scheduled at wider intervals. http://www. 1. of medical care. 1986. Maximize prosthetic function. 1979. Decrease assistive devices. New York. Santschi W (ed): Manual of Upper Extremity Prosthetics. Meier RH: Comprehensive Management of the Upper Limb Amputee. desk/paper tasks). 1991. 5. All these areas ideally work in close harmony with one another. e. This individual is choosing to be essentially unilaterally independent. Gainesville. 7. pp 241-265. 75%-Wearing all day.asp[21/03/2013 21:54:40] . In addition to quantifying prosthetic function and wearing patterns. Maintain prosthetic components.. BIBLIOGRAPHY Northwestern University Medical School: Lower and Upper Limb Prosthetics for Physicians. Acknowledgment The majority of this text. Wearing patterns have been quantified as follows: Full-12 hours or more per day Moderate-6 to 12 hours per day Minimal-0 to 6 hours per day None-0 hours per day. Evanston. It is not solely dependent upon the quality of the prosthesis. 0%-Not wearing or using the prosthesis. or pain problems. 1989. Resume previous vocation or explore new vocational options. Los Angeles.org/alp/chap11-01. more frequent return visits may be necessary. Early fitting is crucial to encourage successful functional outcomes for all upper-limb amputees. Therapeutic Recreation Systems Inc: TRS Product Catalogue. 6 months. oandplibrary. The National Easter Seal Society. Meier R: Amputations and prosthetic fitting. American Orthotics and Prosthetics Association.11: Adult Upper Limb Prosthetic Training | O&P Virtual Library Veterans Administration: A Guide for the Arm Amputee. p 9. 10:2. 8. Baltimore. Friz B: The nurse on the amputee clinic team. Williams & Wilkins. 3. Chapter 11 . 1961. 1984. Baltimore. Levy W. Contact Us | Contribute http://www. Veterans Administration.Atlas of Limb Prosthetics: Surgical. Nurs Outlook 1968. 10:27-34. Prosthetic. Williams & Wilkins. 1984. 1952. 1984. 6. Burrough B. DC. Brook J: Patterns of acceptance and rejection of upper limb prosthesis. Washington. Orthot Prosthet 1985. Hunter A: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prosthesis.asp[21/03/2013 21:54:40] . 39:40-47. in Fisher S (ed): Comprehensive Rehabilitation of Burns. p 280. Baltimore. in Fisher S (ed): Comprehensive Rehabilitation of Burns. Phys Disabil Spec Inter OT Newslet 1987. Barnes G: Hygienic Problems of the Amputee. 5. References: 1. 4. in Fisher S (ed): Comprehensive Rehabilitation of Burns. Heger H. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 11 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 7. Plainshed L. Washington. 1984. 2. Meier R: Amputations and prosthetic fitting. Wilke HH: Using Everything You've Got! Chicago.org/alp/chap11-01. 16:3336. pp 267-310. Millstein S. Prosthet Orthot Int 1986. Williams & Wilkins. Meier R: Amputations and prosthetic fitting. DC. Atkins D: The upper extremity prosthetic prescription: Conventional or electric components. pp 303-304. and motor vehicle trauma. Narakus' "law of seven seventies. James A. edition 2. Prosthetic. irradiation. the standard approach was surgical reconstruction by shoulder fusion. and finger tenodesis. These injuries may be divided into open penetrating trauma and closed injuries. and Rehabilitation Principles Special Considerations: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management John W. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. estimates the current demographics: 70% of traumatic brachial plexus injuries (BPIs) are due to motor vehicle accidents. Michael.asp[21/03/2013 21:54:46] ." based on experience with more than 1. Prosthetic.O. C. and Rehabilitation Principles.12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 12A Chapter 12A . Rosemont. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Because the brachial plexus is tethered by the clavicle and scalene muscles. 70% of those with supraclavicular lesions have at least one root avulsed. There will be no Tinel sign present. Traction on the brachial plexus occurs when the head and neck are moved in a lateral direction away from the shoulder. no one approach has enjoyed widespread success. ©American Academy or Orthopedic Surgeons. Following World War II. Most patients with BPI are males between 15 and 25 years of age. compression. Tl) avulsed. 70% have a supraclavicular lesion. 70% of the vehicle accidents involve motorcycles or bicycles. http://www. Based on a thorough physical examination. there is complete motor and sensory loss in the involved root. American Academy of Orthopedic Surgeons. 1992. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).000 patients over an 18-year span.Atlas of Limb Prosthetics: Surgical. Preganglionic injury indicates that avulsion of the nerve root has occurred proximal to the spinal ganglion. This division of injuries has both prognostic and therapeutic implications. In the 1960s. gunshot wounds. reprinted 2002. 70% of the cycle riders have associated multiple injuries. 70% of patients with lower-root avulsions experience persistent pain. or traction and compression combined.Ed. Tl or C8.oandplibrary. Postganglionic injuries occur distal to the spinal ganglia and have a more favorable prognosis than do preganglionic injuries both for spontaneous recovery as well as for surgical reconstruction. and there also will be denervation of the deep paraspinal muscles of the neck. Closed injuries produce the majority of cases and may be the result of traction. IL. BPI can be divided into preganglionic and postganglionic injuries. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. C8.org/alp/chap12-01. Prosthetic. Postganglionic injuries may be further subdivided into trunk and cord injuries. Click for more information about this text. transhumeral (above-elbow) amputation combined with shoulder Reproduced with permission from Bowker HK. BASIC CONCEPTS Brachial plexus lesions can result from a variety of causes including birth injuries. Treatment recommendations for complete lesions have varied widely over the past 50 years. Traction to the brachial plexus may also occur because of arm movement.P.. elbow bone block. as the arm is brought up and over the head. Compression injuries to the brachial plexus occur between the clavicle above and the first rib below. and frequently the patient will have a Horner's syndrome or a fracture of the transverse process of the adjacent cervical vertebra. Nunley M. 70% of patients with root avulsions have the lower roots (C7. forceful neck motion to the side frequently produces a traction injury to the upper brachial plexus (C5-6).D. It has been suggested that the increasing cost of gasoline results in a larger number of motorcycle riders while the proliferation of helmet laws increases the percentage who survive serious accidents with residual BPI. M. traction will occur within the lower brachial plexus (C8-T1). The fibrotic and denervated biceps muscle is excised and the gracilis muscle inserted in its place. Transfer of the triceps muscle to achieve elbow flexion. A Steindler (flexor-pronator) transfer alone in the case of a completely paralyzed shoulder and paralyzed biceps and brachialis is generally unsatisfactory. through an ipsilateral thoracotomy. After successful vascular anastomosis of the artery and vein. These observations remain valid today. In these patients. If the interval from BPI to reconstruction is delayed beyond 12 months. is frequently ineffective since the triceps is usually weak. Our best results have been where the neurotization is performed within 6 months of injury. and fifth intercostal nerves may be transferred subcutaneously into the axilla to be anastomosed to the musculocutaneous nerve ( Fig 12A-1. and vein. fourth. Postganglionic http://www. Our preference for reconstruction of the important function of elbow flexion is through neurotization with intercostal motor nerves. intercostal motor nerves to the third. An upper lesion in which only the C5 and C6 roots have been avulsed Typically. the results of surgical reconstruction with the intercostal nerves alone have been poor. which led to a dramatic reduction in successful outcomes regardless of the treatment approach. Through a lateral fourth-rib thoracotomy the motor portion of the third. Surgical reconstruction of preganglionic lesions will be discussed separately from postganglionic lesions. Preganglionic nerve root avulsions are not amenable to direct nerve repair. Under these circumstances. the classic pectoralis major and the latissimus dorsi transfer are not possible with a C5-6 avulsion since transfer while these muscles are paralyzed.org/alp/chap12-01.oandplibrary. patients with upper lesions and C5 and C6 root avulsion will have no shoulder function or elbow flexion. A completely flail arm with avulsion of all roots (C5-T1) 2.asp[21/03/2013 21:54:46] . There will be finger and wrist extension and hand function. this tendon transfer works best to the humeral shaft when the patient has some small amount of active elbow flexion present prior to the transfer. Attachment is made proximally with the gracilis origin to the coracoid process and distally to the biceps tendon. CURRENT CONCEPTS Surgery is indicated in nearly every BPI if spontaneous recovery is not expected within a reasonable time interval. Tendon transfer procedures are ineffective.).). and fifth ribs are used to successfully reinnervate the gracilis. Yeoman and Seddon also noted that the loss of gleno-humeral motion caused by BPI limited the effectiveness of body-powered devices and that manual laborers seemed to accept hook prostheses much more readily than did office workers with similar injuries. preganglionic BPI generally falls into one of three categories: 1.). The gracilis is harvested on its neurovascular pedicle with the obturator nerve. fourth. A lower avulsion of the C8-T1 roots 3. a free innervated gracilis muscle has been used quite successfully to replace the biceps ( Fig 12A-3.). however. NERVE SURGERY Preganglionic Depending on the number of roots that have been avulsed. Results of this procedure have been particularly gratifying in young patients ( Fig 12A-4. the goal of surgical reconstruction would be first to re-establish elbow flexion and then to address shoulder stability. Transposition of the medial epicondyle from the elbow with the common head of the flexor pronator muscle group is certainly a possibility. These poor results have usually been attributed to fibrosis of the motor end plates of the biceps muscle. Their retrospective study revealed no "good" results from the primitive surgical reconstruction of that era but predominantly "good" and "fair" outcomes when amputation plus shoulder fusion were performed within 24 months of injury.12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library fusion in slight abduction and flexion was advocated. artery. possible. The classic paper of Yeoman and Seddon noted the tendency to become "one-handed" within 2 years of injury. This yields an excellent reconstruction of elbow flexion if performed within 12 months of injury ( Fig 12A-2. However. The Steindler (flexor-pronator) transfer is only utilized when the patient has weak. useful motor function is obtained in a lesser percentage of patients primarily because of the long distance required for muscle reinner-vation to occur. If complete transection of the brachial plexus has occurred.oandplibrary. It has been our practice to follow patients conservatively for up to 3 months to watch for spontaneous motor recovery. By using the operating microscope. If spontaneous recovery occurs. Following nerve grafting for lower-trunk injury. the results of nerve grafting for upper-trunk lesions have been reasonable. tendon transfer of the trapezius and the levator scapulae has been tried. RECONSTRUCTIVE PROCEDURES Shoulder To be able to use the hand successfully. When the pectoralis major and latissimus dorsi are available for transfer. insufficient muscles remain for successful tendon transfer about the shoulder.12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library Postganglionic lesions frequently involve nerve injuries that are directly reconstructible. C5-6 type results in complete loss of voluntary shoulder and elbow control. In the majority of BPIs. nerve grafting should certainly be performed. deltoid.asp[21/03/2013 21:54:46] . if the biceps muscle has not recovered within 3 months. and biceps function have been lost.org/alp/chap12-01. restoration of active elbow flexion will allow the patient to have a transradial (below elbow) amputation. as a manual laborer suggests consideration of shoulder fusion. is certainly easier to use and better tolerated than a transhumeral prosthesis. Elbow flexion can be restored by intercostal neurotization or tendon transfer. The transradial prosthesis. the majority of these patients should benefit from shoulder fusion. then surgical exploration of the brachial plexus is indicated. it is possible to surgically separate intact fascicles from damaged fascicles at a very proximal level. sometimes with an elbow hinge that can be locked in several positions. If exploration reveals a lesion of the lower brachial plexus (C8 to Tl) that can be re-established with nerve grafting. superior results can be anticipated. Thus. The clinical picture is further complicated since many lesions are incomplete or have been surgically repaired. combined with voluntary elbow flexion. the patient's shoulder must be stable to allow positioning of the hand and forearm in space. Elbow Restoration of elbow flexion is of primary importance for all patients with BPI. However. a later tendon transfer may still be required. normal anatomic variations frequently result in clinical findings that differ from these theoretical types. however. although many can still extend the wrist by using finger extensors and the extensor carpi ulnaris. it should be emphasized that many patients are best served by leaving the shoulder in its flail condition if (1) they do not have pain from chronic traction and (2) their occupation makes a mobile flail shoulder more cosmetically acceptable than a fused shoulder. but present elbow flexors. In the upper BPI in which rotator cuff. Shoulder fusion works best when scapular control has been preserved through the function of Occupation is also a factor. careful assessment of residual function provides the best rationale for orthotic/prosthetic intervention. at which point a decision is made as to whether exploration or other reconstruction is indicated. Due to these limitations. In upper-plexus injuries. Exploration of postganglionic lesions will frequently show combined injuries in which a neuroma in continuity can be identified along with a complete nerve rupture. Although the shoulder will no longer interiorly subluxate. Several cases of successful orthotic design have been when a figure-of-8 harness and Bowden cable are used to provide body-powered reported elbow flexion. Thumb and index finger sensation will be impaired. active function in forward flexion and abduction is not generally possible. http://www. CLINICAL PATTERNS It is possible to summarize the functional deficits associated with particular lesions to simplify our understanding in this area. employment the serratus anterior and the trapezius muscles. Even if the patient has a flail and completely anesthetic arm. then the patient is monitored until the recovery plateaus. when combined with elbow motion. and fingers is lost as well. the force triceps function. However. In the presence of lesions that spare some elbow function. and rear trouser pocket. transhumeral amputation plus shoulder fusion is the most common recommendation in the literature. motion will be smoother if the levator scapulae and rhomboids are also functioning.oandplibrary. be utilized to operate an electric hand.). Surgical reconstruction is often of particular value to this group. some patients find the bodypowered components a good choice. Fig 12A-7. to allow the patient to reach all four major functional areas: face. It was necessary to utilize an outside locking joint normally intended for elbow disarticulation to stabilize the arm. Although complicated harnessing may make donning or doffing the prosthesis independently more difficult. Leffert suggests that trapezius and serratus anterior strength must be good (or preferably normal) in order to provide sufficient control. Fusion in this attitude permits scapular motion. limited body excursion With the widespread availability of externally powered components. or weak shoulder is widely accepted because it is both predictable and uncomplicated.asp[21/03/2013 21:54:46] .). generated along the control cable forced the elbow into full flexion. sensory loss is limited to the ring and small digits. This may also be necessary due to the original trauma or because of Prosthetic fitting is often complicated by residual weakness at the vascular complications. and intrinsics. Although finger flexors and intrinsics are paralyzed. Virtually all authors agree that this group has the lowest long-term success rate regardless of treatment. shoulder or elbow. When direct surgical reconstruction is not feasible. Loss of forearm innervation eliminates myoelectric control sites below the elbow. Whether this will result in increased long-term utilization remains to be documented. but chronic pain is frequently present as well.). an electric elbow. C7-S. but control sites will likely be on the chest or back ( Fig 12A-11. Those who sustain a concomitant traumatic transradial amputation should be able to operate a body-powered or switch-controlled terminal device. illustrates Rowe's recommendations. is now less problematic. Not only does the sensory loss in the hand increase. It is possible to add either static or spring-assisted wrist. perineum. although many authors have noted that a significant percentage Leffert's excellent text notes that arthrodesis of the flail discard their prostheses over time. but all active extension at the wrist. extensors. ).org/alp/chap12-01. It may also be possible to utilize myoelectric control for both elbow and hand function (and perhaps for wrist rotation as well). Not only is the arm totally flail and anesthetic. Unlocking the elbow mechanism is often inconsistent due to limited shoulder movement. The complete plexus type has the greatest loss. midline. fusion increases the leverage on the scapula from the weight of the arm plus prosthesis/orthosis.). C8. http://www. and finger extension to the previous orthosis ( Fig 12A-6. hand. which are not involved in pinch prehension. Advances in available prosthetic componentry have multiplied the options available for amputees with BPI and have increased the percentage who can actuate an active prosthesis. Rowe has noted that shoulder fusion attitudes originally intended for pediatric poliomyelitis survivors are not optimal for BPI. It can be argued that myoelectric control for the terminal device is preferable for precise grasp ( Fig 12A-10. Tl type enjoys the greatest percentage of orthotic success since motor rather than sensory loss is significant. C5-7 type adds radial palsy to the above picture. so a friction elbow or nudge control may be utilized ( Fig 12A-8. PROSTHETIC OPTIONS Transhumeral amputation plus shoulder fusion is still a viable approach to complete and untreatable plexus lesions. hand. transradial amputation is sometimes performed. Tl type has good shoulder and elbow function but loses finger flexors. ). or both Myoelectric control may also be feasible since even very weak muscles may generate sufficient signal to operate an externally powered device. Dralle reported a case with good shoulder control and elbow flexors but no When the amputee attempted to operate a body-powered hook. Microswitch control requires only a few millimeters of motion and can ( Fig 12A-9.12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library Shoulder subluxation is reportedly reduced by such an orthosis as well ( Fig 12A-5. Numerous harnessing variants have been developed to maximize the limited excursion remaining after BPI (See Chapter 6B). The presence of chronic pain complicates prosthetic-orthotic intervention. ) and an interdisciplinary team approach encouraged. It consists of a series of modules that can be interconnected to provide any degree of control desired ( Fig 12A-15. He also notes that fitting more than a year after injury is Robinson has suggested 6 to 8 weeks postinjury as the optimal time much less successful. ). this device has recently become available in the United States. i.oandplibrary. Leffert has reported good success with transradial fittings provided that the amputee could sense elbow position: It is all-important to attempt to preserve the elbow if there is proprioceptive feedback from the joint. a switch-operated electric hand and passive friction elbow joints were incorporated into a prosthesis that the patient reportedly used for many daily activities ( Fig 12A-13. muscle fatigue is frequently overlooked and virtually impossible to predict. Finally. and the prosthetist-orthotist is now faced with a confusing array of residual functions. which can significantly reduce enthusiasm to master an adaptive device. Muscle transfers sometimes result in powerful EMG signals suitable for myoelectric control in abberant anatomic locations. reported a case complicated by complete absence of elbow and shoulder function. ). (see Chapter 8B) is strongly As a result of all these factors. For the completely flail arm. a bodypowered prosthetic hook mounted adjacent to the patient's hand is used to provide grasp ( Fig 12A-16. It is frustrating for all involved when the BPI survivor can operate a sophisticated device flawlessly in therapy or the clinic but does not use it at home long-term because the small mass of functioning remnant muscle becomes totally fatigued after 1 or 2 hours of work. ). Even if the elbow is flail and the skin over the proposed stump is insensate. the majority will have become accustomed to functioning unilaterally. the patient has a prosthesis over his flail arm. special care must be taken to prevent the weight of http://www. In essence. "when the patient is beginning to accept the implications of his injury and yet has not become too one-handed. for orthotic intervention.. Incomplete lesions may require only the elbow or shoulder control modules. Wynn Parry has reported his experience with a series of over 200 cases and states that 70% continue to use a full-arm orthosis for work or hobby activities after 1 year. since the usefulness and degree of acceptance of the prosthesis will be much enhanced by it. It is therefore imperative that the patient be actively involved in all prescription decisions from the outset. In those cases where humeral traction worsens the pain." Once surgical reconstruction and spontaneous recovery are complete. The decision to choose amputation is always difficult. ).org/alp/chap12-01. the opportunity to meet another BPI amputee who has successfully mastered a prosthesis may be helpful. FLAIL ARM ORTHOSES In view of the substantial percentage of BPI amputees who reject prosthetic devices. Since BPI often has a lengthy recovery period. REHABILITATION Modern surgical advances have resulted in a much less predictable range of impairment following BPI. amputation and trial with a prosthesis can be considered. proprioception may be intact and a useful prosthetic fitting may be obtained without stump breakdown ( Fig 12A14. Originally developed in London during the early 1960s. beginning as soon as the patient has come to terms with the serious and potentially permanent nature of his injuries. Wynn Parry recommends utilization of a full-arm orthosis during the recovery period. thorough physical examination including manual and EMG muscle testing is required to assess rehabilitation potential. Nerve transfers further complicate the issue since anomalous neuroanatomy may preclude precise myoelectric control despite a grossly powerful signal. even heroic prosthetic/orthotic interventions are doomed to failure. without a motivated and cooperative individual.12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library difficulty in operating the lock was noted due to the triceps absence ( Fig 12A-12. it has been argued that orthotic restoration is an equally plausible alternative.e. Following surgical arthrodesis of the shoulder. Van Laere et al.asp[21/03/2013 21:54:46] . Psychological and social work consultation may be useful to help the patient discuss the altered body image and employment possibilities that will follow amputation. a diagnostic prosthesis A recommended ( Fig 12A-17. ). 12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library the device from displacing the arm downward at the shoulder. This is often a difficult task since conventional prosthetic harnessing supports axial loads via pressure on the ipsilateral trapezius or by encumbering the contralateral shoulder; neither approach is ideal in the presence of BPI. One alternative is to unweight the arm with a strut along the axillary midline attached to a waist belt or to a well-molded pelvic hemigirdle. Cool from the Netherlands recently reported a clever approach using the weight of the paralyzed forearm acting across a fulcrum at the radial head level to literally lever the humerus back into the glenoid fossa ( Fig 12A-18. ). Although over 1,600 patients have been fitted in Europe, this approach is just now reaching North America. In general, any device should be as lightweight as possible to minimize inferior shoulder subluxation. Since external power is often required, a trial with an appropriately weighted socket can help determine tolerance for the added weight of powered components. LIMB FUNCTION PREREQUISITES David Simpson has summarized the prerequisites for upper-limb function as follows Proximal stability Placement in space Functional grasp It is useful for both physician and prosthetist-orthotist to keep these principles in mind when evaluating the patient with BPI. Proximal stability is absolutely essential for successful fitting. The shoulder girdle and elbow flexors must be strong enough to support the arm or arm remnant plus the orthotic/prosthetic device. If body-powered control is anticipated, they must also be able to resist the forces generated during cable actuation. This force typically varies between 2 kg (4.4 lb) and 10 kg (22 lb), depending on the grip strength desired at the terminal device ( Fig 12A-19. ). When shoulder stability is marginal, a trial with exercises to improve muscular control may be warranted. Functional electric stimulation can also be helpful in strengthening residual musculature. In the absence of intrinsic stability, the prosthetic or orthotic device must stabilize the arm by extending well onto the torso. Many patients find this awkward or uncomfortable, although some will tolerate it ( Fig 12A-20. ). Although Rorabeck has suggested transhumeral amputation without shoulder arthrodesis, an unstable shoulder will always compromise prosthetic function. Surgical stabilization is often the most practical approach despite requiring several weeks' immobilization for the bony fusion to occur. Malone et al. have suggested that postsurgical fitting with a prosthesis immediately following arthrodesis may be useful ( Fig 12A-21. ). Elbow stability can be provided by a variety of locking mechanisms. Unfortunately, many orthoses require use of the uninvolved hand for unlocking. Wrist stability is readily achieved since orthoses that fix the hand in slight wrist extension are well known and well tolerated. Thumb and finger stabilization is determined individually by following accepted orthotic principles. Placement in space is closely related to stability and is imperative to provide a useful work envelope and thereby allow the individual to reach above, below, in front of, and behind the body. In cases where residual shoulder musculature can steady the arm but not support its weight when reaching out, the utility of the prosthetic/orthotic device is severely compromised. Orthotic control of the shoulder is cumbersome and requires extensions onto the torso, as noted previously. Again, surgical stabilization via fusion may be preferable. Elbow placement is more readily provided, usually by Bowden cable harnessing adapted from transhum-eral prosthetic principles (see Chapter 6B). Because the weight of the arm/orthosis/prosthesis provides a reliable extension moment, a locking mechanism is not always required. A flexion moment generated by bicapular shoulder abduction, for example, can be readily controlled by the patient to precisely counterbalance the extension forces due to gravity. This is particularly effective when weak elbow flexors are present but shoulder stability is good. Springs or elastics can also be used to help counterbalance the weight of the forearm ( Fig 12A-22. ). Functional grasp is readily restored in a variety of ways. Body-powered hooks of the : http://www.oandplibrary.org/alp/chap12-01.asp[21/03/2013 21:54:46] 12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library voluntary-opening type are the traditional approach and are often effective. In addition to being lightweight and durable, they provide a constant, limited pinch force without continued exertion by the patient. Electric hands or hooks are increasingly common and offer powerful grip forces with minimal exertion. Switch control is utilized when necessary, but myoelectric control is often more precise, provided that suitable muscle sites can be found. Sophisticated orthoses can also restore grasp to the paralyzed hand by using mechanical or external power. Most are variations of the "wrist-driven" styles originally developed for quadriplegics ( Fig 12A-23. ). Other approaches include mounting a prosthetic hook near the palm of the paralyzed hand and the use of adaptive utensil cuffs for various specific activities. Mastery of any prosthetic/orthotic device is contingent upon its effectiveness in augmenting functional activities. Actively including the BPI individual in the decision-making process, particularly in the choice of specific componentry and design options, increases the success rate. One key to long-term utilization is to identify specific tasks important to the individual that will be facilitated by using the device. A major limitation of all current prosthetic/orthotic grasp modalities is the absence of sensation, which requires close attention to visual cues by the user. As Simpson has noted, when control of the arm becomes the main task, the rate of rejection increases significantly. The difficulties involved in using the insensate "blind" hand are well documented. The alternative of teaching the individual with BPI one-handed independence should always be carefully considered. SUMMARY Despite recent surgical advances, BPI presents one of the greatest challenges to the rehabilitation team. Providing grasp is only the first step and is often the easiest to accomplish. Practical restoration of the ability to place the arm in space can be difficult, while provision of external shoulder stability is cumbersome at best. Surgical stabilization by shoulder fusion should always be carefully considered if functional use of the limb is desired. Residual neuromuscular deficits make fitting the BPI amputee a complicated undertaking. The use of a diagnostic prosthesis prior to determination of the final prescription is highly recommended due to the complexity of interrelated factors. The longer the time lapse between injury and functional use of the arm, the greater the likelihood of a poor result. Early provision of a flail arm orthosis may be useful to encourage two-handed activities during the recovery phase. Timely surgical intervention should enhance residual function. Leffert has emphasized the importance of educating BPI survivors considering prosthetic fitting about what is realistically possible. Patients often come with totally unrealistic ideas of "bionic arms" such as are seen on television. Unless they are disabused of such fantasies, they are unlikely to be satisfied with their results. . . . Whenever possible, patients with brachial plexus injuries contemplating amputation should have the opportunity to see and talk with other patients who have already undergone the procedure. The ideal environment to manage BPI is a multidisci-plinary clinic specializing in this most challenging problem. Despite recent advances in both surgical and pros-thetic-orthotic technique, many individuals with BPI will find that the functional capabilities of the affected limb remain significantly limited. References: 1. Axer A, Segal D, Elkon A: Partial transposition of the la-tissimus dorsi. J Bone Joint Surg [Am] 1973; 55:1259. 2. Carroll RE: Restoration of flexor power to the flail elbow by transplantation of the triceps tendon. Surg Gynecol Obstet 1952; 95:685. 3. Chmell SJ, Light TR, Millar EA: Brachial plexus birth injury-Analysis, treatment and followup of 538 cases (abstract). Orthop Trans 1983; 7:412. 4. Chu DS, Lehneis HR, Wilson R: Functional arm orthosis for complete brachial plexus lesion (abstract). Arch Phys Med Rehabil 1987; 68:594. 5. Clark JMP: Reconstruction of bicep's brachii by pectoral muscle transplantation. Br J http://www.oandplibrary.org/alp/chap12-01.asp[21/03/2013 21:54:46] 12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library Surg 1946; 34:180. 6. Cool JC: Biomechanics of orthoses for the subluxed shoulder. Prosthet Orthot Int 1989; 13:90-96. 7. Doi K, Sakai K, Ihara K, et al: Reconstruction of finger function with free muscle transfers for complete brachial plexus palsy with avulsion of all C 5 to T1 roots. Presented at the 5th Annual Meeting of the American Society for Reconstruction Microsurgery, Seattle, September 1989. 8. Dovelle S, Heeter PK, Phillips PD: "A dynamic traction splint for the management of extrinsic tendon tightness. Am J Occup Ther 1987; 41:123-125. 9. Dralle AJ: Prosthetic management of a below-elbow amputation with brachial plexus injury. Orthot Prosthet 1977; 31:39-40. 10. Fletcher I: Traction lesions of the brachial plexus. Hand 1969; 1:129-136. 11. Frampton VM: Management of brachial plexus lesions. J Hand Ther 1988; 1:115-120. 12. Frampton VM: Management of brachial plexus lesions. Physiotherapy 1984; 70:388392. 13. Friedman AH, Nunley JA, Goldner RD, et al: Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 1990; 72:59-64. 14. Greenwald AG, Schute PC, Shiveley JL: Brachial plexus birth palsy: A 10 year report on the incidence and prognosis. J Pediatr Orthop 1984; 4:689-693. 15. Grundy DJ, Silver JR: Problems in the management of combined brachial plexus and spinal cord injuries. Int Re-habil Med 1981; 3:57-70. 16. Hendry AM: The treatment of residual paralysis after brachial plexus lesions. J Bone Joint Surg [Br] 1949; 31:42. 17. Hovnanian AP: Latissimus dorsi transplantation for loss of flexion or extension at the elbow. Ann Surg 1956; 143:494. 18. Leffert RD: Brachial Plexus Injuries. New York, Churchill Livingstone Inc, 1985. 19. Leffert RD: Rehabilitation of the patient with a brachial plexus injury. Neurol Clin 1987; 5:559-568. 20. Leffert RD, Seddon HJ: Infraclavicular brachial plexus injuries. J Bone Joint Surg [Br] 1965; 47:9. 21. Malone JM, Leal JM, Underwood J, et al: Brachial plexus injury management through upper extremity amputation with immediate postoperative prostheses. Arch Phys Med Rehabil 1982; 63:89-91. 22. Meredith J, Taft G, Kaplan P: Diagnosis and treatment of the hemiplegic patient with brachial plexus injury. Am J Occup Ther 1981; 35:656-660. 23. Michael JW: Upper limb powered components and controls: Current concepts. Clin Prosthet Orthot 1986; 10:66-77. 24. Miller LS, Chong T: Functional bracing for upper brachial plexus injury (abstract). Arch Phys Med Rehabil 1983; 64:498. 25. Millesi H: Brachial plexus injuries: Management and results. Clin Plast Surg 1984; 11:115-120. 26. Millesi H: Trauma involving the brachial plexus, in Omer GO, Spinner MS (eds): Management of Peripheral Nerve Problems. Philadelphia, WB Saunders Co, 1980, pp 565-567. 27. Narakas AO: The treatment of brachial plexus injuries. Int Orthop 1985; 9:29-36. 28. Nunley J: Free muscle transfers in brachial plexus injuries. Presented at the 5th Annual Meeting of the American Society for Reconstructive Microsurgery, Seattle, September 1989. 29. Perry J, Hsu J, Barber L, Hoffer MM: Orthoses in patients with brachial plexus injuries. Arch Phys Med Rehabil 1974; 55:134-137. 30. Ransford AO, Hughes SPF: Complete brachial plexus lesions. J Bone Joint Surg [Br] 1977; 59:417-420. 31. Robinson C: Brachial plexus lesions Part 1: Management. Br J Occup Ther 1986; 49:147-150. 32. Robinson C: Brachial plexus lesions Part 2: Functional splintage. Br J Occup Ther 1986; 49:331-334. 33. Rorabeck CH: The management of the flail upper extremity in brachial plexus injuries. J Trauma 1980; 20:491-493. 34. Rowe CR: Re-evaluation of the position of the arm in arthrodesis of the shoulder in the adult. J Bone Joint Surg [Am] 1974; 56:913. 35. Saha AK: Surgery of the paralyzed and flair shoulder. Acta Orthop Scand Suppl 1967; 97:5. 36. Schottstaedt ER, Robinson GB: Functional bracing of the arm. J Bone Joint Surg [Am] 1955; 38:477-499. 37. Shurr DG, Blair WF: A rationale for treatment of complete brachial plexus palsy. Orthot http://www.oandplibrary.org/alp/chap12-01.asp[21/03/2013 21:54:46] 12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library Prosthet 1984; 38:55-59. 38. Simpson DC: The hand/arm system, in Murdoch G (ed): in Prosthetic and Orthotic Practice. London, E Arnold, 1968. 39. Steindler A: A muscleplasty for relief of flail infantile paralysis. Interstate Med J 1918; 25:235. 40. Thyberg M, Johansen PB: Prosthetic rehabilitation in unilateral high above-elbow amputation and brachial plexus lesion: Case report. Arch Phys Med Rehabil 1986; 67:260-262. 41. Van Laere M, Duyvejonck R, Leus P, et al: A prosthetic appliance for a patient with a brachial plexus injury and forearm amputation: A case report. Am J Occup Ther 1977; 31:309-312. 42. Wardlow M: A modular orthosis for brachial plexus lesions. Inter-Clin Info Bull 1979; 17:9-12. 43. Wayne DA, Boerkoel DR, Knott BA: Functional elbow orthosis for C 5 C 6 avulsion injuries: A case report (abstract). Arch Phys Med Rehabil 1987; 68:595. 44. Wynn Parry CB: Brachial plexus injuries. Br J Hosp Med 1984;32:130-139. 45. Wynn Parry CB: Rehabilitation of patients following traction lesions of the brachial plexus. Clin Plast Surg 1984; 11:173-179. 46. Wynn Parry CB: The management of injuries to the brachial plexus. Proc R Soc Med 1974; 67:488-490. 47. Yeoman PM, Seddon HJ: Brachial plexus injuries: Treatment of the flail arm. J Bone Joint Surg [Br] 1961; 43:493-500. 48. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg [Am] 1973; 55: 1265. Chapter 12A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 12A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www.oandplibrary.org/alp/chap12-01.asp[21/03/2013 21:54:46] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 12B Chapter 12B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles Special Considerations: Fitting and Training the Bilateral Upper-Limb Amputee H. Richard Lehneis, Ph.d., C.P.O. Ruth Dickey, B.S., O.T.R. This chapter is concerned with the unique problems presented by the bilateral upper-limb amputee. Although it is generally recognized that the unilateral upper-limb amputee uses a prosthesis as an assist and the sound limb for sensory feedback and fine manipulatory activities, the bilateral amputee does not have such a choice. As such, the general principles, preprosthetic training, prosthetic fitting and components, and prosthetic training for the bilateral upper-limb amputee differ distinctly from those recognized in managing the unilateral upper-limb amputee. Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text. GENERAL PRINCIPLES The basic objective of prosthetic management of the bilateral upper-limb amputee is to provide the patient with maximum function of the prostheses and residual limbs to be independent in the activities of daily living. Throughout this chapter activities of daily living will be used in the broadest sense to include all aspects of functional skills from self-care to vocational pursuits. To achieve these goals, independence in donning and doffing the prostheses is a necessity. This requires appropriate harnessing, preferably through interconnecting of the harness systems of both prostheses, and a socket design that enhances ease of donning and doffing. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists COMPONENTS The need for maximizing the range of motion must be met by choosing appropriate components and socket designs and alignment. Generally, bilateral wrist-flexion units are a must, particularly if independence in personal hygiene is to be expected. The choice of the terminal device should be, with few exceptions, a prosthetic hook. New amputees rarely appreciate the functional advantages of a prosthetic hook over a prosthetic hand. In these circumstances, it must be explained to the amputee that a prosthetic hook is not an attempt to duplicate the form or function of a hand since it obviously does not look or function like a hand. Rather, the prosthetic hook represents an efficient, built-in tool containing several functions of commonly used tools (e.g., pliers, tweezers). Once the amputee recognizes and appreciates that the hook is not just a poor replacement of a hand, but a tool, often the acceptance of a prosthetic hook becomes somewhat easier. A major problem unique to the bilateral upper-limb amputee is sensory loss once fitted with prostheses. Whenever possible, fitting and socket configuration for these amputees should be such that the prosthesis can be partially removed for sensory feedback through the residual limb and then reapplied. For example, in a prosthesis with a stump-activated elbow-lock control, the socket may be open ended to expose the distal portion of the residual limb for such purposes. To preserve maximum sensory feedback function, it is of utmost importance that the patient be trained not only with the prosthesis but also in the use of the residual limbs for as many activities as possible. Although not very popular in this country, the Krukenberg amputation should always be considered as an alternative, particularly for blind amputees. You can help expand the O&P Virtual Library with a tax-deductible contribution. http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library A final, general consideration relates to the strength and safety of prostheses for bilateral amputees. It should be appreciated that the bilateral amputee does not possess the choice that a unilateral amputee does, that is, using the sound limb for most activities and a prosthesis as an assist. Practically all activities must be performed with the prostheses; thus wear and tear on joints and cables are far greater than for the unilateral amputee. This makes it especially important to provide the greatest degree of reliability and safety through the proper choice of strength of material and components in the construction of the prosthesis. The overall aim of training for the bilateral upper-limb amputee is to provide the maximum degree of independence in all activities of daily living, both with and without prosthetic equipment. The final selection of all equipment for the bilateral amputee, both prosthetic and specially adapted or selected equipment, is based on total needs. Those needs are related to medical status, both diagnosis and prognosis, age, sex, intellectual and psychological functioning, social and cultural values, economic status, and general goals. PREPROSTHETIC MANAGEMENT Preprosthetic management should include all aspects of care preparatory to but not directly related to the use of prosthetic equipment. The crucial role of this preparatory phase should be strongly emphasized from both the physical and psychological points of view. From this phase, important information will be derived that is necessary for prosthetic prescription as well as patient readiness. The two main areas of management to be discussed are postoperative therapy, which deals with physical care of the residual limb and residual motions, and preprosthetic evaluation, which will establish a baseline of the amputee's current functional level. Postoperative Therapy Postoperative therapy, begun as soon as possible after surgery, is directed toward the care of the residual limbs and the strengthening of residual motions, which will be used to control the prostheses and substitute for lost motions. Postoperative treatment is carried out by the occupational and physical therapists. Maximum active range of motion should be achieved in all remaining joints of the upper limbs to provide adequate excursion for operation of prosthetic equipment. In addition, all bilateral upper-limb amputees will need maximum active range of motion of the trunk and lower limbs, particularly at the hip, for flexion and external rotation. For each level of amputation there will be specific exercises related to the parts of the upper limbs to be used for excursion of the prosthetic equipment. For the forequarter amputee, exercises for range concentrate on posture, thoracic mobility, and trunk range. For the shoulder disarticulation amputee, scapular mobility is most crucial. The above-elbow (transhumeral) amputee requires maximum shoulder mobility, and the below-elbow (transradial) amputee requires maximum elbow range and, if possible, maximum forearm rotation. Maintaining and/or increasing range for forearm rotation is vitally important because supination and pronation motions are extremely difficult to incorporate in the prosthesis. Strengthening is necessary for those motions that are required to power and stabilize prosthetic devices. A total-body strengthening program is also indicated to provide the amputee with adequate strength to function without prosthetic devices. Both isotonic and isometric exercises can be used effectively. Isotonic exercises can be in the form of progressive resistive exercises or manual assistance. Proprioceptive neuromuscular facilitation is a particularly effective approach that enables the therapist to work in diagonal planes, vary the amount of resistance, and key into specific areas of weakness. Isometric exercises are effective in maintaining muscle bulk for stabilization of the arm in the socket of the prosthesis. The stability of the prosthesis depends on both the bulk of the stabilizing musculature and the amputee's ability to voluntarily vary stump configuration. The transhumeral amputee depends on the external rotators and biceps for the stabilization necessary to prevent the prostheses from rotating internally during shoulder flexion and abduction. For the transradial amputee the muscles of supination and pronation are effective stabilizers. Massage of the residual limbs improves circulation, reduces edema, keeps the skin mobile, prevents adhesions, and begins the toughening process necessary to protect the limb during use. This technique reduces the amputee's fear of having the residual limbs handled. http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library Maximum shrinkage should occur before fitting the socket. Although shrinkage varies with all amputees, from 2 to 3 months to 1 year or more, with an adequate postoperative program Elastic shrinkers and techniques fitting can usually be considered after 2 to 3 months. The using elastic bandages have been found to be successful for shrinking and shaping. elastic shrinker provides the most consistent pressure; however, caution must be taken so that the shrinker does not slide down the arm and produce a tourniquet effect. On short transhumeral amputations, suspension systems are sometimes required for the shrinker to remain in place. If supervision is inadequate, this is the safest method. The use of an elastic bandage wrapping offers the therapist more control over both pressure and shaping. Wrapping techniques for the short above-elbow limb frequently require use of the opposite axilla. A conical shape is preferred for the transhumeral amputation and a screwdriver shape for the transradial amputation. The latter preserves maximum use of residual rotation. Again, care must be taken in wrapping so as not to produce proximal pressure, which would impair desired shaping, increase edema, and reduce circulation. Residual limb shrinkage using a plaster of paris bandage has also been reported effective when dealing with fatty or edematous stumps. With this method the plaster bandage is applied and suspended from a conventional harness. As shrinkage occurs, new bandages are applied. Most amputees have phantom sensation, the sensation of the presence of their missing limbs. The hands are usually felt more distinctly and over a longer period of time. Usually the sensation diminishes within a year and generally does not interfere with training. Phantom pain is felt as cramping, burning, or lancinating. Cramping is frequently relieved by massage, vibration, or electrical stimulation. Burning pain, although uncommon, often requires drug intervention. Much treatment has been unsuccessful. Lancinating pain is most frequently caused by a neuroma and is sometimes treated by cold, vibration, or electrical stimulation. Surgical removal of the neuroma may be required. Immediate or Early Postoperative Fitting Immediate postoperative fitting of the upper-limb amputee has come about as a result of the success of this kind of fitting for the lower-limb amputee. Results of both immediate fitting (application of a rigid surgical dressing with a terminal device at the time of surgery or in the immediate postoperative period when the sutures are still in place) and early fitting (application after suture removal) of the prosthetic equipment have been similar to those for lower-limb amputees: (1) reduction in postoperative pain, (2) more rapid prosthetic use (and thereby less dependency for some activities of daily living), (3) good psychological adjustment, (4) reduced postsurgical edema, (5) more rapid limb desensi-tization, and (6) rapid healing. Overall hospitalization time is often significantly reduced. In both techniques, the amputee has the terminal device mounted in the plaster of paris socket, and the harness system is adjustable for individual needs. As shrinkage occurs, a new socket is fabricated. The difference between the fittings is that the immediate-fitting socket is not removable whereas the early-fitting socket is. With these techniques the training process precedes the fitting of permanent prosthetic equipment. Proponents of these techniques believe that this facilitates the usual necessary adjustments in the harnessing system and design of the trial prosthesis. Also, the amputee learns early the components of the prosthesis and how to use them in activities of daily living rather than initially using adapted devices and then having to change or modify the process when the permanent equipment is delivered. Another reason for using these early-fitting techniques is to counteract the high rejection rate of prosthetic equipment use that is noted in the unilateral amputee. The longer he relies only on the sound arm for accomplishing functional activities, the less likely is the amputee to make good functional use of the prosthesis. The most obvious candidates for immediate or early fitting are bilateral upper-limb amputees. This group is the most profoundly dependent in all activities. The sooner some of this dependency can be reduced, the sooner they are relieved of some of their frustration and fear of uselessness. Even the fitting of one limb can be of significant help, especially in allowing some independence for self-care such as eating and toilet care ( Fig 12B-1.). Early Performance of Activities of Daily Living A program to give the bilateral amputee some degree of independence in activities of daily living should always be initiated early. This can be done in two ways: (1) by beginning to do http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library some activities with the remaining limbs (both upper residual limbs and lower limbs) and (2) by the use of adaptive equipment. This begins to introduce the problem-solving process and decreases feelings of inadequacy and dependency. Principles of special device application are given in the discussion on training later in this chapter. Preprosthetic Evaluation It is vital to have a coordinated total team effort in the rehabilitation of the bilateral amputee, beginning with the postoperative period and throughout the rehabilitation program. The professional team should consist of the surgeon or physiatrist, prosthetist, rehabilitation nurse, occupational and physical therapists, psychologist, social worker, and vocational counselor. Equally important members of this team are the amputee's family and friends. All the members are required for their particular expertise in providing physical care, equipment, training, future planning, and follow-up. The contributions of both the prosthetist and occupational therapist are specifically discussed in relation to the equipment, treatment, and training in the remainder of this chapter. Preprosthetic evaluation is completed prior to prescription of the prosthetic equipment. It provides an updated account of the amputee's physical and psychological status, gives information that helps determine further therapy needed, and helps make the proper choice of prosthetic equipment. The occupational therapy preprosthetic evaluation includes the following data: I. II. III. IV. V. VI. VII. VIII. Demographic Diagnostic Physical status Residual-limb descriptors Sensory status Current status of activities of daily living Equipment expectations Recommendations PROSTHETIC FITTING AND COMPONENTS The Bilateral Transradial Amputee In general, all below-elbow sockets for bilateral amputees should be designed so as to enhance easy donning and doffing, as well as to permit maximum range of residual motion. For wrist disarticulation and the long and medium-length transradial amputation, a conventional socket is indicated with a sufficiently low anterior trim line to permit full range of elbow flexion. Particular attention should be paid to an intimate interface between the residual limb and the socket to take full advantage of any residual pronation and supination. A screwdriver-shaped cross section in the distal area will permit most efficient transmission of residual pronation and supination to the prosthesis. Flexible elbow hinges attached to the triceps pad are required for socket suspension and to permit pronation and supination. For shorter amputation levels without residual pronation and supination, a socket that encompasses the medial and lateral epicondyles is indicated so that any force applied mediolaterally to the prosthesis will not cause displacement of the socket or at least minimize displacement on the residual limb. Depending on the anticipated activity of the patient, the socket is connected either to flexible hinges and a triceps pad or to metal elbow hinges, either of the single or polycentric type, that are attached to a half cuff. This will reduce socket displacement on the residual limb to a minimum when external loads are applied to the prosthetic forearm. The choice of which elbow hinge to use depends on the residual limb level and the activity of the patient and working environment. Functionally, the shorter the residual limb, the greater the indication for a poly-centric elbow hinge so that prosthetic and anatomic joint congruity can be approached as closely as possible. On the other hand, polycentric hinges are more likely to require frequent maintenance, particularly in certain industrial environments, whereas the single-pivot hinge is sturdier and requires less maintenance. For the very short transradial amputation, a split socket with the elbow hinges attached to the half cuff is indicated. Although this results in a reduction of force that can be transmitted to the forearm, it is deemed far more important to provide full range of motion. It is, however, possible to increase the forearm lift force by using a split housing so that shoulder flexion http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library and/or scapular abduction help to flex the forearm. In this instance, the residual limb is simply used to stabilize the forearm in the desired degree of elbow flexion. Very short residual below-elbow limbs with limited range of motion and/or hypersensitive areas may be fitted with a stump-activated elbow lock that uses the residual limb to trip a lever that locks or unlocks an external elbow lock hinge. A preferred way of using the stump-activated elbow lock is to adapt the locking lever to a U-shaped configuration that may fit in pressure-tolerant areas, thus avoiding any sensitive areas. A further advantage is that it exposes a larger residual limb area for sensory feedback, especially when the forearm is flexed. As previously discussed, for the greatest degree of universality of function a hook terminal device is preferred over a prosthetic hand, although a prosthetic hand may be used interchangeably for certain social activities or professions. Many bilateral amputees prefer two different terminal devices to provide a more varied grip, such as a hook with canted fingers on one side and a hook with lyre-shaped fingers on the opposite. Others will utilize an electric hand on one side for its powerful grip and a body-powered hook on the opposite for its versatility. Bilateral externally powered terminal devices-either hooks, hands, or a combination-have been used successfully. However, body-powered hooks remain the most commonly prescribed devices for bilateral upper-limb amputees because of their light weight, reliability, and versatility. The type of wrist component indicated depends on residual limb length. For wrist disarticulation and medium-length or long transradial amputations, a built-in flexion wrist may be used. The axis of rotation of the flexion wrist should be aligned so that it forms a 45-degree angle with the elbow flexion axis when placed on the prosthetic forearm in the medialvolar quadrant. For high-level transradial amputations when there is no residual pronation or supination, a separate Sierra wrist flexion unit should be installed on a constant-friction wrist. This permits variable angulations of the wrist flexion unit in the constant-friction wrist. When the patient's elbow flexion range is limited, the wrist flexion unit should be installed directly distal to the end of the residual limb. This increases the radius of the flexion arc described by the terminal device in the various flexion positions of the flexion unit, thus increasing the effective range of operation of the terminal device in space. This is especially important for activities near the body midline, such as personal hygiene. In general, the forearm of all transradial prostheses, but especially those for the bilateral amputee, should be aligned with regard to the socket in such a way that it favors an alignment that brings the terminal device closer to the center of the body and forward and upward. The forward-upward alignment may be as much as 30 degrees to simulate normal elbow flexion alignment in the sagittal plane. The inward (toward the center) alignment should be as much as cosmetically possible. Particular attention should be paid to the very short below-elbow residual limbs because such limbs accentuate the normal carrying angle in the frontal plane. Thus a forearm aligned coincident with the center of a very short residual limb would fall way short in bringing the terminal device toward the center of the body and thus would greatly diminish the function of the prosthesis, particularly with regard to personal hygiene. Harnessing for the bilateral transradial amputee is rather simple. Both prostheses are usually interconnected by running the control attachment strap to the front support strap of the opposite prosthesis. They are sewn together in the center line of the back, or they may run to a center ring. Alternatively, some amputees prefer that each arm be harnessed independently so that they have the option of wearing only one prosthesis on occasion. The Bilateral Transhumeral Amputee The medium-length or long above-elbow residual limb may be fitted best with a low lateral socket wall such as developed by McLaurin. The anterior and posterior wings of the socket should extend sufficiently to stabilize the prosthesis against axial rotation. Angulation osteotomy of the humerus, as developed by Mar-quardt, gives the best rotational control. Internal or external rotation of the humerus is thus transferred most effectively to the prosthesis. In this case, the socket proximal trim line can be considerably shorter than in the conventional design. The shorter the amputation level, the higher the socket trim line must extend, particularly the posterior and anterior wings. This is necessary to provide adequate control against longitudinal rotation as well as to provide suspension. As previously discussed, if wrist flexion units are used, they should be of the Sierra type. The http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library built-in flexion wrist does not provide sufficient range of motion for the same reason described for the short transradial unit. The choice of a terminal device is similar to the transradial case, as previously discussed, although the impact on the elbow unit selected must be carefully considered. Conventional elbow joints with alternating locks and a frictioncontrolled turntable for internal-external rotation are standard components to be used. A humeral rotation lock may be indicated when positive locking of internal and external rotation of the elbow and forearm on the humeral section is required for certain vocational and avocational tasks. Although many levels of transhumeral amputations may be fitted with prostheses with dual control cables, the short and very short levels generally do better with some externally powered components to reduce the effort required to operate the prostheses. Electric elbows, electric hooks or hands, or a combination of both are feasible. As previously discussed, body-powered hooks (at least on one side) are preferred due to their versatile grasp and reliability. Normally, no deviation from standard alignment is necessary; however, when excursion is limited, alignment of the forearm and wrist unit similar to that described for the transradial amputee will enhance function. Another alignment consideration is for those amputees who are wheelchair users. In this case, the length and alignment of the humeral section should be such as to be compatible with the armrests of the wheelchair. In all other cases, whenever the length of the residual limb permits, the humeral section should be lengthened and the forearm section shortened while retaining the overall desired length. This shortens the distal lever arm, thus bringing the center of gravity of the forearm closer to the elbow and reducing the force required to flex the elbow. Such a differential in forearm length from the normal is approximately 3 to 4 cm. Any further reduction of the forearm length would diminish the ability of the patient to reach all facial and head areas. The principle of harnessing the bilateral transhumeral amputee is similar to that described for the bilateral transradial amputee, that is, the control attachment strap of one prosthesis is connected to or serves as the front suspension strap of the contralateral prosthesis, thus ensuring independence of control. The elbow control strap and the lateral suspension straps are attached in the conventional manner. Bilateral Shoulder Disarticulation This amputation level is best served by the use of externally energized prostheses such as a myoelectric or switch-controlled electric elbow or terminal device ( Fig 12B-2.,A-D). It should be noted that some clinicians and amputees are willing to sacrifice a certain amount of function as a trade-off for the simplicity and lighter weight afforded by conventional prostheses. If the patient is to be fitted with functional prostheses bilaterally, the conventional shoulder disarticulation socket configuration is indicated. If, however, only one side is to be fitted with a functional prosthesis and the contralateral side is to be used as an anchor for harnessing, a much smaller socket configuration on the control side may suffice. Indications for the various components are the same as those described for the bilateral transhumeral amputee. Various passive, free, or friction-controlled shoulder joints are available. Those that provide motion about at least a shoulder abduction axis are indicated. If, additionally, a shoulder flexion joint is used, it must have a 180-degree extension stop to prevent shoulder hyperextension. Others Other than the shoulder joint, alignment of the bilateral shoulder disarticulation prosthesis is identical to that described for the bilateral transhumeral amputee. Alignment of the shoulder joint should be such that the flexion axis is skewed internally with respect to the frontal plane, that is, it should form an angle of 30 degrees with respect to the sagittal plane. Control harnessing for functional bilateral shoulder disarticulation amputees requires great care. The control attachment straps should be attached somewhat superior to the posteroinferior border of the socket so that they cross each other at an angle; otherwise they may get caught on one another during operation. Furthermore, inadvertent operation may result the closer the control attachment straps approach a horizontal matching alignment. An elastic cross-back strap connecting the posteroinferior corners of the socket and a nonelas-tic chest strap are required to stabilize the sockets against each other and to provide an intimate interface between the socket and the patient. The front support straps are also attached to http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library the posteroinferior corners of the socket. Bilateral forequarter amputees are best managed prosthetically through the use of external power, although some function may be obtained through the fitting of conventionally controlled prostheses through the use of perineal straps and nudge controls for the elbow locks. Mixed bilateral upper-limb amputation levels must be treated by combining the fitting principles described for the various levels of amputation. PROSTHETIC TRAINING As previously stated, the overall aim of prosthetic training for the adult bilateral upper-limb amputee is to provide the maximum degree of independence in all activities of daily living, both with and without prosthetic equipment. The bilateral upper-limb amputee depends significantly more on prosthetic and other assistive/adaptive devices and the ability to skillfully use residual body parts and motions. Therefore a framework for skill acquisition is recommended. In following such a framework, there is no intent to force the amputee into a rigid premeditated program. On the contrary, it has proved to be a highly successful means of teaching the basic skills of prosthetic control, as well as providing a logical means of meeting the specific needs of each amputee. Although a certain amount of trial and error is necessary, a framework reduces unnecessary frustration, time, and energy. Both the amputee and therapist have clear guidelines for monitoring progress and establishing ongoing goals. The training period provides time for ongoing evaluation of prescribed prosthetic and assistive devices from a mechanical and functional point of view. A sound liaison between the prosthetist and occupational therapist permits an exchange of information about functional performance with the prosthesis and allows time for revisions, if necesssary. Re-evaluation by the entire team should occur periodically. Mention should be made of the importance of a positive working relationship between the amputee and the therapist. Training for the upper-limb amputee requires the best possible collaboration of trainer skill and ingenuity and amputee motivation and ingenuity. The therapist must identify those interests and needs that will create motivation to learn in the amputee. The therapist's ability to motivate the amputee directly and to explain the importance of training related to individual needs is crucial for building successful cooperation. For the adult, motivation usually depends on one or more of the following: a desire for independence in activities of daily living; cosmesis, especially that related to social and/or vocational activities; securing or returning to employment; and participation in leisure time activities. The therapist must have full knowledge of current prosthetic equipment, control motions of operation, and mechanical and functional characteristics of components. This should be combined with a sound background in upper-limb anatomy and kinesiology. Much of the actual training is identical to that of the unilateral amputee, and the therapist should be familiar with those principles and techniques. Also necessary are skills in practical problem solving and a knowledge of factors that affect learning. The amputee should continue a general conditioning program concurrent with any other treatment and prosthetic training. The general conditioning program should continue until such time as the use of prosthetic and other equipment and the use of residual body motions for daily needs can maintain that same conditioning. If the amputee is largely accomplishing the functional activities of dressing, grooming, personal hygiene, and eating, those needs are probably being met. Training Process The process described includes four areas of training necessary for the transmission of basic information, acquisition of the skills of prosthetics operation, and methods to deal with special needs. Only the process itself will be defined and outlined; no attempt will be made to provide step-by-step instruction in the techniques themselves. The four areas of training are orientation and initial checkout, controls training, skills training, and functional activity. Orientation and Initial Checkout A clear explanation of the amputees training needs should be given, goals should be identified and/or reviewed, cooperation elicited, and mutual goals set. As a result of the fitting sessions during fabrication of the prostheses, the amputee is often somewhat familiar with the http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library equipment before beginning training. The therapist, however, should not assume this. Since much of the training will be difficult and sometimes frustrating, the need for maximumfunctioning prosthetic equipment is increased. Therefore an initial checkout of the equipment for fit and function is completed at the time of delivery to ensure maximum comfort and mechanical operation. The checkout of fit includes an evaluation of optimum harnessing system placement and socket comfort and fit. Mechanical function checkout evaluates range of motion, cable system operation, control system efficiency, wrist and wrist flexion unit operation, and terminal device operation. Factors are more often identified during the training process since they relate to the kinds and amounts of stress each amputee develops in using the equipment. Any changes that might increase mechanical function should be completed before proceeding with prosthetic training. Checkout of an informational nature should be an innate and ongoing part of the training. Major changes, of course, require more formalized checkout. Instruction in the nomenclature of the equipment is begun during the orientation and frequently reviewed so that the amputee becomes familiar with the specific terminology necessary for discussion of the equipment. This will ultimately be most important when making appointments for adjustments or repairs. Instruction is also accomplished in the "dos and don'ts" of physical care of the prostheses. Often the terminology and care instruction can be given together. Instruction in skin care provides the amputee with information regarding the need for and the kind of protection from the prostheses and harnessing system the skin will require to prevent irritation and pressure. This includes residual limb and skin hygiene and padding requirements for protection and perspiration absorption. Areas of potential pressure and irritation are defined. Directions for general visual examination of the residual limbs and other potential areas of irritation are given to all amputees, as well as specific directions for situations in which sensory impairments prohibit total feedback. Written instructions referring to specific needs are provided, along with pictures (line drawings) illustrating nomenclature, skin care, and prosthetic equipment. Both written and verbal data should be provided in a language that is easily understood. This may require the use of an interpreter for trainees whose preferred language differs from that of the clinician. Controls Training Controls training entails teaching methods of donning and doffing the prostheses and the control motions required for prosthetic equipment operation. This phase of training, although closely connected to and often combined with skills training, is treated separately for the bilateral amputee. This is because he typically needs to learn the more complicated control motions associated with either cross-controlling harnessing systems or two control systems Full concentration is given to teaching necessitated by mixed levels of amputations. necessary body control motions with minimal exaggerated motion and energy expenditure. Auditory and visual cues substitute for a loss of or limitation in the availability of sensory feedback (see Chapter 6D). Transradial Amputees. -Donning and doffing are accomplished by using one of two methods: either over the head or coat application. Removal is accomplished so as to place the prostheses in position for redonning. Controls training for terminal device operation in space requires shoulder flexion and scapular abduction for both single and dual control systems. Passive pre-positioning is needed for control of the wrist unit and wrist flexion unit. Transhumeral Amputees. -Donning and doffing are accomplished by a modified method using additional support and stabilization under the elbow. Doffing again places the prostheses in position for redonning. Controls training for terminal device operation and control of elbow motion and the elbow mechanism is shoulder flexion and scapular abduction. For elbow lock it is shoulder depression, extension, and abduction in a dual control system. Terminal device operation in space requires skillful use of the elbow locking-unlocking mechanism, a control often requiring increased practice for skill, reliability, and efficiency. Auditory feedback can be specifically helpful in the training for use of the elbow lock mechanism. Passive prepositioning is needed for wrist rotation, wrist flexion, and elbow rotation. http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library Shoulder Disarticulation and Forequarter Amputees. -Donning and doffing require a supporting surface for stabilization both when positioning the thorax in the prostheses and while fastening the chest strap. External adaptations are frequently required for attaching the strap because of the size, weight, and reduced reaching range of the prostheses. Doffing requires a support surface to stabilize for chest strap release and for placement for redonning as previously described. Control motions for shoulder disarticulation for terminal device operation and control of elbow motion is scapular abduction. Elbow mechanism control with a waist strap is scapular elevation, with a perineal strap, by trunk elevation, or with a chin nudge. Passive prepositioning is needed for wrist rotation, wrist flexion, elbow rotation, and shoulder motions. Forequarter prostheses offer such little functional replacement that external power becomes mandatory. The time necessary to learn control motions varies significantly from individual to individual. Some learn the controls in the first few minutes after donning the prostheses, whereas others require concentrated practice. Progression to skills training does require a general degree of reliable terminal device operation, elbow control, and prepositioning ability with minimal energy expenditure and exaggerated use of either the body or prostheses. The refining of these motions can be accomplished as training proceeds. Ultimately the decision to move into that phase is made by the therapist. Skills Training The criterion for skillful use of the prostheses is to achieve as nearly normal function as can The third phase of training incorporates the replicate normal limbs doing similar activity. amputee's previously learned control motions, skill, and functional understanding of the prostheses with the principles of proper prepositioning and object stability. This can be accomplished by using training devices geared for increased difficulty and specific skill acquisition. Practice focus changes from concentration on the control motions themselves to control motions for purposeful static and dynamic positioning, prehension, and manipulation. The use of training devices allows this practice while separating achievement of quality performance from the completion of functional activity. Very often the amputee attaches too much initial importance to the skilled accomplishment of functional tasks and when unable to meet those expectations feels defeated and discouraged. The use of training devices permits sequential building and mastering of skills for easier transition to functional tasks. Correct terminal device prepositioning is the key to successful use for functional activity. For the bilateral amputee this requires passive positioning of both the wrist unit for supination and pronation and the wrist flexion unit to allow positioning close to the body for self-care. Prepositioning is accomplished by using the body or other objects in the environment or with the opposite prosthesis. The number and kind of drills used are specific to individual need. Most drills are directed initially toward learning the principles of approach, grasp, and release. For the majority of bilateral amputees, the prostheses are interconnected by their harness systems so that motion in one system produces motion in the other. Specific training is directed toward adjustment of body position to prevent inadvertent overflow between systems ( Fig 12B-3.). The importance of this is most obviously seen in the use of one prosthesis in a static holding position while using the other dynamically. Dominance is usually established in the limb with the most residual motion. Unless there are complications, in limbs of equal length dominance remains with the preferred limb. An exception to this may be the individual with exceptional skill who chooses to use a much shorter, but preferred limb rather than to change dominance. Choice of dominance is usually made when the amputee is performing activities without the prostheses; however, if no preference is shown, the skills training usually establishes dominance. Functional Activity The beginning of the bonding of skillful prosthetic control with functional activity is based on the readiness of the amputee. General guidelines for determination of readiness can be established by observing how skillfully the principles of use are applied, the normalization of body motions, the time necessary to complete a task, and the amount of energy being expended. Also to be considered in making this determination is when the control motion execution is more automatic and secondary in the amputee's concentration. The therapist's http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library skillful choice between devices for learning skills vs. those for learning functional tasks helps the amputee view progress more clearly and decreases frustration. Functional training in activities of daily living can begin soon after basic skills have been achieved. Alternation between both types of activities bonds the functional task and skills more quickly, principally by permitting immediate feedback. Although functional training in activities of daily living has been going on concurrently in alternative forms, the initiation of these activities with prosthetic equipment focuses anew the importance of considering the needs and goals of the individual. Certainly, it would be impossible in a training period to accomplish all the activities that would be needed by the amputee from that day forth; however, with bilateral amputees, it is often necessary to cover more of the actual activities, especially those requiring special techniques or adaptive equipment. Tasks that most notably decrease the amputees dependence on others for personal care should be initiated first. The following list includes a general order of the sequence and areas of focus for activities of daily living: 1. Self-care.-Eating, grooming, dressing, bathing, and personal hygiene. 2. Communication skills.-Writing; telephone use; operation of recording devices; handling books, magazines, papers, etc.; typing; and general office skills. 3. Homemaking. -Cooking, cleaning, washing, ironing, general housekeeping chores, and baby care. 4. Social skills and avocational interests.-Evaluation of the pursuit of former interests and exploration of new interests; social skills that relate to the individual's life-style and interests. 5. Prevocational and vocational exploration. -Evaluation of skills in relation to previous work and/or exploration of new vocational possibilities. As skills improve, the vocational counselor will be able to more accurately assist in this phase. Follow-up as relates to the job may be necessary for adaptations and/or general work setup. 6. Mobility.-Driving and the use of public transportation. The use of a checklist is recommended to ensure that all areas of necessary and desired training have been covered. A final checkout on completion of training provides discharge information on equipment, fit, and function. It is recommended that a final checkout accompany the summary of final function, special devices provided, and recommendations for follow-up. Special Devices Almost without exception, all bilateral upper-limb amputees require some special selection of existing equipment and/or the adaptation of devices to meet their needs, both with and without prosthetic devices. Training would be incomplete without a more specific discussion of the role of assistive/adaptive equipment.[*Assistive/adaptive equipment is "a special device which assists in the performance of self/care, work or play/leisure activities or physical exercise." (From the American Occupational Therapy Association official glossary, January 1976.)] Assistive/adaptive equipment is provided with the same basic considerations as previously discussed for the selection of prosthetic equipment: medical, psychologicalintellectual, social, and economic status. Over the years the old trial-and-error methods have given way to more sophisticated application of devices due to advances in the following areas: 1. Evaluation techniques used to analyze motions both of normal activities and individual functions 2. Increases in technical development of devices, both mechanical and electronic 3. Increased availability of commercial devices to meet varied needs 4. Increased sophistication of materials used in device construction With regard to all of these considerations, the occupational therapist must have knowledge and skill in the following areas as they relate to device application and construction: 1. Evaluation is conducted in two ways: (1) by the analysis of normal motions and forces involved in the activities of daily living and (2) the evaluation of individual limitations through a functional motion test. Thus by knowing the motions required for a specific task it is possible to take into account individual limitations and determine what activities will require assistance and/or substitution. http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library 2. The therapist must have an awareness of commercially available equipment, both adapted or specifically suited to meet individual needs. Prefabricated equipment or component systems frequently save significant time and money for the patient and allow the therapist time to devote to other problem-solving needs that cannot be met by commercially constructed devices. Figure 12B-4 shows parts of the Universal component system that can substitute for a loss of hand function. 3. A knowledge of how to design, construct, and fit adapted devices for individual needs is necessary when commercial devices are either unavailable or too costly. Training the patient in the use of special devices requires knowledge of the mechanical operation of the device itself and control motions required by the patient. The therapist must also be skilled in troubleshooting and problem solving. 4. Finally, the therapist must be able to estimate potential for device use based on psychological and social factors. All of these areas apply to devices in general. For the bilateral amputee, the therapist must apply the principles both with and without prosthetic equipment. This requires the therapist to be fully aware of the functional abilities of both the individual and the prostheses. The principles of motion economy and energy conservation apply to the execution of all activity for environmental organization and individual task setup. A good general guideline to follow is an arrangement whereby maximum independence is achieved with the least amount of time, number of steps, energy expended, and equipment necessary. The use of electronic technology in rehabilitation has added another dimension in devices to increase independence for the very severely disabled amputee through systems devoted to environmental control. Through these environmental control systems it becomes possible to operate various appliances (lights, telephone, alarm systems, intercom, television, electric bed controls, door locks and openers, drapery pulls, etc.) in a living or work area by using residual control motions to operate sensitive microswitches, pneumatic switches, or voiceactuated controls. References: 1. Bailey RB: An upper extremity training arm. Am J Occup Ther 1970; 24:5, 357. 2. Bender LF: Prostheses and Rehabilitation After Arm Amputation. Springfield, Ill, Charles C Thomas Publishers, 1974. 3. Friedman LW: Rehabilitation of amputees, In Licht S (ed): Rehabilitation and Medicine. New Haven, Conn, S Licht Publisher, 1968. 4. Gullickson G Jr: Exercise for amputees, in Licht S (ed): Therapeutic Exercise. New Haven, Conn, S Licht Publisher, 1961. 5. Laughlin E, Stanford JW, Phelps M: Immediate postsurgical prosthetics fitting of a bilateral below elbow amputee, a report. Artif Limbs 1968; 12:17. 6. Reyburn TV: A method of early prosthetics training for upper-extremity amputees. Artif Limbs 1971; 15:1. 7. Santschi WR, Winston MP (eds): Manual of Upper Extremity Prosthetics. Los Angeles, University of California School of Medicine, 1958. 8. Sarmiento A, McCollough NC III, Williams EM, et al: Immediate postsurgical prosthesis fitting in the management of upper extremity amputees. Artif Limbs 1968; 12:14. 9. Upper-Extremity Prosthetics. New York, New York University, Post-Graduate Medical School, Prosthetics and Orthotics, 1971. 10. Zimmerman ME: Analysis of adapted equipment, Part II. Am J Occup Ther 1957; 11:4. 11. Zimmerman ME: The functional motion test as an evaluation tool for patients with lower motor neuron disturbances. Am J Occup Ther 1969; 23:1. 12. Zimmerman ME: The role of special equipment in the rehabilitation of the injured spinal cord, in Cull JG, Nardy RE (eds): Physical Medicine and Rehabilitation Approaches in Spinal Cord Injury. Springfield, Ill, Charles C Thomas Publishers, 1977. Chapter 12B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 12B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www.oandplibrary.org/alp/chap12-02.asp[21/03/2013 21:54:51] 12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 12C Chapter 12C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles Special Considerations: Upper-Limb Prosthetic Adaptations for Sports and Recreation Bob Radocy, B.S., M.S. The concept of specialized adaptive prosthetic components to enable unilateral or bilateral handless persons to access sports and recreation activities is not new. Interest in sports and recreation has always existed for the physically challenged individual, but not until the late 1970s and early 1980s were consumer pressures sufficient to influence the direction of commercial prosthetics. The interest in specialized prosthetic gear escalated throughout the 1980s and is expected to continue to increase in the 1990s. Consumer groups (American Amputation Foundation, Little Rock, Ariz) and organizations such as the National Handicapped Sports Association (Washington, DC) are fueling this interest and fostering an increased awareness of products and the newest technology by communicating to greater populations of the disabled public. Physically challenged persons' expectations and attitudes have altered accordingly. The Olympics has incorporated wheelchair racing, and special ski programs throughout the country have dramatically improved the visibility of the disabled in the public eye. A consciousness of competition has been born. Mainstream participation in sports by the physically challenged is still a primary goal. The disabled have proved that they can be competitive with the able-bodied in many instances if they are equipped with the proper prosthetic technology. Also encouraging this increased participation is the growth of the recreation industry itself. The rapid growth of recreation has affected all groups. Coupled with this is increased leisure time for much of the population, which furthers interest in the pursuit of sports and recreation. Prior to the 1980s, devices commercially available specifically for sports and recreation activities were limited to the Hosmer-Dorrance prosthetic Baseball and Bowling Adapters (Campbell, Calif). Prosthetists fabricated custom devices for other activities, or the patients themselves designed adaptions for particular pursuits. Increasing demand, interest, and grass roots product developments by consumers encouraged manufacturers to begin producing commercial materials and componentry targeted for active physically challenged people with the resultant emergence of a market. Details of developments available for specific activities will be dealt with later in this chapter. Rehabilitation programs are beginning to consider the sports and recreation needs of the patient. Rigorous activities for the unilateral or bilateral handless person cannot be considered prior to a thorough, functional physical assessment and successful completion of a basic rehabilitation program. A holistic approach to rehabilitation applied in a team environment is most effective. Traditional rehabilitation includes physical therapy, occupational therapy, and psychological and prosthetic intervention. Recreation therapy is now also included in many progressive rehabilitation programs. It has proved to be a functional motivator for many patients and is especially effective in pediatrics. Unfortunately, not all health professionals are aware of the importance and positive impact that sports and recreation can have on a patient's overall rehabilitation progress. Federal, state, and local rehabilitation agencies, workmen's compensation specialists, and private insurance companies often need encouragement to ensure that a holistic therapy approach that includes recreation considerations is provided to a hand amputee. Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. http://www.oandplibrary.org/alp/chap12-03.asp[21/03/2013 21:54:57] 12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Therapy programs of all disciplines are responding by adapting to the changing attitudes and needs of the physically challenged. Some patients expect to achieve more than simple participation. They desire to be competitive, and programs are designed to meet these needs. Successful therapies analyze the patient's total potential, including recreation, and structure a rehabilitation strategy to achieve specific goals in a planned, sequential manner. Physical therapy and prosthetic rehabilitation are integrally linked. Performance will not occur unless the person develops the proper physical attributes and capacities, i.e., range of motion, flexibility, and muscle strength, size, and endurance. Muscle hypertrophy enhances strength and can improve prosthetic suspension. Performance can also be limited unless the patient has the proper prosthetic technology to optimize his physical potential. Optimum physical condition can be achieved through resistance exercise. Following traumatic injury physical therapy can begin with low-resistance exercises. Pool therapy is another option and provides a valuable, low-stress exercise environment. Preprosthetic resistance exercise can be the next phase. Refer to Fig 12C-1. and Fig 12C-2. for weight harness systems that permit a wide range of upper-limb exercise conditioning. Many amputees successfully use commercial weight-conditioning equipment such as Nautilus machines, which are available at the YMCA, recreation centers, and private health clubs, as well as in some rehabilitation centers. Home training programs are valuable because they allow the patient to continue rehabilitation and physical conditioning outside the clinical environment. Physical conditioning without a prosthesis has its limits, however. For transradial amputees, progressive resistance exercise and weight conditioning are more complete and effective while using a prosthesis. The overall goal is functional bilateral performance. The patient has physiologic as well as sports and recreational requirements that a prosthesis must satisfy. A thorough assessment prior to design and construction is important to achieve a satisfactory result. Numerous alternatives exist in prosthetic design, materials, and components. Harnesssuspended socket designs with triceps cuffs and the accompanying hardware are traditional. have experienced significant evolutionary progress Supracondylar, self-suspending sockets over the last decade and offer many benefits for the active individual. Partially padded or fully and other lined sockets can enhance comfort. ISNY (Icelandic-Swedish-New York) sockets flexible socket designs also offer specific advantages. Traditional suction and silicone suction suspension systems offer suspension advantages that should be considered. Ideally, a combination of the technologies available will yield the optimum design solution, depending upon the individuals morphology, physical condition, and other needs. The choice between body power and external power is based on environmental considerations, intensity of the sports activities, function, speed, durability, performance, reliability, and cost. Body-powered prostheses are more common in sports and recreation pursuits than are externally powered prostheses due to the demands such activities place on both user and prosthesis.[*The majority of examples throughout the text illustrate bodypowered prosthetic designs. The author made a number of inquiries to generate examples of externally powered prosthetics in sports and recreation but was able to verify only those that he included.] New materials and components for body-powered harnesses and cables can allow quick cable improve the efficiency of power transmission. Rapid-adjust buckles excursion adjustments that can be valuable in activities where gross motor movements are required. Synthetic cable materials such as Spectra (Allied Signal, Inc., Petersburg, Va) provide a lightweight, low-friction alternative to standard braided stainless steel cable. Axilla loop designs and materials are varied and offer greater comfort and therefore improved performance. Materials for prosthesis construction have evolved primarily due to developments in the aerospace industry. Traditional polyester resins and nylon/Dacron laminates are being replaced by acrylic and epoxy resins with carbon fiber, Kevlar, and Spectra reinforcements. Thermoplastics like polyethylene are readily available and allow reshaping of the socket even after the prosthesis is complete, thus enhancing fit and comfort. Terminal device choices abound. Active prehensors in the form of hands, hooks, or hybrid designs may be externally powered or body powered. Passive (nonpre-hensor) designs are now available for specific sports or recreation activities. For example, the Super Sport mitt (T.R.S., Inc., Boulder, Colo) ( Fig 12C-3.) stores energy and provides a safe, flexible http://www.oandplibrary.org/alp/chap12-03.asp[21/03/2013 21:54:57] 12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library prosthetic option useful in contact sports. Wrist components vary in size and design and may be divided into two types: adjustable friction or rapid disconnect. The sports prosthesis usually incorporates a rapid-disconnect wrist if the amputee plans to use more than one terminal device or prehensor. Youth-size rapid-disconnect wrists offer the same convenience. Rapid-disconnect wrist systems can be modified to allow incremental rotation by the installation of a rubber washer or O-ring onto the threaded stud of the prehensor prior to screwing on the rapid-disconnect adaptor. The elastic cushion allows incremental rotation yet does not interfere with the disconnect function. Precise device positioning may be required for optimum performance and is therefore desirable. During prosthesis construction, additional factors that can affect performance need to be considered. Socket alignment dictates the range of elbow motion available. Wrist alignment and wrist mounting angles affect control and load bearing. External contouring can enhance or detract from function depending upon the activity. These alignments and contours should be evaluated actively on the patient prior to lamination. Static and dynamic loads also need to be evaluated. Since pain impedes performance, evaluations should at a minimum include direct axial prosthetic loads, lifting tolerances to a distal load, and pulling and torque (rotational) tolerances on the prosthesis and limb. A prosthesis should comfortably and securely support the patient suspended from a horizontal bar or while performing a handstand or push-up. Cosmetic or aesthetic considerations can also be important to the patient, especially if the user expects to employ the prosthesis outdoors in warm climates. Muscular contours can be simulated, and summer pigmentation may be considered so that the prosthesis is more complimentary to the natural arm. Sports and recreation activities are function specific. Generic prosthetic devices, although versatile, may not provide adequate levels of function, strength, or control to perform optimally in a particular activity. Some people participate in sports and recreation without a prosthesis and become skilled unilaterally. However, the question arises as to whether with improved prosthetic technology they could have developed their skills more easily or performed better. Furthermore, bilateral upper-limb engagement in an activity should contribute to more balanced physiologic development and therefore be encouraged. The remainder of this chapter will be an alphabetic exploration of sports and recreation activities. Prosthetic designs, modifications, custom aids, and commercially available components will be detailed. ARCHERY Archery is a sport with a rich history dating back to before medieval times. Archery develops upper-body strength, coordination, and mental concentration. It has further value as a lifetime recreation or pastime and can stimulate organized social or club ties. Modern archery equipment is reliable, safe, and easily adaptable to certain terminal devices with only minimal modification. A bow riser (handle) can be layered with wraps of rubber bicycle inner tube and foam to create a compressible bow grip. The bow handle must be free to center itself in the prehensor so that the prosthesis does not induce any external "torques" to the bow that will affect arrow flight. A jam pin can be used to prevent thumb opening during the "draw," or the archer can simply maintain prehension as illustrated by the bilateral amputee in Fig 12C-4.. Archers may choose traditional gear such as the longbow or the recurve or any of a number of well-designed compound bows that offer weight and draw length adjustability. A local specialized archery dealer is the best source of information regarding what is most suitable for an individual's needs. In most cases, the bow should be held with the prosthesis and the string drawn with the sound hand. The opposite is possible, however, and the string may be held with the tips of a prehensor or with a special "release aid" devised to secure the string. Some persons with a high-level arm absence or unilateral arm dysfunction have adapted to drawing the string by using a special mouth tab while holding the bow with the sound arm ( Fig 12C-5.). Archery equipment is most easily adapted to prostheses using voluntary-closing prehensors or externally powered hands that have the correct anatomic prehension configuration. Custom http://www.oandplibrary.org/alp/chap12-03.asp[21/03/2013 21:54:57] 12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library prosthesis adapters such as the quick-disconnect unit illustrated in Figure 12C-6 have also been devised. Note that the modern bow stores a great deal of energy. The bow and arrow, besides being recreational equipment, are also considered weapons, so safety consciousness is mandatory at all times. BALL SPORTS Ball sports, including basketball, soccer, volleyball, and football, have unique demands. These sports develop hand and eye coordination, a variety of foot and hand skills, plus team consciousness and cooperation. Adolescents as well as adults enjoy these activities, which are often incorporated into school athletic programs. Prostheses should provide adequate strength, freedom of movement, and safety features. Cosmetic hands and externally powered hands are reported to have been used successfully. The Super Sport (T.R.S., Inc.) ( Fig 12C-7.), an alternative device patterned after the volar surface of the hand, is capable of passive wrist flexion and extension. It absorbs shock and stores externally applied energy for safety and ball control. The Super Sport devices are passive in that they employ no cable, but their polymer construction allows safe participation in vigorous activities. A prosthesis cover fabricated from nylon-covered neoprene rubber can provide additional padded protection to opponents and user alike in sports where interpersonal contact is likely. Baseball Baseball, part of our American heritage, is often the first organized competitive sport a youngster encounters. Playing baseball develops hand and eye coordination, agility, and upper-body strength. Prosthetic requirements vary depending upon whether the player is batting or fielding. Historically, a lack of truly functional prosthetic designs has required most amputee players to adopt one-handed techniques. The success in playing unilaterally depends a great deal on the person's arm morphology. A longer limb most often offers advantages over a shorter one when handling bats, mitts, and balls. Batting two-handed (bilaterally) requires that the prosthesis or bat be adapted so that omnidirectional wrist/forearm action is possible so as to duplicate "wrist break" in a normal swing. This omnidirectional action allows for true bilateral control, power, and follow through, i.e., a smooth, unrestricted swing. One adaptation is the Power Swing Ring (T.R.S., Inc.) ( Fig 12C-8.). The device can be engaged with almost any prehensor, body powered or externally powered. The player can use a standard grip or swing cross-handed, depending upon the stance and handedness. Fielding requires throwing and catching skills. Throwing in virtually all instances is accomplished with the sound hand because prehension and wrist action are coordinated to deliver a powerful and accurate throw. Catching can be difficult with a prosthesis because most amputees cannot pronate or supinate the forearm. The Baseball Glove Adapter (Hossmer-Dorrance Corp.) ( Fig 12C-9.) fits into a first baseman's glove and has been available for many years. It is a specialized body-powered, voluntary-opening split hook that is pulled open with a cable action and then closes the glove when the player relaxes. The Hi-Fly Fielder (T.R.S., Inc.) in composite Fig 12C-10. offers a different approach to catching a ball. Patterned after lacrosse sticks, the device allows either forehanded or backhanded catching techniques, thereby eliminating the need for most forearm pronation/supination activity. No glove is required, nor is a cable used, so the unit is extremely lightweight. The flexible mesh pocket also allows scooping and tossing the ball in a manner similar to playing jai alai. BICYCLING/TRICYCLING/MOTORCYCLING A tricycle was probably your first recreational vehicle. Bicycling and motorcycling are natural extensions of those first tricycling experiences. Bicycling nurtures balance and coordination and develops leg strength and cardiovascular endurance. Upper-limb requirements include being able to grasp and control handlebars and activate gears and brakes. Safe control is the primary goal. The voluntary-opening split hook has proved less than ideal for cycle control due to the limited gripping force and hook contours. http://www.oandplibrary.org/alp/chap12-03.asp[21/03/2013 21:54:57] Voluntary-closing prehensors ( Fig 12C-15. Similarly. This allows the prosthesis to be used entirely for steering control. so people missing one hand may not be impaired or may wish to switch hands to bowl.asp[21/03/2013 21:54:57] . rubber rings can be added to kayak paddles or boat oars to reduce prehensor slippage and improve control while paddling or rowing.R.) with at least 30 lb.. The HosmerDorrance Bowling Ball Prosthetic Adapter ( Fig 12C-12. energy-storing alternative for these activities and can satisfy some specialized recreation niches safely. DANCE/FLOOR EXERCISES/TUMBLING These activities provide overall balance and coordination development while stimulating social interaction and mainstreaming. These activities condition the arms. The sound hand activates gears and brake levers. (Note: The rear brake must activate first to ensure stability in stopping. BOWLING Bowling remains as one of the more popular indoor recreations available. Bowling environments stimulate social interaction through team and league participation.oandplibrary.12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Voluntary-closing devices ( Fig 12C-11. but the rigors of gymnastics and tumbling could prohibit their application. so consultation with a local motorcycle dealer is suggested to ensure safe and proper adaptations. Unilateral participation without a prosthesis is certainly possible. and stability. Locking-type prehensors should never be employed in water sports activities for safety reasons. Bilateral amputees and unilateral ones who do not wish to switch dominance need to use a prosthesis. The natural gross motor patterns of paddling or rowing harmonize with the action of voluntary-closing devices and thereby create the required prehension. ) can be adapted to these activities with minimal modification. Gross motor bilateral upper-limb motions are emphasized. but considerations include strength. Requirements vary depending upon the specific activity. The prosthesis must be utilized to either grasp a reel handle for line retrieving or to hold and control the fishing pole. ) and http://www. A simple hole bored through the end of a canoe paddle and padding the handle shaft with rubber inner tubing will improve prosthetic control.) Gears can be grouped for easy access. of elastic band resistance is suggested. is a flexible. Inc) ( Fig 12C-13.. Bowling is primarily a unilateral activity. Externally powered hands are a possibility for dance. Brake systems can usually be combined in tandem to be activated from a single pedal. the prosthesis is used for steering control. flexibility. and stability. If a split hook is to be used. It incorporates a flexible coupling and a cable-activated release system so that the ball can be cast smoothly and with control.S.S. balance. The Super Sport mitt in Fig 12C-14. thus eliminating the front brake lever.R. Inc. and cosmesis. Typically. The local bicycle pro shop can be a source for information or for modifications to ensure that the adaptations are completed safely. Voluntary-closing prehensors such as the Grip (T. and torso while developing balance and coordination. Motorcycling usually requires operation of a clutch lever. but a prosthesis may enhance performance. 7 Farm Hook (Hosmer-Dorrance Corp.org/alp/chap12-03.) is available ( Fig 12C-11. and adequate gripping power and prehension configurations are required. ) and externally powered hands grip the handlebars securely for safe steering control. If one is used. ) and allows one hand to control the front and rear brake systems simultaneously. Modifications should be performed by competent mechanics. CANOEING/KAYAKING Canoeing and kayaking are exciting and demanding recreations. Passive cosmetic hands have been used as well as padded hooks. It develops hand and eye coordination as well as overall coordination and balance. stability. Unilateral amputees can clutch and throttle with the same hand with a little practice. ) is a time-proven prosthetic aid for bowling. balance. FISHING Persons missing a hand(s) or who have a limb paralysis or dysfunction have a number of fishing options. the Dorrance no. A Dual Brake Bicycle Lever (T. shoulders. then omnidirectional wrist action is desirable. ) both provide significant gripping force. Both offer improved performance because they enable the player to have an unrestricted swing allowing for a smooth follow-through. Accordingly. but without a functional wrist. Fig 12C-25. Pistols are more difficult to hold and modify due to their compactness. Note. ).12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library externally powered prostheses function well with reels by providing a controlled grasp on the reel handles or rod. Voluntary-closing prehensors such as in Fig 12C-23. or an externally powered hand can be used to guide a club. Many reels are available in either rightor left-handed retrieve models so that the amputees may select their preference. Whether the prosthesis is used for control or triggering is dependent upon dominant handedness or dominant eye. Ohio) is depicted in Fig 12C-17. ND). Calif). Somewhat similar to the Robin-Aids device. lures. illustrates an adaptation that utilizes a chest support and harness system for mounting the fishing rod. Inc. Grand Forks. In many cases simple modifications suffice. Vallejo. hold and control or to trigger a firearm ( Fig 12C-21. which can prove difficult for many terminal devices or prosthetic hands. the Robin-Aids golfing device (Robin-Aids Prosthetics. A flexible or multiaxis joint is required to enable a complete bilateral swing. Persons missing one hand have played golf single-handedly. Inc. The United States Golfing Association (USGA) has established rules (USGA 14-3/15) regarding the use of artificial limbs while playing golf. or hunting is a pastime ingrained in American life and indirectly facilitated by participation in our military services. A military sling can add stability. and externally powered hands ( Fig 12C-24. GUNS/HUNTING Handling firearms for self-defense. .oandplibrary. Inc.. the game is primarily being played unilaterally.. Fig 12C-26. Rifles are easily modified by adding a ring or custom adapter to the forearm of the stock ( Fig 12C-22. Automatic fly reels have been evaluated as well but exhibit difficulties in removing the line from the reel and from a lack of power in line retrieval. A standard split hook. Figure 12C-18 shows a prototype fly-fishing reel system that removes the reel from the rod entirely. Chadron.asp[21/03/2013 21:54:57] . with the strap grasped by or wrapped around a prosthesis. Golf provides coordination. A prosthesis may be used either to support. Pawhuska. adjustable for club grip diameter. develops trunk and upper-body flexibility. Upper-limb prostheses need to attach to the club handle or grip in some fashion. Neb). Using an unmodified club is an additional benefit. the AGG also employs a flexible coupling linking the prosthesis to the club and utilizes a slide-on handle. balance. Fig 12C-19. shows a shotgun heavily modified to be controlled and fired entirely with one http://www. ). often controlling pistols and rifles with minimal or no modifications. and judgment. Fig 12C-16. A novel modified reel design (Ampo-Fisher I. and this leads to the necessity in some instances for a "cross-handed" grip to use the device successfully. Another design. Bass-matic Corp. Okla) are also available for one-handed control. Custom handles added to the forearm of the stock can also provide excellent control and stability. uses a flexible coupling for duplicating wrist and forearm movements. and weights.. timing.. illustrates a Canadian modification whereby the club attaches directly to the prosthesis. Fig 12C-20. Many custom designs have evolved. but most amputees use prostheses for bilateral assist. Electric reel systems (Royal Bee Corp. however. most split-hook systems have a tendency to pull or slip off under load. It is a social game into which many disabled groups have been able to mainstream easily. Canton. This device is commercially available and meets the requirements of the USGA. and improves judgment. various body-powered pre-hensors. that secures the club in place. recreation. a complex shooting system commercially available to people with high-level bilateral arm dysfunction or absence. These are most applicable to people with high or severe levels of dysfunction. many persons missing a hand(s) may have an interest in playing the game. illustrates the Amputee Golf Grip (AGG) (Recreation Prosthetics. GOLF Golf is one of the most popular outdoor sports. A small pair of locking needle-nose Vise Grip pliers provides an excellent accessory for handling small hooks. shows the SR-77 (SR-77 Enterprises. Shooting develops hand and eye coordination. that most of these devices function more easily depending upon handedness.org/alp/chap12-03. Manually winding the line around the spool is required with this design. oandplibrary. saddles. horseback riding is enjoyed by many individuals. Additionally. Music fosters socialization and provides individual and group pleasure. Youngsters in these areas play in regulated hockey leagues much like Little League for baseball. but remains an elite pastime. MUSIC Instrument playing is a recreation many aspire to achieve. HORSEBACK RIDING Although a more select recreation. especially in the West. jamming. especially in the northern latitudes of the United States and throughout Canada. ) or another to play the piano ( Fig 12C-30. Since safety is an issue. so proper instruction and safety procedures are mandatory. It develops agility. PHOTOGRAPHY Photography is an enjoyable hobby for many people and poses few problems for someone missing a hand. regardless of format. It can be dangerous for the novice as well as the expert. MOUNTAINEERING Mountaineering including rock or technical climbing is becoming more popular throughout the country. a rider should be able to adjust gear. Demands include a reliable prosthesis with secure hardware. and externally powered hands could provide the necessary functions. ). can be manipulated with externally powered or body-powered prostheses. and balance. Either kind can also be employed to grasp the reins or horn without an adapter and provide sufficient prehension for saddle adjustments. Communicating with a music teacher for a particular instrument is an invaluable source of inspiration. can be especially useful. The timely release of the reins or horn could be as important as grasping them and should be taken into consideration when evaluating prosthetic alternatives. Externally powered hands as well as body-powered prehensors have all been adapted from time to time for instrument play. or clinging to rock surfaces. and self-confidence. Prosthetic requirements include a means of holding and manipulating the hockey stick. endurance. Mountaineering demands stamina and strength. A local gunsmith is an excellent source of information and can usually customize firearms. Imagination is the key to developing an adaptation that works successfully for the amputee. coordination. ) is one simple adaptation for riding. Riding emphasizes balance and coordination combined with leg and torso strength and control. Prototyping is usually required with trial and error to develop a useful adapter. due to their superior grip forces. Safety is always a consideration.asp[21/03/2013 21:54:57] . Virtually all adaptations for playing musical instruments are custom-made. Prosthetic requirements vary widely since playing is instrument specific. Figure 12C-28 illustrates a transradial amputee using a stainless steel Grip (T. and a terminal device that can stand abuse as a tool for prying. flexibility.R. Hockey develops strength. HOCKEY Hockey continues to be popular. gripping strength to handle and manipulate >ropes and gear. The amputee is belayed with a top rope for protection from falls.12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library arm. and coordination.org/alp/chap12-03. Inc.. metal terminal devices should be used with caution. The stick should be capable of pivoting out of the way and preferably disconnecting to prevent injury during a fall or upon contact with other players. Riders must be capable of grasping either a saddle horn or the reins for control of the mount.) prehensor during a mountaineering training session. An adapter to play a guitar will differ dramatically from one for a violin ( Fig 12C-29. http://www. Externally powered hands and voluntary-closing prehensors. balance. Playing an instrument develops hand and eye skills. coordination. rhythm. Such a bar can be controlled by many different types of prehensors. The Rein bar ( Fig 12C-27. Most cameras.S. Padded or covered body-powered devices are preferable. bridles. and straps. jarring falls are common for the novice. is the Hosmer-Dorrance Ski Hand. All present externally powered systems are subject to water damage. Fig 12C-32.S. skiing is a recreation that provides the physically challenged individual with the opportunity to mainstream as well as to compete. but the force of the falls might damage the arm and hand. and strengthens muscle groups of the arms. Fig 12C-34. Competitive swimming or training may require a prosthesis to improve stroke resistance on the affected side(s). Swimming stimulates the cardiovascular system. The flexible polymer body allows the ski pole to be snapped forward manually like a pendulum for pole planting.. It should be chosen with safety and durability in mind. body-conditioning exercises.org/alp/chap12-03. This allows limited control. with equipment innovations occurring continually. surfing. Custom adapters are useful in securely balancing or stabilizing the camera to allow for easier focusing and metering adjustments prior to releasing the shutter. Most body-powered prostheses can be designed for saltwater or freshwater activities if desired. It accepts all still and video cameras equipped with a tripod mount receptacle. is designed to replace a standard terminal device and attaches directly to the prosthesis. The All-Terrain Ski Terminal Device (AT-Ski-TD) ( Fig 12C-33.800 m with normal lap times. A prosthesis can provide shock absorption and protection from a fall while enabling the participant to make easier binding engagements and adjustments. Skiing is a sport that builds self-esteem and confidence as well as the physical attributes of balance. Sailing is usually a social event and easily accomplished by a person missing a hand. the AMP-U-POD (T. Many amputees swim successfully without an arm prosthesis. SNOW SKIING As mentioned in the beginning of this chapter. It develops coordination and balance and is available to a handless person with little or no adaptation. which force-fits down over the top of a modified ski pole. ) is another alternative. so poles are really more of a necessity than a convenience. A prosthesis can also aid in getting up following a fall.asp[21/03/2013 21:54:57] . Conventional terminal devices are of little use for swimming.) ( Fig 12C-31. Amputees have employed one pole successfully as well. Hard. A cosmetic passive hand or Super Sport would be suitable options. with the pole being manually swung forward for a pole plant.12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Custom adapters have also been developed. and gear is the primary function required. and coordination. Cross-country or Nordic skiing. in contrast.oandplibrary. Arms can be used to initiate turns but are not absolutely necessary for turning. It is adjustable and allows for either manual or cable-activated pole plants. An externally powered prosthesis could be used. SNOWBOARDING Snowboarding is one of the fastest-growing recreations in the country. One specialized adapter. is enhanced by upper-body propulsion. Split hooks have been used for skiing. SAILING Sailing can range from a quiet meditative experience to one in which the sailor is on the cutting edge of excitement. and many hand-less people downhill ski without these accessories. Inc. and skateboarding. illustrates one approach that uses a commercially available swimmer's training paddle fixed to the forearm with surgical tubing. Fig 12C-35. controls. or "shredding. Snowboarding. Snow skiing does not necessarily require the use of ski poles. low-stress. and legs. strength. torso. It incorporates a system for rapid pole disconnecting or connecting and uses a pivoting pole-mounting system to relieve stress on both prosthesis and skier during a fall. The amputee swimmer using this system is a physician who regularly swims 1. SWIMMING Swimming is considered to be one of the best overall. with the pole strap wound or tied into the hook. ). The Ski Hand is manufactured in several sizes to accommodate different ages of skiers.R. Leg and torso control is the primary requirement. shows the POSOS/Tablada design (Professional Orthopedic Systems of http://www. Wrist extension is required to plant a pole accurately and quickly. Handling ropes." combines aspects of skiing. increases flexibility. Externally powered systems are prohibited due to constant water exposure as in waterskiing. An approved life vest is strongly recommended. illustrate one successful body-powered system. which is commercially available.R. dexterity. is the Freestyle TSD (therapeutic swim device. and Fig 12C-40. It stimulates balance. and strength. Competitive swimming generally requires a custom prosthesis. This action conserves energy because water resistance is reduced after the power stroke. a prosthesis design is required that minimizes socket pistoning. Requirements include prostheses that provide positive gripping prehension and quick-release capability as well as the ability to handle cylindrical shapes like masts and booms. Specific static and dynamic stress evaluations conducted during construction of the prosthesis can help ensure a high-performance result. Unlike the previous custom models. WINDSURFING A unique and demanding water sport. Ontario. and legs. Fig 12C-39. uphauling. A waterskiing system with a single ski rope handle works with a simple shallow hook terminal device ( Fig 12C-38. A self-suspending supracondylar-style socket can usually provide adequate suspension yet be "torqued" off the skier's arm if the hook fails to twist off the handle during a fall. the Freestyle TSD's patented design (Robert Gabourie. Saltwater windsurfing requires corrosionand rot-resistant prosthetic components.12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Sacramento. arms. The device flares open for resistance and propulsion during the power stroke. Catharines. Another model illustrated in Fig 12C-36.org/alp/chap12-03.oandplibrary. will establish accurate design criteria. Additional needs include handling rope. Canada) allows it to collapse when retrieved. including those for sports and recreation. so release in all cases must be immediate. and Fig 12C-37.asp[21/03/2013 21:54:57] . Tablada and others have demonstrated that the "resistance" device should be applied as close as possible to the end of the affected limb for best efficiency. The variety of requirements and the functional specificity of sports activities make it impossible to consider one prosthetic system or device as a viable solution to all the needs of active hand amputees. Calif). windsurfing combines the talents of sailing. A thorough assessment of the patient's needs. St. Harnesses for body-powered systems should be worn outside wet or dry suits to allow unrestricted function. The amputee should never lock onto a ski rope handle with any type of prehensor and should not wear a prosthesis that requires a harness and cable.. Externally powered systems are also not recommended because of potential water damage. A ¼-in. Additionally.-thick neoprene sleeve will float most arm prostheses in the water and add to the skier's stability prior to takeoff. The success of the physician's design also lends credence to flexible or soft socket designs that adhere closely to the shape of the limb. SUMMARY The function-specific nature and varied demands of sports and recreation activities create continuous challenges for the prosthetics profession. ). Patient education and communication continue to be very important. Consumers are becoming better informed and frequently desire a prosthesis suitable for a variety of activities.S. This system uses a flat paddle and rigid prosthesis with a preflexed elbow. Inc.). or serious injury can result. coordination. The prototype hook illustrated was customfabricated from nylon. Falls occur without warning. and hang gliding. WATERSKIING This water sport can be very dangerous but is also exhilarating and develops overall balance and strength in the back." and cause a loss of stroke volume during strokes such as the Australian crawl. http://www. The flat paddle eliminated the tendency of the prosthesis to "submarine. Niagara Prosthetics. and proper training is recommended to ensure a safe experience. Morphology and physiology are integrally linked with prosthetic design and construction. Precautions are necessary to ensure safety. and maneuvering the mast with the sail in the water. surfing. Another approach is to install a quick-disconnect system on the ski rope at the boat and have a spotter always ready to release the rope in case of a fall to prevent injury. Caution is advised. T. 5. Royal Bee Corp. Orthot Prosthet 1972. of Pawhuska.Atlas of Limb Prosthetics: Surgical. Ala. Orthot Prosthet 1983. Inc. 2.12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library Today no single technology is either versatile or cost-effective enough to serve alone. Godfrey of Greenville. of Campbell. M. Elliot Marcus. 9:31-34.. of Chadron. creativity.oandplibrary. Neb. Prosthetic. Ontario. Canada. Robin-Aids Prosthetics.. et al: The application of ISNY principles to the below-elbow prosthesis. 7. of Huntsville. Radocy R: Technical note: An alternative design for a high performance below elbow prosthesis. et al: ISNY flexible sockets for upper-limb amputees. Shellye B. Okla.. of Grand Forks. Berger N. communication. Okla. Chuck Tieman of Blackwell. Professional Orthopedic Systems of Sacramento. The physically challenged person has more opportunities to mainstream and compete in activities of sports and recreation than ever before. SR-77 Enterprises. and a willingness to teach as well as to learn will inevitably lead to even greater possibilities in prosthetic rehabilitation. Inc. Radocy B: Technical note: The rapid adjust prosthetic harness. Colo. J Assoc Child Prosth Orthot Clin 1989. Calif. Inc. Acknowledgments The author thanks the following individuals and organizations: Ron Baird of Longmont. J Prosthet Orthot 1989. Clin Prosthet Orthot 1985. Okla. Orthot Prosthet 1986. Fillauer CE. Okla. Chapter 12C . 8. 3. 4. materials. 24:8-11. 9:23-35. Foresight. 40:43-47. of Helena. Hosmer-Dorrance Corp. New designs. NJ. 26:16-23. Bassmatic Corp. and devices applicable to sports and recreation are evolving. Billock JN: Upper limb prosthetic management hybrid design approaches. Wash.. Clin Prosthet Orthot 1989. Bill White of Waterford. 6. et al: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. Billock JN: Northwestern University supracondylar suspension technique for belowelbow amputations. 39:16-20. Orthot Prosthet 1985. of Pawhuska. and more commercially available components are allowing easier access to specific activities. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 12C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Penn. The Free Handerson Co. SC. Fishman S. Felice Celikyol of the Kessler Institute in West Orange. References: 1. 1:92:103. components.asp[21/03/2013 21:54:57] . Mont. The War Amputations of Canada of Ottawa. Customized designs continue to arise.D. and Biff Williams of Spokane. Contact Us | Contribute http://www.org/alp/chap12-03. Calif. Recreational Prosthetics. 37:55-56. ND. Calif. of Vallejo. Fornuff DL: Flex-frame sockets in upper extremity prosthetics. Ken Whittens of Duncan. patience. Ph. a transhumeral prosthesis offering proportional control of both hand and elbow.org/alp/chap12-04. The Otto Bock hand survives from that era. the Otto Bock hand became more efficient. Very ambitious multiple-motion hands such as the Sven hand in Sweden as well as others in Yugoslavia.D. design of multiply hinged fingers. External Power Beginnings In the late 1960s and early 1970s. Rosemont. reprinted 2002. and small electric motors allowed the first electric hands to be developed by the Viennatone and Otto Bock Company in Europe and the Veterans Administration/Northwestern University (VA/NU) electric hand in the United States. the first generation of portable batteries. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. ©American Academy or Orthopedic Surgeons. 1992. although much changed and improved since its earliest versions. American Academy of Orthopedic Surgeons. will provide sufficient motivation in the next decade. One can only hope that new technologies. Steel cables applied in the classic Bowden bicycle-type cable allowed the replacement of leather thongs and inefficient pulleys. with sufficient miniaturization so that a completely self-contained transradial (below-elbow) prosthesis can be made for most amputees. Click for more information about this text. and several other centers. as well as the Veteran's Administration. and cosmetic sockets to be made for arm prostheses without long hours of hand labor. Aluminum manufacturing made hook-type terminal devices more durable and light. Rancho Los Amigos Hospital. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). more powerful electric motors and better batteries allowed both hands and elbows to evolve to a more natural-appearing prosthesis. utilized advanced techniques for electromyographic (EMG) control applied in a http://www. As mentioned. Second-Generation Externally Powered Devices Evolution of smaller.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 12D Chapter 12D . Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.asp[21/03/2013 21:55:02] . Reproduced with permission from Bowker HK. lighter-weight. These hands. Prosthetic. and Rehabilitation Principles Special Considerations: Trends in Upper-Extremity Prosthetics Development Harold H. Prosthetic. IL. Locking elbow joints made of aluminum and steel finally provided active positioning with locking at the elbow for the transhumeral (above-elbow) amputee. The Post-World War II Era The late 1940s and early 1950s saw the application of new materials that had evolved from the aircraft and other industries during the war. and neoprene linings made of improved rubber materials allowed better fric-tional surfaces.Atlas of Limb Prosthetics: Surgical. have not yet proved to be commercially feasible. Laminated sockets made of new resins with fiberglass and other materials allowed betterfitting. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Sears. the INAIL (Officina Orthopedia per Invalidi del Lavoro) Center in Italy. Prosthetic. supported by a more enlightened valuation of amputees' needs by society. and Canada were developed.oandplibrary. INTRODUCTION AND BACKGROUND Research and development of arm prostheses has historically been spurred either by great tragedies such as wars and birth defects or by the introduction of new technologies that allow new solutions to persistent problems. and Rehabilitation Principles. edition 2. with a much more anthropomorphic Japan. electronic circuits using transistors. Early electric elbows were developed at Massachusetts Institute of Technology (MIT) (sponsored by Liberty Mutual Insurance Company). The Utah Artificial Arm. technical stumbling blocks.asp[21/03/2013 21:55:02] . Some A vibrotactile skin interface was prototypes from the early field tests remain in place today. were the first to attempt a method of "natural" extension of remnant limb function called extended physiologic proprioception (EPP) by using pneumatic actuators Pattern recognition was an alternate without a great deal of electronic sophistication. the Utah Arm. and a much less complex elbow developed at New York University (NYU). while a modular design allowed rapid serviceability and upgrades as the design evolved. Jacobsen's postulate control. faced with the challenge of hundreds of thalidomide-induced birth defects. who sensed pinch force of the hand tips via strain gauges. cost. the work of the late Carl Sumida of UCLA. single muscle by using autoregressive moving average (ARMA) techniques was attempted at the University of Illinois. The Grip voluntary-closing approach has now been expanded to child sizes as well as adult versions.oandplibrary. which represented the pinch force of the utilized an electrotactile display thumb vs. The Grip terminal device by Therapeutic Recreation Systems was the first new voluntary-closing terminal device to be offered since the American Prosthetic Research Laboratory (APRL) hook and hand developments of the early 1950s.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library practical way via miniaturized electronics. At the University of Utah. pursued at the University of Utah. The Child Amputee Prosthetics Program (CAPP) terminal device. plus a special adapter attached to the user's own tools.org/alp/chap12-04. is based on the ability of the EMG to linearly predict the force in a muscle and thus for the muscles of the shoulder to predict the torques about the shoulder of the amputee. Providing a much simpler. available. Modern injection-molded composite plastics offered a strong but very light shell. Approaches Developed for EMG Control Evolution of transistorized circuits finally allowed practical EMG amplifiers to be used in a prosthesis. This method was dubbed extended physiologic taction (EPT). although some object to the "lobster claw" appearance. the first finger of the hand. Simpson and others. The group at the University of New Brunswick to the amputee. and the "Contour http://www. Terminal Device Development Several new hook-type (or "nonhand") terminal devices have resulted from research in the 1970s. the first proportionally EMG-controlled elbow. experiments were conducted with a mechanism that simply pushed against the skin with a force proportional to the pinch force at the tips of a hook terminal device. Computers allowed researchers to investigate more sophisticated control methodologies in an effort to create a naturally performing arm with multiple degrees of freedom. Other terminal device innovations have included the ACRU hook with classic Dorrance-type finger shapes. utilized by Shannon in Australia. and may form the basis for other developments in the future. A nerve stimulation technique was utilized at Duke University. introduced replaceable soft plastic covers and a center-pull cable actuation. the NYU elbow has been used primarily as a switch control device. or the lack of extended funding necessary to develop a practical system. lower-cost alternative. technique that attempted to recognize the intent of the amputee based on the pattern of Statistical analysis of the EMG from a EMGs from several muscles in the remnant limb. Sensory Feedback Systems Several research groups have developed laboratory-tested systems and have even fieldtested prototype feedback systems extensively. The one-speed drive simplifies both control and mechanism. With the estimated force information.. None of the experimental systems described have achieved widespread commercial application due to limitations such as size. e. some of this work provided a theoretical basis and test bed for products that were eventually commercially available. Laboratory tests demonstrated that this simple feedback was capable of improving a subject's control over the terminal device to near-normal levels. the commands to the prosthesis are computed by using kinematic equations of a normal arm linkage to produce a more or less "natural" control of the Although no arms with simultaneous multiple degrees of freedom are commercially limb. Other electronic elbows include the Boston Elbow.g. although sacrificing a number of features. with a telemetry system transmitting across the skin so that the stimulation of the nerve would be proportional to the pinch force on the tips of a hook terminal device. and appearance of traditional hook-type http://www. It is apparent that externally powered systems have limitations in distribution (primarily due to a lack of third-party funding) and in applications in extremely rugged situations where environmental conditions would damage electronic components. Children's Hospital at Stanford has experimented with hydraulic actuation in which hydraulic pressure generated by a harness pull (usually between the amputee's scapulae). limited cable excursion can be "reused" by a rachet-type mechanism. Novel pulley-routing methods to eliminate the external cable housing (which adds weight and interferes with clothing) have been the topic of private investigations by arm amputee Joe Ivco. however. but when unlatched allows the elbow to swing freely. nonhand pre-hensor The CAPP terminal device is currently being developed in an adult size to allow a shape. was designed to offer more efficient gripping shapes without sacrificing the advantages that have been proved in the Dorrance-type hooks.e. FEASIBLE DEVELOPMENTS WITHIN 10 YEARS Body-Powered Arm Systems Although the "sound and fury" over the last two decades of upper-limb prosthetics research has been generated by externally powered arm and hand research. as well as plans for a multidirectional wrist. New terminal device designs have several features in common. continuous utilization of this same terminal device shape by those amputees who started with The Utah Terminal Device. Triceps power capture (TPC) harnessing utilizes a latch that harnesses elbow extension directly to terminal device opening. others at the University of Utah ( Fig 12D-4. i. developed by the author and the CAPP children's device. Preliminary results by Carlson indicate from 20 to 100 times longer cable life over this particular wear point. hydraulic actuation is not considered to be practical by the Stanford group.) is another simple device that could increase the efficiency and lifetime of a body-powered control cable by eliminating the sharp bend of the traditional lift tab. high-force mode.). durability. At this time. a resurgence of interest in body-powered arm systems is beginning. He too seeks a more efficient and lighter-weight cable actuation mechanism (see Fig 12D-1.) allows both voluntary-closing and voluntary-opening actuation in a nonhook.org/alp/chap12-04. two-speed drive that allows quick operation as well as a slower. also seeks to harness elbow extension to operate a children's-sized at Delft University hand that could be more comfortable and cosmetic by eliminating the shoulder harness. Terminal Device Designs New materials and new designs hold the promise for improved terminal devices. allows a hydraulic "slave" to drive the terminal device and/or other motions.asp[21/03/2013 21:55:02] .12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library Hook" by Hosmer. although accompanied by the awkwardness of the operation of the latch. A Stanford design (see Fig 12D-3. A flexible tube containing hydraulic fluid connects the cylinder in the harness with the terminal device. Strong and lightweight plastic shells are also in development. Much current work continues to focus on nonhand approaches. Inc. possible due to internal routing of the more flexible fibrous cables. The new body-powered elbow under development at the University of Utah seeks to implement internally routed fibrous cables in a new mechanism that will allow cable recovery. the weight and maintenance of a precise socket fit remain drawbacks to most myoelectric systems.).oandplibrary. An alternative harnessing technique for transradial prostheses evolved from a student design project at Stanford. Fibrous cables woven of extremely high strength polymers promise to make possible Better cosmesis may also be a more efficient body-powered system of lighter weight.. Also. A myoelectric hook drive developed at Northwestern University in the early 1970s utilizes classic "lyre-shaped" hook shapes powered by a two-motor. The evaluation reports the expected benefit of freedom from shoulder Work harnessing. The "lift pulley" by Carlson (see Fig 12D-2. This has been dubbed "synergetic" drive. notably the application of modern materials to improve the weight. New materials have raised the possibility of more efficient actuation of body-powered systems. Shoulder disarticulation designs are evolving to utilize newer. may be possible eventually. Lack of positionability at the wrist significantly limits the function available from any terminal device. allowing amputees greater transpiration of heat and perspiration. especially for myoelectric prostheses. New transhumeral socket shapes are also being developed with the more flexible materials mentioned above. Much of the medial surface of the socket can be single walled.asp[21/03/2013 21:55:02] . Prototype shoulder joints developed at the University of Utah that lock in 2 degrees of freedom are shown in Fig 12D-7. Variations on the traditional double-wall socket are being explored currently by incorporating a flexible inner socket with a "skeletal" outer suspension. Surfaces can be smooth and aesthetic and yet allow the hollow interior to be used for routing of cables or installation of more efficient actuation mechanisms. http://www. and Northwestern University has announced the development of a shoulder joint also. which proves to be somewhat cooler. Sensing shapes for a transhumeral socket may be awkward since a circumferential apparatus will not be possible with the remnant limb in an anatomic position. should be feasible. terminal devices may be improved and new versions available in the future. Wrist components.org/alp/chap12-04.. with more cosmetic colors and potentially greater durability of gripping surfaces utilizing newer polymer coatings rather than rubber. lightweight vacuum-formable materials and techniques that transfer the weight of the prosthesis over the load-bearing areas of the shoulder. which could potentially have a controllable lock to allow better positionability of the prosthesis at the shoulder joint. (Longview. Other components that may be improved by the application of new materials and design include the shoulder joint. also are under development at the University of Utah. have also proved feasible for some longer transhumeral amputees. Inc.e. however. e. The experience with some myoelectric devices.. the Utah Artificial Arm.. i. Studies of terminal device function have shown that since man-made devices have limited prehension capabilities.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library terminal devices. Flexible materials either molded (such as room-temperature vulcanization [RTV] silicone materials) or vacuum-formed (such as Surlyn and others) are being used regularly in lower-limb prosthetic sockets and are beginning to be applied to upper-limb sockets as well. Sockets narrow in the mediolateral dimension for transhumeral amputees apply techniques evolved for the new-style "ischial containment" sockets for transfemoral (above-knee) amputees. Present voluntary-closing. just as a snug-fitting ski boot provides better comfort and control than a loose one. Breathability. Self-suspending suction sockets.g. routinely fitted to transfemoral amputees. Part of the challenge of using CAD/CAM techniques will be the intimate fittings being sought in the upper limb. it is imperative that the amputee position them precisely for each particular prehension task. Socket Designs for Transhumeral and Shoulder Disarticulation Modern materials for sockets may allow improvements in the comfort and weight required to be suspended on the amputees remnant limb.e. has shown the potential for exoskeletal structures of modern composite plastics (reinforced with fiberglass and graphite). Greater flexibility reduces hard edges and surfaces and allows the prosthetist to experiment with more intimately fitting techniques that promise better comfort.oandplibrary.. Computer-aided design/computer-aided manufacturing (CAD/CAM) techniques being developed for the lower limb may soon be applied in upper-limb sockets. Research at the University of Utah as well as other centers seeks to apply exoskeletal structures in bodypowered prostheses. The Utah Terminal Device has been developed with the capability for a voluntary-closing mechanism as well as a voluntaryopening one. Transradial sockets. New fibers such as Kev-lar. with stabilizing "wings" around the lower part of the rib cage. and improved fiberglasses should allow prosthetists to make lighter-weight and stronger sockets since fewer layers of material will be required. Spectra. positionable in multiple degrees of freedom. i. Micacorp. Such intimate-fitting sockets can often be selfsuspending as well. Carlson at the University of Colorado in Boulder has also done work on a "holding assist" for body-powered terminal devices as well as a "synergetic" mechanism that could drive both a fast and slow (but more powerful) finger of a voluntary-closing terminal device. pulling the cable closes the hook. There is promise that modern plastic materials may provide enough strength to replace the heavier metal terminal devices of the past. Structures for body-powered arms may also be improved by the application of new materials. Wash). is currently manufacturing a lockable shoulder joint. The other promise of CAD/CAM techniques is easy modification of the shape by using the digitized image. The joystick-type sensors actually control 2 degrees of freedom simultaneously by a bilateral forequarter amputee.oandplibrary. Recharging is not necessary. The problem of inconsistent contact of electrodes with skin could be improved by the combination of more intimate-fitting socket designs plus improved electrode designs. Control Methods Nearly all of the currently used myoelectric prostheses utilize the classic two-site agonistantagonist control method. Extended physiologic proprioception (EPP) is again being pursued as a method for providing control over an electric-powered motion by using the innate controllability the amputee has over an existing more proximal joint. Power Sources Since batteries are a multibillion dollar consumer industry. Research should improve some of the remaining difficulties. Whether rechargeable or disposable. no practical application is currently available commercially. The postulate-based control developed at the University of Utah could possibly be refined into a practical system by simplifying the 14-muscle approach of the laboratory to a 4. Practical experiments have controlled an electric elbow by converting the force information to a command for the elbow. wrist.to 5-muscle clinical system. Locking shoulder joints designed. simultaneous control of more than 1 degree of freedom is not easily accomplished. like power steering on a car. despite extensive research in the past on several methods for control of multiple degrees of freedom. For instance. thus eliminating the control cables (the most unpopular feature of body-powered arms). their application to arm prosthetics is not expected to expand due to the convenience of batteries and electric motors. Present externally powered arms offer powered degrees of freedom at the elbow. Also. The previously mentioned EPP controllers have been demonstrated with the Boston Elbow and the Hosmer Elbow. However. However. Brunswick. so that the position sensation is provided. most commercially available devices must be considered firstor second-generation technology. at the http://www.asp[21/03/2013 21:55:02] . existing electric elbows will be adapted easily to a position controller input. as shown in Fig 12D-5. Internally implanted EMG electrodes that transmit the EMG signal across the skin via telemetry have been used experimentally at the University of Alberta and may hold promise for the future since they eliminate the problems with the Some work in this area continues at the University of New skin-electrode interface. However. A mechanical link to the elbow-forearm motion is provided by connecting the control cable directly to the forearm around a pulley. Fortunately. Postulate control could conceivably provide simultaneous control of 2 or 3 degrees of freedom in a single prosthesis. This provides the "physiologic proprioception" of Simpson's theory.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library External Power The application of external power to artificial hands and elbows. and the next decade should see many continuing improvements on what has been an encouraging start. this technology can be expected to continue to advance in the next 10 years. The technical improvements have increased the capacity of rechargeable batteries in recent years. Although pneumatic and hydraulic power sources are still considered in some centers. Improved resistance to electrical interference from outside sources is possible and would improve the performance of most myoelectric systems. As mentioned previously. the issues of biocompatibility and additional surgeries are drawbacks for most patients. and hand.org/alp/chap12-04. Sensors for the tension in a control cable have been developed that use either load-cell-type force transducers or force-sensitive resistive material. the remnant motions of the shoulder or humerus could be used for patients without good control over residual EMG signals. the use of readily available consumer batteries is expected to become more and more commonplace.. Fig 12D-7. with the other components. and the price per battery is usually low enough to compete with an expensive rechargeable battery pack. disposable alkaline batteries have become a viable alternative for many amputees. shows position-controlled versions of the Utah Arm also. This is the most physiologically natural control and is usually easy for an amputee to master. and Fig 12D-6. has had a great impact on upperlimb prosthetics in the last two decades. Note that both postulate control and pattern recognition approaches require multiple EMG sites as well as a sophisticated calibration procedure to the amputee and the EMG signals that are produced. although little actual force is required. myoelectic control could be used from biceps and triceps. Externally Powered Hands Progress is likely in externally powered hands because in this area (more than others) developments may be "market driven.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library University of Utah. Also. and forearm pronation and supination. it is difficult to envision any significant simplification or reduction of the challenge. the market is large enough that manufacturers may realize a return on their investment. Position control and EPP are not without their drawbacks. Composite/plastic structural materials also offer promise for lowering the weight of artificial hands when used to replace metal structural elements and gearing.oandplibrary. By using another mathematical device known as a "perceptron" the parameters can be analyzed to distinguish among the functions performed by the muscle. Improved motors will allow not only smaller and lighter hands but also more efficient energy consumption for longer battery life. work at Delft University in is seeking to develop a child-sized hand powered by small gas canisters. Any approach will require sophisticated control logic and electronics as well as multiple motors and an external power source. fingers that curl around an object). Scotland. Variations of currently available hands will be seen.asp[21/03/2013 21:55:02] . the group at the University of New Brunswick has claimed good success at distinguishing separate functions from a single EMG signal." Since amputees have a strong desire for improvements and since all prostheses require some type of terminal device.. The Netherlands Since greater energy storage is possible in such a canister than in an equivalent-weight battery. Dedicating a remnant body motion to one or more motions of the prosthesis may involve a sacrifice of natural function for some patients.org/alp/chap12-04. faster. A wrist-driven child's hand is also being produced ( Fig 12D-8 ). however. Innovations such as brushless dc motors and cobalt samarium magnets are lowering the size and weight required to deliver a specific torque output. This method awaits a practical field trial. http://www. if available. Although EPP is certainly a feasible approach for control of multiple degrees of freedom.e. Alternatively. but the gap is narrowing. plastic materials have not had equivalent strength-weight ratios to metals. Examples include the hand under development at Princess Margaret Rose Hospital in as well as other hands under development that promise a compliant grip. Electric motors continue to improve each year. A modular system of knuckle and thumb drives is planned so that as many as six sizes could be produced from symmetrical structural components. elbow flexion. then a second independent direction of shoulder motion must be harnessed for control of prehension. with the goal of more cosmetic and cleanable gloves ( Fig 12D-9. Reviving the pneumatic drive approach used in previous decades. It is also likely that hands with tip prehension between the thumb and first finger will be developed so that two fingers may have a key-grip-type prehension that has not been available in electric hands. This area is also promising because several technical improvements are feasible. (i. New design approaches in hands should provide a greater range of gripping modes.. if the shoulder motion (protraction) in longer transhum-eral amputations is dedicated to elbow control. as well as gloves that are more easily replaced by the users themselves. e.). synergetic drive in the palm that eliminates some gearing used in previous adult hands (see Fig 12D-10. A need exists for gloves that are more readily custom-colored to the skin tone of the amputee. When a computational technique known as a Hopfield network is used. elbow extension. where muscle intent may be more difficult to decipher. and smaller hand for children may be possible. Silicone production gloves are under development also. Gloves for externally powered hands should see the use of reinforced silicone materials that are more easily cleaned and more natural looking. ). A similar drive will also be made for the adult-sized Otto Bock hand. a lighter. Heretofore.g. demonstrate the practicality of the concept and the large work envelope possible with them. By using time series analysis methods similar to Graupe's work described earlier. the EMG signal can be rapidly analyzed and represented as a time series with numerical parameters that vary according to the function performed by the muscle (the biceps or triceps in this case). likely with added improvements in reliability and lighter weight. The Otto Bock hand in 1990 has been introduced in a child's size with a direct drive from a two-motor. However. Elbow Prostheses The trends toward smaller motors and improved plastics should also benefit transhumeral amputees. Pressure-sensing technologies are under development in the robotics industry. a pinch force of over 8 lb for each finger and a speed of 2 radii per second have been achieved. As mentioned previously. Technologies utilizing reflection of light across a thin layer of polymer (polytetrafluoroeth-ylene [PTFE] or Teflon) have been experimented with. the technology promises to be relatively expensive and thus less attractive for commercial application in an era of cost containment by third-party payers. strong and lightweight plastics. . the feasibility of miniature motor and drive systems for individual fingers and a thumb has been demonstrated ( Fig 12D-12. e.e.asp[21/03/2013 21:55:02] . this approach will require the development of a very small actuator that can be installed within a socket. the motors will drive linear actuators mounted in a structural framework that will replace the pneumatic actuators in the early "Simpson" arm prostheses of the 1960s and use an updated EPP-type controller. although implantable materials are required that can transduce the action Efficient telemetry electronics will also be potentials of a nerve over a long period of time. However.oandplibrary. As shown in Fig 12D-11. An externally powered hand used with a body-powered elbow is commonly fitted at many centers and will be even more feasible when body-powered elbows offering greater efficiency of cable control become available. and miniature electronics may allow a practical prosthesis in the future. extended physiologic taction (EPT) may prove feasible by using a small "pusher" actuator to present a pressure proportional to the pinch force on the amputee's skin.. combined with variable elbow joint impedance (resistance) controlled by the coactivation of the two muscles. ). One might say that the multiple-degree-of-freedom control theories developed and demonstrated by Jacobsen and others await lighter and smaller actuators and computerized implementation. A few modules of different sizes are planned that will be used to drive different joints in various sizes of prostheses. Weir reports that by using a "syner-getic" drive. i. uses a prosthesis control emulator to compare control Some more recent work at MIT methods for a myoelectric elbow (a Boston Elbow). in this case a position controller commanded by the difference of two muscle EMG signals. from single digits to transcarpal. and "spin-off' from that area into prosthetics may make its application in prosthetics possible.. Experimental work on EMG control theory is not presently being pursued widely. http://www. an adult-sized elbow may be also used as a child's shoulder. Partial-Hand Prostheses One area that has been neglected in prosthetics research and development is the transcarpal. or partial-hand. etc. New electric drive modules for upper limbs are being developed at the Princess Margaret Rose Hospital in Edinburgh. They found that their "natural" controller had performance closer to the intact natural elbow. as has the application of strain gauges directly to the metallic fingers of an artificial hand. perhaps within the socket. Development is difficult because of the wide variety of loss suffered by these patients. Nerve stimulation has appeared promising in the past. necessary to transmit across the skin barrier.org/alp/chap12-04.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library Sensory Feedback in Artificial Hands Although previously mentioned work showed promise for the feasibility of a practical sensory feedback system. Other techniques such as electrotactile and vibro-tactile feedback may be possible as well. A simulation of "natural" control was made. The group hopes to compare other control schemes in the future such as the Utah Arm controller. Although the weight and size constraints remain daunting. "Hybrid"-type fittings using one or more externally powered joints combined with body-powered components should continue to grow in popularity.g. Presentation of the pinch force information to the amputee is another side of the problem. Future possibilities of small battery supplies. The MIT group uses a crank-turning apparatus to compare this type of control with both the natural elbow and the high-impedance controller for the Boston Elbow. prosthesis. Also. either private or governmental. Rather.g. control of humeral rotation simultaneous with other motions will require a more sophisticated control scheme than those available commercially. which makes installation difficult and makes it awkward to combine with a flexion joint. Studies have shown the cost-effectiveness of successful rehabilitation. Experiments conducted by using pyrolytic carbon materials and hydroxyapatite materials show promise for allowing attachment of man-made materials directly to bone. robotics.oandplibrary. composite plastics. higher-torque wrist rotation modules seem feasible and attractive to many amputees. Development is also hindered by the fact that traditional reimbursement levels in prosthetics are based on devices made with older technologies. industry cannot expect a high-volume return from their development efforts for the small upper-limb amputee population. Research centers as well as industrial research also have difficulty gaining and maintaining momentum because of limited funding in prosthetics research.. but the energy and torque requirement to move an entire prosthesis at the shoulder joint is high and requires a large battery supply and large drive unit (see Fig 12D-11. such improvements affect not just the performance of a mechanical device. Current externally powered wrist units require significant length (approximately 2½ in. and a reasonable weight is now technically feasible with presently available technology. usually distributed according to the size of the population of need. A joint that may be locked or unlocked and repositioned easily by its wearer could add significant function for the high-level shoulder disarticulation or for the interscapulothoracic (forequarter) amputee. etc. aircraft. an artificial hand with compliant gripping modes. However. However. etc. Direct attachment to remnant skeletal elements may yet see progress in the decade of the 1990s. sensory feedback.asp[21/03/2013 21:55:02] .). Ideally. Also. usually with lower manufacturing costs. External power of humeral rotation should be expected as well since a modular wrist rotation device could conceivably also be used for humeral rotation.g. Perhaps a simplification of one of the experimental methods for control of multiple degrees of freedom will prove successful. ). Externally powered solutions are being pursued by the Edinburgh group.. COMMENTS ON THE RESEARCH AND DEVELOPMENT ENVIRONMENT IN UPPER-LIMB PROSTHETICS Those interested in the development of new upper-limb prosthetic devices face a predicament: great possibilities without the availability of sufficient resources to achieve them. allocates but a sliver of total medical research funds for the development of prosthetic devices. the trans-skin interface may be a more difficult problem since the risk of infection threatens not only the viability of attachment but also the health of the patient. Smaller. prosthetics is an area where significant progress can be made rapidly. Another effect of the meager funding available for prosthetics research is that very little basic research can be pursued in this area. This shortage of resources can be traced directly to the small size of the patient population. Potentially this can be used to influence both funding sources and reimbursement sources to value the improvements of research and development for their life- http://www. to problems in prosthetics.. New devices invariably cost more than the older devices they replace because of the capital costs of starting new products in addition to development costs. who can see the technology developed for other industries. consumer electronics. However. This situation is inherently frustrating for both the amputee and the developer. lifelike cleanable gloves. a wrist rotation unit can be used with wrist flexion either proximal or distal to the rotation joint itself. e. that still awaits application in artificial limbs. For example. one positive aspect of prosthetics research is that when new technologies become available. prosthetics must adapt technologies from other industries.org/alp/chap12-04. batteries. However. Research funding.. A team with experience and a track record takes several years of continuous work to establish. the price tag necessary to deliver such a prosthesis would probably not be reimbursed by any present funding sources. but have a profound impact on an amputee's life and livelihood.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library Other Components Improved shoulder joints should eventually be developed. electronics. and discontinuities in funding break up a development team so that the advantage of continuous experience in the field is lost along with the momentum. e. Scott RN: The application of neural networks to myoelectric signal analysis: A preliminary study. American Society of Mechanical Engineers (ASME) Trans 1980. J Rehabil Res Dev 1990. 17. 1990.oandplibrary. 1989. 10:274-358. J Bone Joint Surg [Br] 1988. Goulding PP: Extended Physiological Taction. Kato I. References: 1. psychological outlook. 15. 18. Douglas WB: A new prosthesis for the upper-limb. Kelly MF. 22. 20. Freedy A. Strysik JS. http://www. Straight R: Development of advanced body-powered prosthetic arms. 15:70-77. Jacobsen SC: Laboratory evaluation of a unified theory for simultaneous multiple axis artificial arm control. Int Orthop 1981. Gow D: Written communication. J Prosthet Orthot 1988. IEEE Trans Biomed Eng 1990. Jacobsen SC. Carlson L. 28:21. Radocy R. Grahn EC: Design of a modular extended physiological proprioception controller for clinical applications in prosthesis control. 23. 6. Solomonow M: Studies toward a practical computer-aided arm prosthesis system. Bull Prosthet Res 1974. 11. Carlson L. Washington. 2. Knutti D. Herberts P. Heckathorne CW. 10:213-225. Lyman J. Carlson L: Oral communication. 9. and general health as a direct result of improvements in technology. Salt Lake City. Kruit J. Graupe D. Progress reports. University of Utah. 1984. Yugoslavia. LeBlanc MA: Clinical evaluation of externally powered prosthetic elbows. Salt Lake City. Clippinger F: A sensory feedback system for an upper-limb amputation prosthesis. Childress DS: Design and evaluation of a prosthesis control system based on the concept of extended physiological proprioception. Parker D. 5. LeBlanc M: Evaluation of a new design: Body powered upper-limb prosthesis without shoulder harness. 1989. IEEE Trans Biomed Eng 1982. 12. Presented at the International Conference of the Association for the Advancement of Rehabilitation Technology. 37:1037-1047. 4. SMC 5:252-259. Jacobsen SC. J Rehabil Res Dev 1991. 19. 1:45-49. 1987. Scott G: Extended physiological proprioception for the control of arm prostheses. 26. 10.21:19-31. J Med Eng Technol 1978. Parker PA. 14. DeLuca CJ: Control of upper-limb prostheses: A case for neuroelectric control. Dubrovnik. Hemisphere Publishing Corp. Design and Evaluation of a Sensory Feedback System for Myoelectric Control of a Terminal Device (thesis). 8. Bull Prosthet Res 1974. 24. pp 90-91. Nelson C: New Designs for Prosthetic Prehensors. 26:14. Proceedings of the Ninth International Symposium on Advances in External Control of Human Extremities. Meek SG. Johnson RT. IEEE Trans Syst Man Cybernet 1975. Alstrom C. 13. Artif Limbs 1971. 37:221-230. Dick TD. Meeks D. J Prosthet Orthot 1991. 70:140-144. Erb RA: Cosmetic covers for upper and lower extremity prostheses. 25. Korner L: Experience with Swedish multifunctional prosthetic hands controlled by pattern recognition of multiple myoelectric signals. pp 226-227. DC. Presented at the 12th Annual Rehabilitation Engineering Society of North America (RESNA) Conference. J Rehabil Res Dev 1991.asp[21/03/2013 21:55:02] . 16. 2:57-61. 29:249-269. Doubler JA. Glass JM: Characterization and Testing of Synthetic Hy-droxyapatite and Hydroxyapatite Composite (dissertation). J Rehabil Res Dev 1984. 28:4. rev ed. Hogan N: Functional assessment of control systems for cybernetic elbow prostheses Part II: Application of the technique. 1990. June 1988. 3. Lamb DW. Progress reports. Cool JC: Below-elbow prosthetic system. 1982. 21. Marshall PD: Spectron 12 cable for upper-limb prostheses.12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library enhancing effects on an amputee. 7.org/alp/chap12-04. University of Utah. 1987. Jerard RB. 5:15-21. New Orleans. Cline W: Functional separation of EMG signals via ARMA identification methods for prosthesis control purposes. 1991. et al: Development of the Utah Artificial Arm. Abul-Haj CJ. 102:199-207. LeBlanc M. Andrew JT: Written communication. Department of Bioengineering. Sadamoto K: Mechanical Hands Illustrated. Montreal. Department of Bioengineering. independence. Advanced prosthetics research has the potential to improve productivity. 3:130-141. IEEE Trans Biomed Eng 1990. 1991. 32. New York. et al: Myoelectric control systems-Progress report No. Hoffer JA. Hulbert SF. et al (eds): Biomedical Materials Symposium Number 2: Bioce-ramics Engineering in Medicine (Part I). October 1989. Salt Lake City. Children's Hospital at Stanford: Improvement of Body-Powered Upper-Limb Prostheses. size 2: A new alternative for adolescents and adults. In-terscience Publishers. et al: Guidelines for standards for externally powered hands.oandplibrary. 30. pp 146-150. UNB Bio-Eng Inst Res Rep 1980. pp 473-474. 1951. Caldwell RR. 39. Bull Prosthet Res 1969. Renning J. Final Report. 28:21. Presented at the 12th Annual Rehabilitation Engineering Society of North America (RESNA) Conference. J Rehabil Res Dev Winter 1991. 1990. Shannon GF: A myoelectrically controlled prosthesis with sensory feedback. Simpson DC: The choice of control system for the multi-movement prosthesis: Extended physiological proprioception (e.p. Med Biol Eng Comput 1979. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 12D The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 13:25-28. 1989. 33. Stein RB. Contractors Final Report. 29. Springfield. 1974. Charles C.Atlas of Limb Prosthetics: Surgical. 37. Thomas. Chapter 12D . Plettenberg DH: A myoelectrically-controlled.).asp[21/03/2013 21:55:02] . Bull Prosthet Res 1978. New Orleans. Mooney VL. Mason C. Wright DW. Bull Prosthet Res 1980. 10:215. 258:9-17. Charles D.org/alp/chap12-04. Ill. Shaperman J. Rehabilitation Engineering Center. Taylor DR. 31. 1972. Nader N: The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop 1990. Weir RFF: The design and development of a synergetic partial hand prosthesis with powered fingers. 10:8-35. 28. 17. Department of Bio-engineering. 17:5162. Northrup Aircraft. Prosthetic. 80:2. Radocy R: Oral communication. 36. 34. Scott RN. Brittain RH. Sears HH: Evaluation and Development of a New Hook-Type Terminal Device (dissertation).12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library 27.p. 35. 41. in The Control of Upper-Extremity Prostheses and Orthoses. Contact Us | Contribute http://www. et al: New approaches for the control of powered prostheses: Particularly by high-level arm amputees. Finley FR: Pattern recognition arm prosthesis: A historical perspective-final report. Predeki PK. Wirta RW. Levine SN. University of Utah. Motis GM: Final Report on Artificial Arm and Leg Research and Development. et al: Skeletal extension of limb prosthetic attachments-Problems in tissue reaction in Hall CW. 1983. 17:73-80. Peizer E. Setaguchi Y: The CAPP terminal device. 38. pneumatically-powered hand prosthesis for children. 40. Prosthet Orthot Int 1989. American Academy of Orthopedic Surgeons. These need to be understood for an appropriate interpretation of some of the limitations displayed by patients. The second. 1. At the same time the quadriceps ties the femur to the leg so that the thigh also advances (although at a slightly slower rate).oandplibrary. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists Functional Elements The three components of walking-progression. Prosthetic. Prosthetic. 1992. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. ©American Academy or Orthopedic Surgeons. Effectiveness depends on free joint mobility and muscle action that is selective in both timing and intensity. the clinician becomes able to define the significant deficits and plan appropriate corrective measures. You can help expand the O&P Virtual Library with a tax-deductible contribution.asp[21/03/2013 21:55:07] . During this time the opposite limb is in swing.). Reproduced with permission from Bowker HK. Rosemont.org/alp/chap13-01. NORMAL GAIT Gait Cycle Each sequence of limb action (called a gait cycle) involves a period of weight-bearing (stance) and an interval of self-advancement (swing) ( Fig 13-1. Walking depends on the repeated performance by the lower limbs of a sequence of motions that simultaneously advances the body along the desired line of progression while also maintaining a stable weight-bearing posture. standing stability.e. There also are minor differences among individuals. 2. IL. when both feet are in contact with the ground) and usually involves the initial and terminal 10% intervals of stance. during walking all three action patterns are intertwined throughout each stride.).13: Normal Gait | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 13 Chapter 13 . The loss of some actions necessitates substitution of others if forward progression and stance stability are to be preserved. Although for this description they will be separated.Atlas of Limb Prosthetics: Surgical. Thus. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. During the normal gait cycle approximately 60% of the time is spent in stance and 40% in swing. starts with the onset of single-limb support. http://www. Through a detailed knowledge of normal function and the types of gait errors that the various pathologic conditions can introduce. M. Progression There are two main progressional forces: 1.D. The middle 40% is a period of single stance (single-limb support). As the foot drops toward the floor.The primary one is forward fall of the body weight ( Fig 13-2. This begins in single stance as the ankle dorsiflexes beyond neutral and accelerates with heel rise. and Rehabilitation Principles Normal Gait Jacquelin Perry. The exact duration of these intervals varies with the walking speed. Pathologic conditions alter the mode and efficiency of walking. The momentum generated by these two actions is optimally preserved at the onset of the next stance phase by floor contact with the heel. edition 2. and Rehabilitation Principles. which is generated by the contralateral swinging limb ( Fig 13-3. reprinted 2002.. and energy conservationinvolve distinct functional patterns. This action is particularly important before the body is aligned for an effective forward fall. The reciprocal action of the two limbs is timed to trade their weight-bearing responsibility during a period of double stance (i. Prosthetic.). Normal function is also optimally conservative of physiologic energy. Click for more information about this text. the pretibial muscles draw the tibia forward ( Fig 13-4.). and walking continually alters segment alignment. During the midstance period the body http://www. however. so there are no restraining rims available in the sagittal plane and. This is the torque created. The length of the lever (moment arm) is the perpendicular distance between the body weight line and each joint center. There is minimal postural change occurring during normal gait. arms. Also. as evidenced by the ease with which one carries packages. Thus the ever-changing alignment of body weight is stabilized by selective muscular control. Thus. the person is able to attain passive stability. The skeletal architecture is designed for mobility. Conversely. Once the forefoot becomes the major area of support. and trunk are the passenger unit because they are carried rather than directly contributing to the act of walking. Arm swing is primarily a passive reaction to the momentum generated. The body is top-heavy. At the beginning and end of stance. This makes the pelvis an element of both the passenger and the locomotor units. Muscle action within the neck and trunk serves only to maintain neutral vertebral alignment. here a free range of dorsiflexion-plantar flexion and in-version-eversion exists.org/alp/chap13-01. The timing and intensity of each muscle's activity are dictated by the relationship of body weight to the center of the joint that muscle controls. This necessitates both a free joint range and ability of the calf muscles to yield as they provide tibial stability. this demand is gradually replaced by passive support from tense fasciae. Body weight is the basic force. At the hip anteriorly and the knee posteriorly a strong ligament stabilizes one side of the joint. ankle. Standing Stability Balance is challenged by two factors. Instead. By contrast. for optimum foot support (equal anterior and posterior leverages). only through direct muscular control is the tibia stabilized over the foot. No similar mechanism exists at the ankle or subtalar joints. The small amount of active control has not proved essential. If these segments were square blocks. the anterior (forefoot) lever that extends to the weightbearing surface of the metatarsal heads averages 10 cm in an adult. At the onset of stance. the articular surfaces are segments of a circle. This increases the demand for active control of the ankle and subtalar joints.oandplibrary. the demand for active ankle restraint (a plantar flexion force) does not begin until body weight moves forward of that joint axis. The resulting accelerations increase the ground reaction force to a value greater than the body weight. The head. leg. for the significant factor is the rounded contour of the tuberosities and not the full length of the os calcis. during the support phases there must be adequate passive mobility at the ankle. During walking the body divides itself into two functional units-passenger and locomotor. but its effect is modified by the direction in which it is moving. This long lever (33 cm in an average adult ) makes balance of the passenger unit very sensitive to alignment changes of the supporting limbs. with two highly mobile junction sites. As body weight moves forward.13: Normal Gait | O&P Virtual Library throughout the stance period the heel. Instead. the femur and tibia are tall narrow bones. no intrinsic stability. flexion torques are created at the hip and knee that must be restrained by active muscular effort. Additionally. experimental restraint of arm swing registers no change in the energy cost of walking. Passive stability is further challenged by the fact that the foot does not provide equal areas of support anterior and posterior to the ankle axis. the body weight line (vector) must be anterior to the ankle joint. The composite effect is determined by measuring the instantaneous ground reaction forces.asp[21/03/2013 21:55:07] . The locomotor unit consists of two limbs joined by the intervening pelvis. the lumbar spine and hip joints. consequently. This means that other stabilizing mechanisms are needed. Thus. muscular response must increase rapidly. For this to occur the foot must be appropriately positioned by the end of swing and controlled as weight is applied.). During walking the trunk and limb segments are continually moving from behind to ahead of the supporting foot. a product of force times leverage. Thus passive stability is a fleeting experience. Then. By using hyperextension to align body weight on the opposite side. Posteriorly the weight-bearing segment of the heel is little more than 1 cm. weight-bearing stability of the limb is maximal when its three components (thigh. and forefoot serially serve as a rocker that allows the body to advance over the supporting foot ( Fig 13-5. The composite mass center of these segments is just anterior to the tenth thoracic vertebra and thus lies well above the hip joints. and foot) are vertically aligned so that one is directly over the center of the other. there would be a broad shoulder to allow considerable tilting before balance was lost. Theoretically. body weight drops rapidly toward the floor. standing stability. This normally is accomplished by two mechanisms: momentum is substituted for muscle action wherever possible.oandplibrary. although the latter arc of motion occurs in the double-stance period when the limb is being rapidly unloaded. All three approximate 4 degrees and follow the swing limb. With toe-off the foot is quickly raised to neutral dorsiflexion and maintained in this position throughout swing. this is oxygen used per meter traveled. The stance limb contributes by two actions. body height is lowest because the two limbs are diagonal. The result is eight functional units. it again begins to flex.13: Normal Gait | O&P Virtual Library rises slightly as the limb becomes more vertical. and displacement of the body from the line of progression is minimized.). Also. As the heel is loaded.-The knee also experiences two phases of flexion and extension in each gait cycle ( Fig 13-7. Energy Conservation The basic measure of efficiency is energy expenditure per task performed. PHASES OF GAIT The functional significance of each joint's motion pattern at any point in the gait cycle is dependent on the total limb requirements for effective progression and stance stability. At the onset of a double stance. This is identified by subdividing the continuum of limb action according to the tasks that must be accomplished. Throughout stance there is progressive extension into 10 degrees of hyperextension. With the onset of double stance. For a normal adult step length of 70 cm the height loss would be abrupt. At this time plantar flexion is resumed and reaches 20 degrees by the end of stance.-Two periods of plantar flexion and dorsiflexion are experienced in each gait cycle ( Fig 13-6. For walking. and ankle dorsiflexion of 22 degrees would be needed by the trailing limb. Then flexion begins in terminal double stance and continues through most of swing. Joint Motion The interplay of progression. it rapidly flexes to 15 degrees. At the beginning of the weight-bearing period a reciprocal relationship between knee flexion and ankle dorsiflexion adjusts limb length as it moves from a diagonal to a vertical alignment. http://www. Then the action reverses and gradually reaches 10 degrees of dorsiflexion. the force demands presented to the muscles vary by both the loading experience and the alignment of body weight over the joints.asp[21/03/2013 21:55:07] . Optimum use of momentum occurs during the person's natural gait velocity. Both a slower and a faster pace increase the energy cost. knee. Hip.org/alp/chap13-01. when the supporting limb is vertical. and energy conservation results in a complex and continually changing relationship among the various limb segments as the body advances over the supporting foot and the toe is lifted to clear the ground. the highest position occurs in the middle of single stance. When the 30-degree posture is reached. 2. As the foot strikes the ground. Conversely. normal gait involves three pelvic motions: lateral drop. Minimization of body displacement from the line of progression is accomplished by coordinating pelvic. Through these actions the potential 7-cm displacement is reduced to 5 cm. the foot drops into 10 degrees of plantar flexion. 1. Each joint performs a representative pattern of motion. Then it progressively extends to neutral. Ankle. That motion pattern requires the least energy expenditure per meter traveled. and ankle motion to keep the relative limb length fairly constant throughout stance.). Thus efficiency is improved by reducing the amount of muscular effort required to walk.). This somewhat reduces the weight directed toward the ground. the hip is in 30 degrees of flexion. At the onset of stance the ankle has a 90-degree position. a 30% saving. heel rise in the latter half of stance adds relative length to the trailing limb.-Only a single arc of hip extension and flexion occurs in each gait cycle ( Fig 13-8. Oxygen is consumed as the muscles contract. Knee. Each constitutes one phase of gait. To reduce these extremes. Consequently. This action continues in swing to reach 60 degrees before extension is resumed. Swing-phase motion depends on muscle action. and anterior tilt. it is maintained until stance resumes. During stance the postural changes are induced passively by the influence of body weight. Selective neural control and proprioception as well as adequate strength are needed for appropriate muscle response. transverse rotation. Beginning in full extension (or flexed 5 degrees). Because one gait cycle blends into the next in an endless fashion. Although this was adequate for amputees. Although this is a momentary posture. and to appreciate the penalties that disabled performance imposes. Initial floor contact is the most consistent event in both normal and pathologic gait and. there is also transverse rotation at the subtalar The point of heel contact is lateral to the middle of the ankle joint ( Fig 13-10. and paralytic patients. heel strike is heard but no foot slap. The ankle is in an approximately neutral position (perhaps plantar-flexed 3 degrees). http://www. will serve as the first gait phase. While these sagittal motions are occurring. This action dominates the first 6% to 8% of the gait cycle.org/alp/chap13-01. the foot quickly drops into 10 degrees of plantar flexion in a controlled manner. The action at the ankle precedes and contributes to that occurring at the knee. An unstable lever results from differences in bone length between these points. As the foot responds. To avoid such confusion. Stance To allow progression while also maintaining weight-bearing stability. knee extension. Three torques are generated: ankle plantar flexion. the limb performs five distinct tasks that define the phases of stance. support for the talus is reduced. a heel rocker action is initiated that leads to two significant motion patterns. so forefoot contact is gradual. Normal function is the model for judging a patient's gait. long extensors of the great and common toes. Dorsiflexion of the ankle to neutral is dependent on free joint mobility and active control by the pretibial muscles (tibialis anterior. Strong action by the pretibial muscles retards the terminal arc of ankle plantar flexion. At this moment the free drop of body weight creates a vertical vector passing through the heel that is anterior to both the knee and the hip. The significance of the observed deviations relates to the changes in total limb posture that occur during the individual gait phases. and hip flexion ( Fig 13-9. The strong ankle ligaments carry the tibia and fibula with the talus so that the entire ankle joint turns inward. This joint. Knee extension is accomplished by quadriceps action. Disability reduces the limbs' effectiveness by altering their pattern of motion. arthritic. amputee. and the hip is flexed 30 degrees. Initial Contact Of primary concern is the way the foot strikes the floor. it is significant because of its influence on subsequent knee action. Thus. ). Because it has proved universally applicable to normal.asp[21/03/2013 21:55:07] . thus. Control of both knee and ankle is critical to having normal heel strike. a generic terminology was developed.oandplibrary.13: Normal Gait | O&P Virtual Library Normal events have customarily been used to designate the different gait phases. Thus the basis of gait analysis is to have a firm concept of limb function during each gait phase. many other types of disability prevented the patients from accomplishing some of the key actions. and peroneus ter-tius). Loading Response Acceptance of body weight in a manner that ensures limb stability and still permits progression is the goal at this time. to know the purpose of the normal motion patterns. Ankle. As weight is dropped onto the limb.). creates a valgus thrust on the subtalar joint. The talus falls into internal rotation. The motion is initiated when body weight is applied to the foot at the dome of the talus while floor contact is still at the tip of the os calcis. -After floor contact by the heel. Hip position does not influence the mode of floor contact but does determine the angle between foot and floor. Heel strike with the foot at a 25-degree angle to the floor is the normal occurrence. any event can be selected as the starting point. it is the system that will be used in the ensuing discussion. The knee is extended between 0 and 5 degrees of flexion. The terms thus became meaningless. An available range and timely tibial restraint are the critical events during midstance. ). and the quadriceps relaxes. The basic arc is from -5 to +5. Both these muscles markedly increase their activity after initial contact. Rapid realignment of the vector to the body center brings the weight line close to the hip joint axis (see Fig 13-11. and an extensor moment is begun. Thus an ankle rocker is created for body progression. Assistance by the gastrocnemius reduces the effort that the soleus must exert. As the pretibial muscles contract to restrain ankle plantar flexion. An extensor thrust created by propulsion of the limb through the heel rocker advances the femur as well as the tibia. The large hip flexion moment present with the impact of initial floor contact is reduced by two passive actions. There is increased quadriceps activity to restrain the rate of knee flexion. ). As the body vector moves anterior to the ankle. As body weight advances across the arch. Participation by the hamstrings is reduced because of their actions at the knee. Conversely.org/alp/chap13-01. Marked reduction of semimembranosus and semitendinosus activity is the Persistence of the biceps femoris (long head) probably relates to its external response. The need for active muscular control is terminated. and hip. As a result the body weight line shifts posterior to the knee. -Flexion of the knee to 15 degrees is initiated by the heel rocker action. -Little change in thigh position occurs during the loading response. From this position there is gradual dorsiflexion. At approximately the middle of the midstance phase the body vector moves anterior to the joint center. knee. -Knee flexion induced during the loading response increases slightly and reaches its maximum of 18 degrees just as single-limb support is initiated. While these two muscles are acting to avoid excessive tibial advancement. and this occurs through residual momentum and that generated by the contralateral swinging limb. Motion of the knee then reverses to progressive extension. a dorsiflexion moment is created that would accelerate the rate of limb advancement if it were not controlled. but it also induces a flexion torque at the knee. they are doing so in a yielding manner. Knee. the base of the vector moves from the heel to the forefoot. with 10 degrees of dorsiflexion being attained just as the heel rises to initiate terminal stance. and advancement of the body vector lessens the flexor torque. and a flexion torque (moment) is induced ( Fig 13-11. Quadriceps action is maximal at the onset of midstance. Allowing the tibia to advance beyond the neutral position so that body weight moves over the forefoot is the critical action. The soleus responds by restraining the tibia's progression. and it advances the leg faster than the thigh and trunk can follow. extension stability is provided passively. Midstance Advancement of the body and limb over a stationary foot is the functional objective of this gait phase.asp[21/03/2013 21:55:07] . they also draw the tibia forward. with resulting changes in joint posture and muscle control ( Fig 13-12. Hip. Judicious restraint is an essential component of knee stability. -At the onset of single stance the ankle is still slightly plantar-flexed (5 degrees). Ankle rocker action allows progression to continue.13: Normal Gait | O&P Virtual Library Knee. This alters vector alignment at the ankle. Two types of muscle action result. rotation action at the knee. a period of single-limb support begins. As the other foot is lifted for swing. This is a rapid action. It then progressively declines as the knee extends over the vertical tibia. ). http://www. which depends on the tibia's being actively restrained by the soleus so that the femur can advance at a relatively faster rate.oandplibrary. Active muscular restraint of the hip flexion moments is provided primarily by the gluteus maximus and adductor magnus. Maximum stability is gained by having the foot stationary and in total contact with the floor (heel and first and fifth metatarsal heads). Ankle. thus the desired degree of ankle dorsiflexion is attained. Once the vector becomes anterior to the knee axis. no longer are the hamstring muscles needed to prevent knee hyperextension. with the body falling forward of its area of support. While most of body weight is concentrated on the metatarsal heads. -Progressive decline in hip flexion and entry into extension allow the trunk to remain erect while the limb becomes more vertical. Hip abductor muscle activity is intense throughout midstance while the extensors are quiet. The longand short-toe flexors also support the arch by the compressive force that their longitudinal alignment provides. ). forward alignment of body weight passively extends the knee. cuneiform-cuboid. -With the tibia stabilized on the foot. All the foot and toe muscles are active. With heel rise the body vector is concentrated at the forefoot ( Fig 13-14. the body's center of gravity drops slightly during advancement. This locks all the midfoot joints (transverse tarsal. This creates the primary propulsive force for walking. and passive abduction is induced. Foot. Hence stabilization in a relatively neutral position is the objective so that the forefoot can act as the propulsive rocker. intercuneiform.13: Normal Gait | O&P Virtual Library Hip. As body weight begins to fall toward the other limb.asp[21/03/2013 21:55:07] . a strong dorsiflexion torque is generated through the midfoot. At the same time it is restrained by the peroneals (longus and brevis). which is tensed as the MP joint dorsiflexes. Lifting the opposite limb removes support for that side of the body ( Fig 13-13.-With body weight being applied at the ankle (talus) and supported by the forefoot. The distance between the vector and ankle joint axis generates a maximal dorsiflexion torque. however. The line between the second Inversion of the and fifth metatarsal heads is 28 degrees anterior to the coronal plane. Compression from the toe flexors and tension from the plantar fascia also stabilize the MP joints so that the phalangeal bases can add to the base of support. At the end of terminal stance when the vector is at the margin of MP support. creates new demands in the coronal plane. -Passive extension of the hip joint continues as body weight advances beyond the supporting foot and the trunk remains erect. The anterior joint structures are maximally stretched by falling body weight. Maximum extension varies between 0 and -5 degrees. Hip. Throughout terminal stance the ankle and foot are the critical sites of action. The unsupported pelvis falls and creates quick hip adduction in the stance limb.oandplibrary. The onset of single stance. This must be restrained if the ankle is to maintain its neutral position. Preswing http://www. -At the onset of heel rise the ankle drops into the maximum dorsiflexion (10 degrees) occurring in stance. Heel rise signifies the onset of this second phase of single stance. ). the hip abductors terminate their action. There is no quadriceps action at this time. Stability is gained by inversion. Heel rise also initiates dorsiflexion at the metatarsophalangeal (MP) joint. This is rapidly limited to 4 degrees and then reversed by active abduction to the extent of slight over correction. At the end of terminal stance the body is well forward. Passive arch support is gained from the plantar fascia. This commonly stimulates the iliacus to provide a restraining force. Body weight is rapidly falling toward the other limb. the bases of the proximal phalanges contribute by enlarging the support area. Knee. Now the forefoot serves as the progressional rocker. With the limb acting like a spoke in a wheel. This posture is initiated by the obliquity of metatarsal support. There is no hip extensor activity during terminal stance. By the end of stance there are 10 degrees of hyperextension. Motion then reverses to reach 5 degrees of plantar flexion by the end of single-limb support. and the MP joint dorsiflexes approximately 20 degrees. Terminal Stance Forward fall to generate a propulsive force is the primary objective. Inversion is preserved by the tibialis posterior and soleus. Both the soleus and the gastrocnemius respond vigorously and cease abruptly as the single-stance period is terminated and body weight is rapidly transferred to the other foot. the knee begins to flex. subtalar joint so changes the axes of the talonavicular and calcaneocuboid joints that they cease to be parallel. for knee extension stability is gained from the body vector's continually being anterior to the knee joint axis. Stability is accomplished by the triceps surae. and metatarsal bases). These motions are accomplished passively.org/alp/chap13-01. Ankle. Although the iliacus is the major force advancing the thigh. Knee. This accelerates advancement of the leg and foot. This is not a major weight-bearing obligation. By the end of midswing. the knee joint axis is moved anterior to the body vector. -Flexion of the hip joint is initiated with the recovery from hyperextension to neutral that occurs during this phase. Ankle. The critical area of response is the knee. Rapid transfer of body weight to that limb allows the desired actions to follow. Despite the fact that this is a critical event. often accompanied by the rectus femoris. ). Ankle and Foot. http://www.asp[21/03/2013 21:55:07] . knee flexion (30 degrees) equals that of the hip. There is no flexor muscle action. Verticality of the tibia continues the need for active control of the foot. -Dorsiflexion to neutral is accomplished and then maintained. which occurs because the body weight has rolled so far forward on the forefoot rocker that the tibia no longer is stable. A flexion torque is created ( Fig 13-15. The muscles contracting quickly to lift the foot are the tibialis anterior. The quadriceps (mainly the rectus femoris) may react briefly to restrain the rate of passive knee flexion if needed. there is not a dominant flexion force. the need for speed generates assistance from the sartorius. and adductor longus. It sustains MP joint compression and restrains dorsiflexion while floor contact is maintained. the changes in the tibial alignment make foot control critical for floor clearance ( Fig 13-17. The critical event is complete knee extension ( Fig 13-18.org/alp/chap13-01. Hip. Knee. -Dorsiflexion of the ankle is initiated. -Relaxation of the flexor muscles allows the knee to extend passively. -There is rapid passive flexion to 40 degrees. -The amount of knee flexion required for toe clearance of the floor (60 degrees) is attained by adding 20 degrees to the 40-degree posture acquired during preswing. Only the flexor hallucis longus remains active. Hip. Knee.-There is rapid ankle plantar flexion to a 20-degree position. Thus toe clearance of the floor is not dependent on ankle dorsiflexion during the initial phase of swing. Ankle. is active. Initial Swing Recovery from a trailing posture is the task that is accomplished. and the tibia is vertical. ). -Maximum flexion to 30 degrees is reached by continued iliacus action. -From the neutral position attained at toe-off the hip rapidly flexes to 20 degrees. gracilis. Hip. Terminal Swing Advancement is terminated. Momentum from the advancing thigh is supplemented by action of the short head of the biceps femoris and the sartorius and gracilis. Midswing As limb advancement continues. a passive event since all the significant musculature is relaxed at the time of contralateral foot contact. As the tibia advances.13: Normal Gait | O&P Virtual Library Preparation of the limb for swing is the purpose of the actions that occur during the preswing phase. but only half the 20-degree plantar flexion present at toe-off is recovered in this brief time. and the limb is prepared for stance. Swing Lifting the foot from the ground and limb advancement followed by preparation for stance are the objectives of the three phases of swing. The tibialis anterior and other pretibial muscles respond accordingly.oandplibrary. ). The iliacus. ). Floor contact by the other foot initiates this interval of terminal double support. for the load is primarily on the other foot. This involves two critical actions: flexion of both the hip and the knee ( Fig 13-16. and peroneus tertius. long-toe extensors. 177:9. Baltimore. the hamstrings and single joint hip extensors exchange their intensities. et al: Timing and relative intensity of hip extensor and abductor muscle action during level and stair ambulation: an EMG study.oandplibrary. 5. Simultaneous contraction of the hamstrings to decelerate hip flexion also prevents hyperextension of the knee. Wright Air Development Center Technical Report 55-159. Phys Ther 1983. coordinate their actions to provide continual progression and weight-bearing stability with minimal displacement of the body's center of gravity.S. Ankle. Williams & Wilkins. under the selective control of 28 major muscles. Ralston HJ. and Mechanical Aspects of the Body With Special Reference to the Limbs.13: Normal Gait | O&P Virtual Library Hip. Drought AB. the loading response is an increase in the intensity of these hip and knee extensor muscles to stabilize the trunk and limb against the rapid transfer of body weight. Todd F: Human Walking. Dynamic dorsiflexion provides the necessary foot control. Ohio. 1976. Further progression of the tibia is gained by heel rise and forward roll over the forefoot in terminal stance. and biceps femoris long head-exhibit peak activity at this time. Active continuation of these events in initial swing and midswing lifts the toe to clear the floor and advances the limb. Perry J: Anatomy and biomechanics of the hindfoot. -Continued neutral dorsiflexion is the basic posture. and limb advancement. Activation of the hip abductors (which actually began in the loading response) ensures lateral stability of the pelvis and trunk on the supporting limb. extension of the knee to neutral (0 or -5 degrees) continues under active control. These muscles increase their intensity as progression increases the demand torque at the junction of foot and leg (the ankle). Subtalar and midfoot stability is gained from the perimalleolar muscles. 4. The pretibial muscles tend to diminish their intensity of action as the semivertical position of the foot presents a lessdemanding torque. All three muscles-semimembranosus. 63:1597. Lyons K. 6. subtalar.org/alp/chap13-01. For this purpose momentum supports limb weight while the hamstrings prevent further motion.asp[21/03/2013 21:55:07] . 3. Baltimore. and metatarsophalangeal). Kory RC: Walking patterns of normal men. The quadriceps provides the needed extensor force. Inman VT. single-limb support. limb advancement ceases. and flexion is initiated. semi-tendinosus. Following initial floor contact. The knee and hip are unlocked from their extended positions. Preparation of the limb for weight acceptance begins in terminal swing when the hip extensors and quadriceps are activated. 2. Dayton. At the end of midswing. Continuation of the swing-phase ankle dorsiflexor control provides a heel rocker for progression and shock-absorbing knee flexion. knee. Dempster WT: Space Requirements of the Seated Operator: Geometrical. To meet these demands each limb performs eight motion patterns that have been identified as the phases of gait. Gronley JK. ankle. 1981. Ankle plantar flexion modulates the heel rocker to protect the quadriceps from overde-mand. and the preparations for stance begin. Clin Orthop 1983. but the foot may drop into slight plantar flexion (3 to 5 degrees) at the end of the phase. Wright-Patterson Air Force Base U. J Rone Joint Surg [Am] 1964. Williams & Wilkins. Murray MP. -The 30 degrees of flexion attained in midswing is maintained. The sequence of muscle action relates to three major tasks being accomplished during each gait cycle: weight acceptance. Stability for the phases of single-limb support (mid and terminal stance) depends almost entirely on timely and graded action of the soleus aided by the gastrocnemius. Knee. SUMMARY Five joints in each limb (hip. Progression of the limb and body over the stationary foot depends on graduated ankle dorsiflexion to advance the tibia. Knee and hip extensor stability is provided passively by body alignment. Inman VT: The Joints of the Ankle. Preparation for limb advancement begins in the final phase of stance (preswing) as the limb is unloaded by the rapid transfer of body weight onto the other limb. References: 1. 7. Ralston HJ: Effects of immobilization of various body segments on the energy cost of http://www. Kinematic. Perry J. All heads remain active. -Because gravity must be opposed and only a brief time is available for this. 46:335. To ensure knee stability. Prosthetic. 9. Henderson WH: Action of the subtalar and ankle joint complex during the stance phase of walking. 10. Desai SM.asp[21/03/2013 21:55:07] . human locomotion. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 13 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Dortmund. (suppl):53. Int Z Angew Physiol 1958. J Bone Joint Surg [Am] 1953. J Rone Joint Surg [Am] 1964. W Germany. 35:543.org/alp/chap13-01. 11. J Rone Joint Surg [Am] 1966. 48:66. Slack Inc. 1964. 12.oandplibrary. Eberhart HD: The major determinants in normal and pathological gait. Wright DG. 17:277. 46:361. Ergonomics 1965. Chapter 13 . Proceedings of the 2nd IEA Conference.13: Normal Gait | O&P Virtual Library 8. Perry J: Gait Analysis of Normal and Pathological Function.Atlas of Limb Prosthetics: Surgical. Saunders JBCM. 1992. Ralston HJ: Energy-speed relation and optimal speed during level walking. Contact Us | Contribute http://www. Inman VT. Sutherland DH: An electromyographic study of the plantar flexors of the ankle in normal walking on the level. Determination of causes.14: Analysis of Amputee Gait | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 14 Chapter 14 . This process works well so long as the clinic team understands normal gait. that is. and sufficient expertise to produce clinically useful insights and understanding. IL. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. -The phrase "gait deviation" is defined as any gait characteristic that differs from the normal pattern. concomitant medical conditions. alignment. biomechanics. 2. a number of research studies have presented objective. and it is certainly true that there are many prosthetic causes for gait deviations. observational gait analysis involves the identification of gait deviations and determination of the causes associated with each deviation. but do not ignore the patient.S. M. any of which may cause deviant gait. Rosemont. and Rehabilitation Principles Analysis of Amputee Gait Norman Berger. more immediately available procedure requires only the eye. or old habit patterns. differences in the patterns of the prosthetic and normal sides. While all our detailed knowledge of normal locomotion will be useful. quantified analyses of amputee gait. 1990 Revision. I. the phase of the walking cycle in which each deviation occurs is identified. Clinicians. ©American Academy or Orthopedic Surgeons. it is equally true that there are many non-prosthetic causes. Although the future may see sophisticated measurement equipment efficient and inexpensive enough to be used routinely in daily treatment programs.oandplibrary. The component parts of the gait analysis procedure are as follows: 1. A particular patient may have restricted range of motion at one or more joints. reprinted 2002. and electromyographs. Prosthetic. the treatment team can then plan and recommend corrective actions to improve the situation. and function for the individual patient. 3. electrogoniome-ters. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. However. With this accomplished. edition 2. Basically. ANALYSIS OF TRANSTIBIAL (BELOW-KNEE) AMPUTEE GAIT A number of important deviations that may appear in the gait of transtibial amputees are discussed below. Click for more information about this text. New York University Post-Graduate Medical School. keep in mind that the single most outstanding characteristic of the normal pattern is symmetry. and prosthetic fit and alignment. Between heel strike and midstance A. With equipment such as force plates. while frontal-plane motions are best seen from the front or rear. Observation. muscular weakness.Atlas of Limb Prosthetics: Surgical. Analyze the prosthesis. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. American Academy of Orthopedic Surgeons. 1992. Permission to reprint is gratefully acknowledged. for the unilateral amputee deviations are often identified by observing asymmetry.asp[21/03/2013 21:55:12] . Excessive knee flexion http://www. Prosthetics and Orthotics. Sagittal-plane motions are best seen from the side. *Much of the material in this chapter is taken from the manual Lower-Limb Prosthetics. excessive fear. tend to rely on observational gait analysis to provide information about prosthetic fit. To assist in observing these sometimes subtle characteristics and in understanding their causes. This simpler. however.org/alp/chap14-01. Reproduced with permission from Bowker HK. the brain. observational gait analysis remains the procedure of choice for the present and is therefore the focus of this chapter. Prosthetic.-The obvious place to look is at the prosthesis. Prosthetic. Thus. and Rehabilitation Principles.-It is essential to observe from at least two vantage points. Identification of gait deviations. the knee joint will be restricted in extension. Also. This abrupt contact of the foot with the floor will tend to decrease the range of knee flexion. thus decreasing the tendency of the force couple to rotate the prosthesis in a flexion direction.. The supracondylar/suprapatellar-suspended prosthesis relies on a carefully molded convexity above the patella to ensure adequate suspension. Absent or insufficient knee flexion The transtibial amputee may walk with absent or insufficient knee flexion on the amputated side for one or more of the following reasons: 1. This location causes the suspension tabs to tighten as the knee joint extends and to loosen as the knee flexes. the suspension tabs will tighten to such an extent as to prevent the knee joint from reaching full extension. 2. B. Flexion contracture or posterior misplacement of the suspension tabs The knee cuff used to suspend the prosthesis is attached to the socket posterior to the axis of motion of the knee joint. If the attachment points are unduly posterior.. Excessive dorsiflexion of the foot or excessive anterior tilt of the socket Normally. The knee will begin to flex only after the heel cushion has been fully compressed. the amputee's knee may have to flex through more than the normal range to allow the sole of the foot to reach the floor. contact of the sole of the foot with the floor coincides approximately with the end of knee flexion and the beginning of knee extension. foot contact with the floor after heel strike is the result of ankle plantar flexion and knee flexion. These situations are comparable to a flexion contracture in which tight posterior tissues do not permit full knee extension. Excessive plantar flexion of the foot In normal walking. Excessive anterior displacement of the socket over the foot As illustrated in Fig 14-1. Immediately thereafter. additional knee flexion is required to allow the foot to reach the floor after heel strike. an excessively soft heel bumper will allow the prosthetic foot to plantar-flex too rapidly and thus slap the floor. The transtibial amputee may exceed this range of knee flexion on the amputated side for any of the following reasons: 1. cushion-heel (SACH) foot with an excessively soft heel cushion.oandplibrary.14: Analysis of Amputee Gait | O&P Virtual Library During normal gait the knee is approximately in complete extension at heel strike. posterior displacement of the socket decreases the distance between the lines of action of the force transmitted through the socket (A) and the reaction force from the floor (B). an overly stiff cushion or bumper will not absorb the impact of the heel striking the floor. thus tending to produce abrupt and excessive knee flexion. If the prosthetic foot is set in too much dorsiflexion or the socket displays more than the usual 5 degrees of anterior tilt. With a single-axis ankle. Posterior displacement of the socket over the foot As illustrated in Fig 14-2. The force couple tending to cause rotation of the prosthesis in a flexion direction thus increases as the socket is moved farther anteriorly. placing the socket forward relative to the prosthetic foot increases the distance between the lines of action of the force transmitted through the socket (A) and the reaction force from the floor (B). Excessively stiff heel cushion or plantar-flexion bumper If plantar flexion of the foot is restricted by an overly stiff heel cushion or plantar-flexion bumper. 4.asp[21/03/2013 21:55:12] . the knee begins to flex and continues to do so until just after the sole of the shoe is flat on the ground. there will be a momentary delay between heel strike and the initiation of knee flexion. The effect of this force couple will be somewhat reduced if the heel cushion or bumper is soft enough to absorb the impact of the heel striking the floor. 2. At normal walking speeds (100 to 120 steps per minute). the average range of knee flexion after heel strike is from 15 to 20 degrees. If the socket is placed so far posteriorly that the line of force transmission through the socket falls posterior to the floor reaction. 3.org/alp/chap14-01. foot flat will occur prematurely and prevent normal knee flexion after heel strike. If the prosthetic foot is in an attitude of plantar flexion. 3. If this anterior convexity is excessive. the prosthesis will http://www. Excessively soft heel cushion or plantar-flexion bumper In the case of a solid-ankle. Weakness of the quadriceps muscle If the quadriceps is not strong enough to control the knee at heel strike. and flexion begins.asp[21/03/2013 21:55:12] . in turn. the closer is the line of action of forces transmitted through the socket to the end of the keel in a SACH foot or to the toe-break in a wood foot. (3) adopting a forward lurch of the head and the shoulder. 2. but if it is excessive. At heel-off or immediately thereafter. Excessive anterior displacement of the socket over the foot The farther forward the socket is placed.14: Analysis of Amputee Gait | O&P Virtual Library tend to rotate backward. stump discomfort may occur at heel strike. the knee is extending. the sound limb is swinging. the resulting lack of anterior support would allow premature knee flexion or drop-off. A slight amount of this lateral thrust is fairly common. that is.org/alp/chap14-01. 2. Consequently. this lateral thrust can be minimized or eliminated by "out-setting" the prosthetic foot slightly. 4. In almost all instances.oandplibrary. 5. Excessive lateral thrust may be caused by such factors as the following: 1. This can be accomplished by (1) shortening the prosthetic step. and damage to the skin and to the knee ligaments may result. so all of the body weight is supported by the prosthetic foot on the floor. This knee flexion coincides with the passing of the center of gravity over the metatarsophalangeal joints. When the quadriceps muscle contracts. III. Early knee flexion (drop-off) Just prior to heel-off during normal gait. A brief period of instruction with adequate follow-up may establish a less deviant walking pattern. a force couple is created that tends to rotate the socket around the stump. the medial socket brim presses against the femoral condyle while the lateral part of the brim tends to gap. Habit Amputees who have established a pattern of walking with the knee held in extension after heel strike may continue to walk in the same manner when they are making the transition to a patellar tendon-bearing prosthesis. Posterior displacement of the toe-break or the keel http://www. the distal end of the prosthesis shifts medially. These gait maneuvers tend to force the knee into extension and thereby lessen or eliminate the need for quadriceps activity. 6. Excessive lateral thrust of the prosthesis Lateral thrust derives from the tendency of the prosthesis to rotate around the amputated limb. simulating genu valgum) is placed on the vertically positioned residual limb. Excessive medial placement of the prosthetic foot At midstance.. (2) digging the heel into the ground by means of increased hip extensor activity. and the patient's weight tends to be borne on the lateral border of the foot. II. as illustrated in Fig 14-3. This. pressure between the anterodistal surface of the tibia and the socket is increased considerably. When this occurs. Possible causes for this lack of anterior support are as follows: 1. or (4) some combination of these. Between midstance and toe-off A. Anterodistal discomfort Supporting body weight with the knee in a flexed attitude is possible only if the knee extensors act with sufficient force to restrain the flexion moment. Abducted socket If a socket that has been set in excessive abduction (brim tilted medially. the amputee may complain of uncomfortable pressure on the medioproximal aspect of his knee. If the body weight is carried over these joints too soon. If this supporting foot is too far medial to the line of action of forces transmitted through the socket. knee motion reverses. the knee will be forced toward hyperextension rather than flexion. increases the lateral thrust of the socket brim. To avoid this pain the amputee may walk so that the forces acting on the knee tend to extend rather than to flex that joint. the amputee may compensate in much the same way as he would if there were anterodistal tibial discomfort. At midstance A. The distance that the center of gravity must move forward to pass over these prosthetic equivalents of the metatarsophalangeal joints is thus minimized and allows knee flexion to occur too early. 5. This is usually present when an amputee walks with an abducted gait. the width of the walking base is significantly greater than the normal range of 5 to 10 cm (2 to 4 in. the amputee leans toward the prosthesis.). Causes: 1.oandplibrary.). The sequence of presentation is based on the preferred vantage point for observation. Insufficient support by the lateral socket wall. Hard dorsiflexion bumper Some of the gait deviations discussed below in relation to the transfemoral amputee may also be noted in the transtibial patient. the pelvis will tend to drop on the sound side when the prosthesis is in stance phase. lateral bending counteracts the tendency toward pelvic drop on the sound side. Anterior displacement of the toe-break or the keel 3. Excessive posterior displacement of the socket over the foot 2. There is exaggerated displacement of the pelvis and trunk ( Fig 14-5. and no separate discussion is warranted. LATERAL TRUNK BENDING Description: The amputee leans toward the amputated side when the prosthesis is in stance phase ( Fig 14-4. Under such circumstances. 4.14: Analysis of Amputee Gait | O&P Virtual Library 3. Excessive dorsiflexion of the foot or excessive anterior tilt of the socket 4. The resulting tendency of the pelvis to drop on the sound side is counteracted by lateral trunk bending.asp[21/03/2013 21:55:12] . Soft dorsiflexion bumper These conditions also minimize the distance that the body weight must move forward before anterior support is lost. the knee joint would remain in extension during the latter part of the stance phase. Delayed knee flexion The reverse of the situation described above occurs if the body weight must be carried forward an unusually long distance before anterior support is lost. the incidence is small. By shifting the center of gravity toward the prosthesis. ANALYSIS OF TRANSFEMORAL (ABOVE-KNEE) AMPUTEE GAIT Eleven common transfemoral deviations and their usual causes are presented. particularly on the lateral distal aspect of the femur.). Excessive plantar flexion of the foot or excessive posterior tilt of the socket 4. the earlier and more abrupt will be the knee flexion. Lateral trunk bending. This excessive anterior support can be brought about by the following: 1. and the amputee might complain of a "walking-uphill" sensation since his center of gravity would be carried up and over the extended knee. Weak hip abductors. Most of the causes of abducted gait can be responsible for lateral bending. How to observe: From behind the patient. the amputee relieves pressure on the lateral aspect. This alignment fault reduces the effectiveness of the hip abductors in stabilizing the pelvis. with the first 6 deviations best viewed from the rear or the front and the remaining 5 best seen from the side. Abducted socket. To check this tendency. Short prosthesis. However. The shorter this distance. 6. WIDE WALKING BASE (ABDUCTED GAIT) Description: Throughout the gait cycle. By bending to the prosthetic side.org/alp/chap14-01. When to observe: From just after heel strike to mid-stance. When to observe: During the period of double support. Pain or discomfort. 3. 2. B. If the lateral wall does not block lateral movement of the femur. http://www. CIRCUMDUCTION Description: The prosthesis follows a laterally curved line as it swings ( Fig 14-6. When to observe: Throughout swing phase. Too small a socket. Foot set in excessive plantar flexion. The ischial tuberosity is above its proper location. C. The following are among the factors that may produce excessive length: A. or pressure from the medial socket brim. Insufficient friction in the prosthetic knee. In the normal pattern. 3.asp[21/03/2013 21:55:12] . Widening the base helps to solve these problems.14: Analysis of Amputee Gait | O&P Virtual Library How to observe: From behind the patient. Feeling of insecurity. Excessive length makes it difficult to place the limb directly under the hip during stance and to clear the floor during swing. Manual knee lock. The amputee tries to gain relief by abducting his prosthesis. Because of this time lag. Causes: 1. The amputee compensates by widening his walking base. or too tight an extension aid. 2. thus moving the medial part of the brim away from the painful area. Foot set in excessive plantar flexion.oandplibrary. heel rise is excessive. maximum elevation of the body occurs when the supporting limb is in the middle of stance phase and the other limb swings alongside it. Inadequate suspension allowing the prosthesis to slip off the stump (piston action). Prosthesis too long. VAULTING Description: The amputee raises his entire body by early and excessive plantar flexion of the sound foot ( Fig 14-7.). Too small a socket. excessive friction.org/alp/chap14-01. How to observe: From behind or from the side of patient. excessive friction. B. SWING-PHASE WHIPS http://www. Insufficient flexion of the knee because of insecurity or fear. 4. thus forcing the amputee to swing it to the side to clear the ground. the body is no longer at maximum elevation as the prosthetic foot is at its lowest point in swinging through. 4. Mechanical hip joint set so that the socket is abducted. adductor roll. When there is insufficient friction. 5. D. The following are among the factors tending to produce excessive length: 1. Excessive length of the prosthesis. Manual knee lock. 2. Causes: 1. or a tight extension aid preventing the knee from flexing.). and the prosthetic foot would fail to clear the ground unless the amputee gained additional time and clearance by vaulting. 5. The ischial tuberosity is above its proper location. The discomfort may be due to such factors as skin infection. Pain or discomfort in the crotch area. Shank aligned in the valgus position with respect to the thigh section. 6. E. Insufficient flexion of the knee because of insecurity or fear. When to observe: During swing phase of the prosthesis. 2. Contracted hip abductors. The amputee vaults to gain additional clearance so that the prosthetic foot will clear the ground as it swings through. 3. Inadequate suspension allowing the prosthesis to drop (piston action). How to observe: From behind the patient. and the shank takes a longer time to swing forward. Causes: The basic cause of this deviation is a prosthesis that is too long. Cause: Too hard a heel cushion or plantar-flexion bumper.asp[21/03/2013 21:55:12] . Excessive friction at the prosthetic knee. How to observe: From the side. Pressure from contracting muscle bellies causes the prosthesis to rotate around its long axis. Causes: Excessive heel rise results when the following are present: 1. How to observe: From in front of the patient. that is. When to observe: At the end of swing phase. Forceful hip flexion to ensure that the prosthetic knee will be extended fully at heel strike. Manual knee lock. Listen for slap. the foot rotates laterally.). sometimes with a vibratory motion ( Fig 14-9. A socket that is too tight or improperly contoured to accommodate muscles. 2. whips may be seen because of the following: A. When to observe: At heel strike. ). How to observe: From the side.org/alp/chap14-01. the reverse may also be seen. 3. Cause: The plantar-flexion bumper is too soft and does not offer enough resistance to foot motion as weight is transferred to the prosthesis. Fear and insecurity. Insufficient heel rise results when the following are present: 1. How to observe: From behind the patient. However. When to observe: During first part of swing phase. ). 2. ). When to observe: At and just after toe-off.). B. Insufficient friction at the prosthetic knee. FOOT SLAP Description: The foot plantar-flexes too rapidly and strikes the floor with a slap ( Fig 14-10. Improper alignment of the knee bolt in the transverse plane. 2. With a suction socket and no auxiliary suspension. Lateral whip-At toeoff the heel moves laterally ( Fig 14-8.). UNEVEN HEEL RISE Description: Usually the prosthetic heel rises higher than the sound heel.14: Analysis of Amputee Gait | O&P Virtual Library Description: Medial whip-At toe-off the heel moves medially ( Fig 14-8. When to observe: Just after heel strike. http://www. Insufficient tension or absence of an extension aid. TERMINAL IMPACT Description: The prosthetic shank comes to a sudden stop with a visible and possibly audible impact as the knee reaches full extension ( Fig 14-12. Weak and flabby musculature that rotates freely around the femur. Listen for the impact. The amputee walks with little or no knee flexion. FOOT ROTATION AT HEEL STRIKE Description: As the heel contacts the ground. 4.oandplibrary. Too tight an extension aid. Causes: 1. 3. the prosthetic heel rises less than the sound heel ( Fig 1411. How to observe: From the side. Weak hip extensors. Absent or worn resilient extension bumper in the knee unit. Contact Us | Contribute http://www. Too tight an extension aid. To do this he takes a short. The total length of the stride taken with each foot will be the same ("stride" signifies the distance between successive positions of the same foot. When this restraining force is lost. The pelvis tends to tilt downward and forward because the center of gravity is anterior to the support point (a theoretical point around which the supporting forces are balanced). Weak abdominal muscles. the resulting forward pelvic tilt and compensatory backward trunk bending cause increased lordosis. Pain or insecurity causing the amputee to transfer his weight quickly from the prosthesis to his sound leg. Causes: 1. Hip flexion contracture or insufficient socket flexion. rapid step with his sound foot. 2. When to observe: During successive periods of double support. the amputee may roll his pelvis forward to assist the weak extensors to control knee stability. 2. A flexion contracture aggravates the tendency of the pelvis to tilt anteriorly because the shortened hip flexor muscles exert a downward and forward pull on the pelvis when the femur is at the limit of its extension range. Insufficient support from the anterior socket brim.) taken with the prosthesis differs from the length of the step taken with the sound leg. How to observe: From the side. The pendular swing of the shank produces a prosthetic step length that is longer than the step length on the sound side. In addition. Causes: 1. 5.Atlas of Limb Prosthetics: Surgical.asp[21/03/2013 21:55:12] . The abdominal muscles restrain the tendency of the pelvis to tilt forward. and the amputee will show increased lordosis. 3. Prosthetic. ).org/alp/chap14-01. The extensors help to restrain the tendency of the pelvis to tilt forward. 4. 4.14: Analysis of Amputee Gait | O&P Virtual Library Causes: 1. Chapter 14 . Insufficient friction at the prosthetic knee. UNEVEN STEP LENGTH Description: The length of the step [*The term step refers to the distance between successive positions of the sound foot and prosthetic foot. Hip flexion contracture. 3. If the abdominal muscles are weak. This maneuver snaps the shank forward into full extension. 3. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 14 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .oandplibrary. When to observe: Throughout stance phase. How to observe: From the side. Insufficient friction at the prosthetic knee or too loose an extension aid. EXAGGERATED LORDOSIS Description: The lumbar lordosis is exaggerated when the prosthesis is in stance phase. Any restriction of the hip extension range must be reflected by a shorter step length on the sound side. and the trunk may lean posteriorly ( Fig 14-13. 2. The amputee's fear of buckling causing him to extend the hip abruptly as the knee approaches full extension. Insufficient socket flexion. some of this restraint is lost. and a "steady-state" condition is achieved that reflects the energy expended during the activity. Aerobic vs.Atlas of Limb Prosthetics: Surgical. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Prosthetic. Waters. carbohydrates and fats are oxidized through a series of enzymatic reactions leading to the production of ATP. the adequacy of prosthetic fit and prosthetic gait experience is not always specified. Second. M. which is exhaled in the expired air. Anaerobic Metabolism During continuous exercise there is an interplay between the aerobic and anaerobic metabolic pathways that depends on the exercise work load. there is often no distinction between amputees who use upper-limb assistive devices and those who do not.oandplibrary. ©American Academy or Orthopedic Surgeons. IL. American Academy of Orthopedic Surgeons.D. The lactate is buffered in the blood by bicarbonate. this can be summarized by the following reactions: Lactate + NaHC03 —> Na lactate + H 2 0 + C02 (gas). and this leads to the formation of C02 . Although there is a considerable body of literature on the physiologic energy expenditure of amputee gait.asp[21/03/2013 21:55:17] . young (usually traumatic) amputees are not consistently distinguished from older (usually vascular) amputees.15: The Energy Expenditure of Amputee Gait | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 15 Chapter 15 . ENERGY SOURCES After several minutes of exercise at a constant sub-maximal work load. the rate of oxygen consumption reaches a level sufficient to meet the energy demands of the tissues. During more strenuous exercise both anaerobic http://www. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Click for more information about this text. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists Anaerobic Oxidation A second type of oxidative reaction is available that does not require oxygen. and Rehabilitation Principles The Energy Expenditure of Amputee Gait Robert L. Therefore the majority of the data presented in this review are based on investigations that utilized consistent procedures conducted in the Pathokinesiology Laboratory of Rancho Los Amigos Medical Center. a direct comparison of the results of the different studies is difficult for the following reasons. edition 2. Prosthetic. Third. where ADP is adenosine diphosphate. and there are significant differences between these two groups with respect to gait performance. Aerobic Oxidation The functional unit of energy for muscle contraction is adenosine triphosphate (ATP). and Rehabilitation Principles. reprinted 2002. Prosthetic. The net equation for the glycolytic metabolism of glucose is as follows: Glucose + 2Pi + 2ADP —> 2 Lactate + 2ATP. During mild or moderate exercise the oxygen supply to the cell and the capacity of aerobic energy-producing mechanisms are usually sufficient to satisfy ATP requirements. 1992. Reproduced with permission from Bowker HK. In aerobic oxidation (citric acid cycle). You can help expand the O&P Virtual Library with a tax-deductible contribution. Rosemont.org/alp/chap15-01. First. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. The net equation for the aerobic metabolism of glucose is as follows: Glucose + 36ADP + 36P i + 36H+ + 60 2 —> 6C02 + 36ATP + 42H2 0. but the rate of 0 2 uptake may be normal. When exercise is performed at more strenuous work rates above the anaerobic threshold. The power requirement (rate of 0 2 consumption) is the milliliters of 0 2 consumed per kilogram body weight per minute (mL/kg-min). Up to approximately 20 years of age.oandplibrary. the maximum oxygen uptake declines primarily due to a decrease in both maximum heart rate and stroke volume and generally due to a more Differences in body composition and hemoglobin content are factors sedentary life-style. there is a linear relation between the rate of 0 2 uptake and heart rate. From a practical standpoint. the anaerobic pathway provides muscle with an immediate supply of energy for sudden and short-term strenuous activity. however.asp[21/03/2013 21:55:17] . The rate of 0 2 consumption relates to the level of physical effort. Walking. As reflected in the above equations. Physiologic work is the amount of energy required to perform a task. Age influences the V02 max. and the 0 2 cost determines the total energy required to perform the task of walking. of exhausting work. http://www. The maximal aerobic capacity also depends on the type of exercise performed. however. thus indicating a physiologically inefficient gait. The 0 2 cost may be elevated. Maximal Aerobic Capacity The maximal aerobic capacity (V0 2 max) is the highest oxygen uptake an individual can attain It is the single best indicator of during physical work while breathing air at sea level. will be limited by the slow speed. For any given work load. the maximum oxygen uptake increases. it is extremely important to recognize that the velocity is in the denominator and the rate of 0 2 consumption is in the numerator of the energy cost calculation. The amount of energy that can be produced by anaerobic means is limited. thus reflecting the additional anaerobic activity. it is possible to determine the gait efficiency. therefore. that account for a difference in the V02 max between the sexes. Commonly there is a misinterpretation of the clinical data concerning the 0 2 cost and 0 2 rate. Generally an individual is able to reach his V02 max within 2 to 3 minutes physical fitness. Physiologic work (02 cost) during level walking is the amount of oxygen consumed per kilogram body weight per unit distance traveled (mL/ kg-m). Power and Work Units The terms power and work are utilized to describe energy expenditure. The respiratory exchange ratio (RER) is defined as the ratio of expired carbon dioxide (C02 ) to inspired oxygen (0 2 ). and the subject will therefore not experience fatigue during customary walking activities but. In the interpretation of data. Anaerobic oxidation is also limited by the individual's tolerance to acidosis resulting from the accumulation of lactate. approximately 19 times more energy is produced by the aerobic oxidation of carbohydrates than by anaerobic oxidation. an individual can sustain exercise for a prolonged time without an easily definable point of exhaustion.15: The Energy Expenditure of Amputee Gait | O&P Virtual Library and aerobic oxidation processes occur. By comparing the energy cost of pathologic gait to the corresponding value for normal walking. Thereafter. the RER rises and reflects the contribution of anaerobic energy production required to meet the additional ATP demands. The serum lactate and expired C02 levels rise. The 0 2 cost is determined by dividing the power requirement (rate of energy expenditure) by the speed of walking. If exercise is performed at a constant rate at which the aerobic processes can supply the necessary ATP production.org/alp/chap15-01. the V02 max during upperlimb exercise is lower than with the lower limbs. The oxygen demand is directly related to the muscle mass involved. heart rate and intra-arterial blood pressure are higher in upper-limb exercise than lower-limb exercise. Oxygen Pulse In the absence of cardiac disease. The oxygen pulse is higher during arm exercise than during leg exercise.1 and 12. A special problem confronting most older vascular amputees is their limited exercise ability. thus indicating anaerobic metabolism is not required. Senior subjects have a slightly lower rate of oxygen consumption and average CWS than do young adults. Loading Loading the body with weights increases the rate of energy expenditure depending on the location of the loads. higher heart rates are associated with leg exercise than with arm exercise. and this may be a purposeful effort to keep the exercise within the aerobic range. and other factors.oandplibrary. increasing the level of hemoglobin. Diabetes decreases capillary permeability and therefore oxygen supply to the muscle due to basement membrane thickening. In different amputee groups walking without crutches. Bed rest for 3 weeks can result in a 27% decrease in the V02 max by decreasing cardiac output. the rate of oxygen consumption for young adults aged 20 to 59 years and senior subjects between 60 and 80 years of age does not significantly differ and averages 12. but there is also a central decline in stroke volume and cardiac output as a result of inactivity. Any disease process of the respiratory. This conclusion is supported by the result of V02 max measurements during one-legged and two-legged exercise in normal subjects and transfemoral amputees. UNILATERAL AMPUTATION http://www.org/alp/chap15-01. and increasing the muscular mass (hypertrophy). increasing the capacity of the cells to extract oxygen from the blood. or metabolic systems that restricts the supply of oxygen to the cell will also decrease the V02 max. Loads placed peripherally on the foot have a much greater effect than do loads placed over the trunk. CWS. Physical work capacity and V02 max are reduced not only due to the effects of aging but also due to commonly associated diseases in dysvascular amputees such as arteriosclerotic heart disease and peripheral vascular disease. therefore. This finding is predictible since forward foot acceleration is much greater than trunk acceleration and. The ratio of the rate of 0 2 uptake to heart rate is the oxygen pulse. These findings are of clinical significance for patients requiring lower-limb prostheses and indicate the importance of minimizing weight. the rate of oxygen consumption at the CWS requires approximately 32% of the V02 max of an untrained normal subject 20 to 30 years of age and nearly 48% of the V02 max of a senior The RER is less than 0. As a result. which is the ratio of the mean rate of 0 2 uptake and heart rate. the average amputee leads a less active life-style resulting in a lower level of physical conditioning. which suggests that despite successful prosthetic use. Energy Expenditure During Normal Walking At the chosen walking speed (CWS). Training A physical-conditioning program can increase the aerobic capacity by several processes: improving cardiac output. The status of physical fitness can be assessed by examining the oxygen pulse.asp[21/03/2013 21:55:17] .15: The Energy Expenditure of Amputee Gait | O&P Virtual Library When performing exercise at the same rate of 0 2 uptake.0 mL/ kg-min. On the other hand. endurance is increased.85 for normal subjects of all ages at their subject 75 years of age. the 0 2 pulse is lower than normal. The fact that walking taxes less than 50% of the V02 max in normal subjects in all age groups and does not require anaerobic activity accounts for the perception that walking requires little effort in healthy individuals. cardiovascular. It is significant that with advancing years older persons progressively have smaller aerobic reserves to accommodate to the added physiologic penalties imposed by amputation. greater effort is required. Placement of a 20-kg load on the trunk of a male subject did not result in a measurable increase in the rate of energy expenditure. Not only A sedentary life-style has the opposite effect on maximum oxygen consumption. a 2-kg load placed on each foot increased the rate of oxygen uptake 30%. stroke volume. muscular. Deconditioning due to sedentary activity or any disease process that impairs the delivery of oxygen to the cells also decreases the oxygen pulse. does atrophy of peripheral musculoskeletal structures occur. Expressed as a percentage of the V02 max. oandplibrary. This difference was insignificant in the vascular transfemoral amputation group and probably relates to the fact that even with a prosthesis. Relationship of Mechanical and Physiologic Energy Expenditure http://www. the greater energy cost and slower speed.asp[21/03/2013 21:55:17] . crutch walking without a prosthesis should not be considered an absolute requirement for prosthetic prescription and training. The arms and shoulder girdle musculature must lift and then swing the entire body weight forward with each step. had not received radiation or chemotherapy for at least 6 months prior to testing. progressing from the transtibial.). Crutch walking without a prosthesis with a three-point gait pattern in unilateral amputees may be a primary or secondary means of transportation when an adequate prosthesis is unavailable or inadequate. Swing-through crutch locomotion requires a high rate of physical effort in comparison to normal walking. the 0 2 cost progressively increased at each higher amputation level ranging from the transtibial to the transpelvic levels ( Fig 15-1. knee disarticulation. the greater the loss of the normal locomotor mechanisms. Clearly as more joints and muscles of the leg are lost due to higher-level amputations. It may be concluded that a well-fitted prosthesis that results in a satisfactory gait not requiring crutches significantly reduces the physiologic energy demand. 61.org/alp/chap15-01. Crutches Lower-limb amputation with or without prosthetic replacement imposes energy penalties for ambulation. Unilateral Prosthetic Ambulation The combined results of two studies in which patients were tested at their CWSs under similar conditions illustrate the importance of the level of amputation. 52. had no evidence of tumor recurrence. The average rate of oxygen consumption for different-level amputees was not dependent on level and was approximately the same as the value for normal subjects ( Fig 15-2. prostheses at least 6 months and did not use upper-limb aids (with the exception of some transfemoral amputees in the vascular group). In the groups of traumatic and surgical amputees described above. thus increasing the energy demand and heart rate. In the first study. most of these patients relied on crutches for some support. and Patients had also worn their transfemoral levels following amputation secondary to trauma. knee disarticulation. and did not utilize crutches. had worn their prosthesis for at least 6 months. energy expenditure in unilateral amputees was measured at the transtibial.15: The Energy Expenditure of Amputee Gait | O&P Virtual Library Prosthesis vs. and transpelvic levels in the traumatic and surgical amputee groups. therefore. heart rate.). hip disarticulation. transfemoral. 47. These values averaged 71. Swing-through crutch-assisted gait is required in amputees walking without a prosthesis.) ( Table 15-1. The reduced speeds at higher amputation levels are inversely proportional to the increased 0 2 cost. A direct comparison of walking in unilateral amputees with and without a prosthesis utilizing a three-point crutch-assisted gait pattern revealed that all. and 40 m/min ( Fig 15-3. Other investigators who have tested amputees at their CWS have also reported that the rate of 0 2 uptake was approximately the same as for normal subjects at their CWS. healthy hip disarticulation and transpelvic (hemipel-vectomy) amputees were tested at their CWS by utilizing a similar methodology. The CWS depended on the level of amputation and declined at each higher amputation level. with the single exception of vascular transfemoral amputees. Since crutch walking requires more exertion than walking with a prosthesis does. and 0 2 cost when using a prosthesis. had a lower rate of energy expenditure. These findings indicate that amputees slow their CWS to keep the rate of 0 2 consumption from rising above normal limits. In the second study. Patients with higher-level amputations had a less efficent gait and higher 0 2 cost than did those with lower-level amputations.). The patient must choose between walking without a prosthesis and using crutches or walking with a prosthesis and utilizing the remaining muscles to substitute for lost function and control the additional mass of the prosthesis. These surgical amputees met the following criteria: were young and healthy at the time of testing. If amputation is required. arms. Of particular clinical importance. Dysvascular Amputees Dysvascular amputees walking with a prosthesis also selectively adjust their CWS to keep the 0 2 rate from rising above normal limits.15: The Energy Expenditure of Amputee Gait | O&P Virtual Library Human locomotion involves smooth advancement of the body through space. and trunk (HAT) in the vertical and lateral directions. Of interest. most have a very slow gait velocity and an elevated In contrast. every effort should be made to amputate below the knee. knee motion plays a more important role in minimizing the vertical rise and fall of the HAT. and consequently amputation at the transfemoral level substantially increases the energy cost and lowers the speed to keep the rate of energy expenditure from rising above normal limits. Length of the Residual Limb Gonzales et al. as long as ankle stability is provided. and the CWS progressively slows at higher amputation levels.oandplibrary. the hip disarticulation or transpelvic-level amputation further increases energy cost and reduces speed. prosthesis with a thigh corset. (There is no difference in the 0 2 rate at the transfemoral level due to the fact that some of the dysvascular transfemoral amputees required crutches involving significant upper-limb exercise reflected by the higher mean heart rate. If able to walk. As with traumatic amputees. have an adequate gait. Only a small percentage of these patients are functional ambulators. Table 15-2 summarizes data on both traumatic and vascular patients with bilateral amputation. traumatic transfemoral amputees heart rate if crutch assistance is required. It is not surprising that the physiologic cost of walking with a well-fitted Syme ankle disarticulation or transtib-ial prosthesis increased the energy cost minimally. On the other hand. This conserves both kinetic and potential energy and is the principle of biological "conservation of energy. Bilateral Amputees Few energy expenditure studies have been performed on bilateral amputees.) It is logical to conclude that the higher exercise capacity of the typical younger traumatic amputee enables selection of a higher 0 2 rate and CWS at any given amputation level than that selected by his older dysvascular counterpart. vascular patients with the Syme ankle disarticulation/Syme ankle disarticulation combination walked faster and had a lower 0 2 cost than did vascular patients with the transtibial/transtibial combination. This parallels the findings among the unilateral amputees demonstrating that performance relates to amputation level. Traumatic transtibial/transtibial amputees walked faster and at a lower http://www. the loss of ankle and foot motion has a small effect on mechanical and physiologic energy expenditure. No significant differences were noted in speed or energy expenditure between groups. Therefore." Saunders et al. 0 2 cost progressively increases. Ankle motion during stance serves to improve shock absorption and smooth out the points of inflection of vertical rise and fall of the HAT and the consequent vertical ground reaction force. It may be concluded that every effort must be made to protect dysvascular limbs early so that transfemoral amputation does not become necessary. Interpretation of the data on bilateral traumatic amputees must be made with caution since relatively few subjects have been studied. low-amplitude displacement of the center of gravity of the head. a stump as short as 9 cm will result in acceptable transtibial performance that is superior to performance at reported values at the knee disarticulation and transfemoral levels. Most older patients who have transfemoral amputations for vascular disease are not successful long-term prosthetic ambulators. limb motion is based on the need to maintain a symmetrical. This limited information indicates that the bilateral amputee expends greater effort than the unilateral amputee does. While the goal of walking is progression in the forward direction. The CWS and rate of 0 2 uptake were significantly higher for the traumatic transtibial and knee disarticulation amputees than for the dysvascular transtibial amputees and ankle disarticulation amputees.org/alp/chap15-01. described six determinants of normal gait that minimize energy expenditure. Since hip motion also plays an important role in minimizing vertical rise and fall of the HAT.asp[21/03/2013 21:55:17] . evaluated transtibial amputees with stumps ranging from 14 to 19 cm in Patients wore a patellar tendon-bearing prosthesis except for one who had a length. Perry J. Steve L: Stubby prostheses: An alternative to conventional prosthetic devices. New York. should a unilateral transtibial amputee undergo another transtibial amputation. 14. 12. Elftman H. pointed out that in view of the fact that approximately 24% to 35% of diabetic amputees lose the remaining leg within 3 years. J Bone Joint Surg [Am] 1953. McGraw-Hill International Book Co. Corcoran PJ. While walking on stubbies is cosmetically unacceptable for most patients (except for gait training or limited walking in the home). measured energy expenditure in a 21-year-old bilateral knee dis-articulation/knee disarticulation patient who walked on stubby prostheses The patient walked faster at a slightly greater rate of oxygen consumption with a walker. 58:42-46. 5:81-87. Scand J Rehabil Med 1973. WB Saunders Co. Gonzales et al. et al: Rehabilitation of the geriatric amputee. Contact Us | Contribute http://www. Saltin B: Maximal oxygen uptake and heart rate in various types of muscular activity. in Klopsteg PE. Astrand PO. 9:351-377. 4. Wainapel et al. Hislop HJ. it is important to preserve the knee joint even if the stump is short since. Perry J. Lunsford BR. J Appl Physiol 1973. 22:62-66. Waters RL. Arch Phys Med Rehabil 1974. 13.org/alp/chap15-01. Astrand PO. 1989. pp 250-260. 1977. Gonzalez EG. 3. 6:215-222. 7. Orthop Clin North Am 1978. 6. of special interest. Saunders JB. 35:649-654. 16:977-981. than with conventional prostheses and crutches. Salvanelli ML: Energy expenditure in hip disarticulation and hemipelvectomy amputees. in Moore WS.oandplibrary. J Bone Joint Surg [Am] 1976. Eberhart HD. pp 472-482. Antonelli D. Prosthetic. Wainapel SF. et al: Energetics: Application to the study and management of locomotor disabilities. Roettger RF. 5. J Am Geriatr Soc 1974. Astrand I. 35:543-558.). et al: Energy-speed relation of walking: Standard tables. 1954. 8. Philadelphia. March H. Chapter 15 . Waters RL. et al: The energy cost of walking of amputeesInfluence of level of amputation. Finally. Steinberg FU. Perry J. 11. 66:264-266. he would still expend 24% less energy than would a patient with a unilateral transfemoral amputation. Garcia WJ. ed 2. Perry J. Inman VT. 9. Nowrozzi F. Bilateral vascular amputees rarely achieve a functional ambulation status if one amputation is at the transfemoral level. 10. McGraw-Hill International Book Co. Waters RL. Inman VT: Locomotor mechanism of amputee. New York. J Appl Physiol 1961.Atlas of Limb Prosthetics: Surgical. Eberhart HD: Major determinants in normal and pathological gait. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 15 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 64:300-303. J Orthop Res 1988. Chambers R: Energy expenditure of amputee gait.asp[21/03/2013 21:55:17] . James U. 55:111-119. et al (eds): Lower Extremity Amputation. Arch Phys Med Rehabil 1983.15: The Energy Expenditure of Amputee Gait | O&P Virtual Library energy cost than did their vascular transtibial/transtibial counterparts ( Table 15-2. Waters RL. et al: Reduction in maximal oxygen uptake with age. Reyes RL: Energy expenditure in below-knee amputees: Correlation with stump length. References: 1. Wilson PD (eds): Human Limbs and Their Substitutes. Rodahl K: Textbook of Work Physiology. the data from this single patient illustrates that it can result in a functional gait. 2. Nordgren B: Physical work capacity measured by bike ergometry (one leg) and prosthetic treadmill walking in healthy active unilateral above knee amputees. Hallback I. Arch Phys Med Rehabil 1985. Astrand A. and infections account for fewer cases. In grade MB open fractures of the tibia and fibula. The history. LEVEL SELECTION Prediction of healing is the most important part of level selection. a vascularized and innervated flap has saved a weight-bearing foot in an area where an amputation would have been performed. Split-thickness skin grafts do not do well when applied to weight-bearing surfaces of the foot. Rosemont. the center must be called for instructions on handling of the residual limb and the severed part. Experience in the treatment of such problems aids in providing an "experienced hand and eye" to give information beyond that obtained from vascular and other laboratory tests. temperature curves. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. IL. Microvascular techniques are used below the ankle and standard vascular techniques above the ankle.org/alp/chap16-01. quality of life. reprinted 2002. edition 2. Several hundred major limb replantations have been performed at the Sixth Peoples Hospital in Shanghai. The casual surgeon should not embark upon the care of a patient with malignancy of the lower limbs.).16A: Partial-Foot Amputations | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 16A Chapter 16A . ©American Academy or Orthopedic Surgeons. but still a viable foot. perfusion techniques. http://www. The most suitable levels for replantation are in the distal levels of both the upper and lower limbs. It is now just over a quarter of a century since a successful replantation of an arm was performed. and Fig 16A-4. and endoprosthetic replacements. external skeletal fixation. Thus. Debriding of the wound. These procedures are appropriate only for the trained surgical team in a replantation center. clinical course. there may be a marked loss of soft tissues with a deficiency of tissue A transtibial envelope. Hair growth.). M. but will be quite short. and split-thickness skin grafts allowed full salvage and function ( Fig 16A-3. soft-tissue infection. Prevention of major amputation in patients with diabetic foot problems has aided in increasing Multispecialty clinics and the "team approach" are proving superior. China. and sporting The treatment of neoplasms has activities has increased in incidence and severity.D. rapidity of onset of the problem. and muscle loss would have required a transtibial amputation ( Fig 16A-2. bone.). skin turgor and appearance. palpation of pulses.asp[21/03/2013 21:55:22] . Reproduced with permission from Bowker HK. However. Trauma from industrial. Many replacement teams have been formed in the United States. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. and response to antibiotic treatment all aid in evaluation of the patient's problem.Atlas of Limb Prosthetics: Surgical. all length possible should be saved. and Rehabilitation Principles Partial-Foot Amputations: Surgical Procedures F. local resection. neoplasms. A severe foot that would have required a higher amputation fracture/dislocation with skin. Prosthetic. American Academy of Orthopedic Surgeons. The ultimate surgical treatment for traumatic amputation is replantation of the severed part. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). 1992.oandplibrary. and Rehabilitation Principles. and physical examination provide a wealth of information. nail growth. Jr. Prosthetic. amputation is indicated. function of midfoot amputations is such that it is wise to shorten long uncovered metatarsals in order to obtain sufficient plantar skin coverage. skin temperature with differences from level to level and from side to side. it is possible to salvage a ( Fig 16A-1. Vascular disease and trauma are the major causes of lower-limb amputation. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. white blood cell response. Congenital and acquired deformities. As a general rule. latissimus dorsi muscle transfers. Before transfer of any patient and the severed part. undergone marked changes.. Prosthetic. With newer techniques of microvascular transfer of innervated flaps. motor vehicle. Click for more information about this text. William Wagner. Atherosclerosis with or without diabetes mellitus accounts for nearly 80% of the problems severe enough to require amputation. necrotic or absent bone. Amputations should be performed by surgeons familiar with staging techniques. there will be increasing sharpness of the sound until a "water hammer" effect will be heard just before the blockage. and doctor to hear the difference between the diseased vessels and a normal one. With few exceptions.org/alp/chap16-01. a very complete vascular examination can be performed at the bedside with a portable transcutaneous Doppler ultrasound flowmeter. fluorescein tests.). In this case. TRANSCUTANEOUS DOPPLER ULTRASOUND This instrument provides a sensitive stethoscope or flow detector that is able to measure the pulse when it cannot be palpated or heard with an ordinary stethoscope and can be used for ( Fig 16A-5. If the ischemic index is insufficient for local healing at a functional level. However. Immediately afterward. the cuff width should be 120% of the diameter of the limb at the level being Thus. and similar tests have all been described as aids in evaluating the arterial blood flow. Successful revascularization procedures such as endarterectomy. Frequencies of 9 to 10 MHz are recommended for the foot and toes. which will then be transferred to the end of the tibia and fibula to provide a transtibial amputation of Thus. and 0. histamine wheal. a consultation is obtained from the vascular surgery service. Oscillometry. or bypass procedures can aid in local healing of the lesion. In addition to the tests mentioned. 0. saving all tissue possible from the injured foot can result in a more sufficient length. 0. and the experience and skills of the operating surgeon are adequate for the procedure proposed. and toe fillers aid in the restoration of function of short transmetatarsal. Systolic pressures are measured from the groin to the toes at various levels. A variation can be heard that is represented by the dicrotic notch. functional amputation. angiography.). Amputation is performed where healing is indicated by vascular analysis. Sole stiffeners. an intraoperative test appears to have value in predicting healing.50 at the ankle. balloon dilatation. adequate function is predicted. will lead to relatively little disability that usually can be compensated for with simple shoe corrections. Lisfranc.17 at the midfoot. the higher the frequency of the signal. A drop of 30 mm of pressure from one level to the next lower indicates a very definite decrease in circulation. As recommended by the American Heart Association. When the flow becomes markedly decreased. the most functional residual foot is at the transmetatarsal level or lower. and 20 mm at midfoot. the instrument determining blood pressure at that point does not need to be directional. A triphasic full pulse is one similar to that heard at the brachial artery. rocker bottoms. laser Doppler.. Transfer of the everters and dorsiflexors may aid in balancing the residual foot.75 at the calf. With relatively little experience. and several relatively inexpensive portable machines are available. If bleeding is prolonged beyond 3 minutes. examination of the lower limb. ergo-metry. radionuclide washout. 60 mm at the ankle. a wind tunnel effect is heard with marked broadening of the width of the wave ( Fig 16A-6. Appearance of bleeding at the skin level after release of the thigh tourniquet has been timed. 90 mm at the calf. plethysmography. an ankle disarticulation is indicated if the skin of the heel is intact. Doppler ultrasound. either partial or complete. a heel cord lengthening is needed to reduce distal pressures. with all of these tests. The major vascular tree can be mapped with the instrument and areas of lessened flow and zero flow determined and marked on a chart ( Fig 16A-6.oandplibrary. For this purpose. and Chopart levels. The ischemic index would be 1 at the arm and thigh. Collateral circulation is also mapped. Loss of the toes. Occasionally. A unit with an audible response is valuable in allowing the patient. For example. the systolic pressure may be 120 mm at the arm and at the thigh. clinical judgment still remains the most important part of level selection. there is an 80% to 85% chance for successful healing of the amputation incision. VASCULAR ANALYSIS Level selection in dysvascular patients has frequently been difficult.asp[21/03/2013 21:55:22] . there may be just background noise and various indications of nonpulsatile flow or complete silence. there will be silence until collateral flow begins to come into the distal vessel. four different-sized cuffs are usual for a satisfactory complete measured.16A: Partial-Foot Amputations | O&P Virtual Library Length can be preserved through the use of a neurovascular island fillet from the foot. the next higher level should be tested. The tourniquet is not used if there has been previous vascular surgical procedures in the limb. If there is a sudden acute blockage just below a relatively normal flow. family. An ischemic index is calculated for each level by dividing the systolic pressure measured in the limb by the brachial artery pressure. The smaller the vessel to be measured. http://www. If there is a virtual block. When the most distal skin bleeds within 3 minutes after release of the tourniquet.). This indicates a virtually normal flow. Pulsation of the flow can be determined. Individual selection is made from preference of the patient. Intravenous regional anesthesia with a two-level tourniquet is excellent and appears to interfere least with the patient's general condition. Hospital mortality has been less than 1% in the ankle disarticulation and foot amputation levels. A contraindication to the use of the tourniquet would be recent vascular surgery. These. http://www. Inclusion of the infectious disease consultant as a member of the team has aided greatly in the care of these difficult patients. SPECIFIC SURGICAL TECHNIQUES Guillotine Amputation This method of amputation has had a resurgence as a preliminary procedure to remove a In some cases sepsis can be controlled by amputation or severely infected part of the foot. INFECTION Many traumatic foot wounds and most diabetic ulcers are infected. coexisting medical problems. OPEN VS. and preferences of the anesthesiologist and surgeon. Kritter states that he is now irrigating the wounds of similar patients without antibiotics and believes that the irrigating effect is the more important. The fluid dilutes the hematoma and aids in the removal of blood clots and debris between the sutures.16A: Partial-Foot Amputations | O&P Virtual Library can allow local surgical procedures to be performed. Removal of the major amount of infected or gangrenous tissue by amputation usually leaves a number of bacteria behind in the surrounding cellulitis and lymphangitis. or may allow amputation to be performed at a low enough level to save the knee ( Table 16A-1. The ankle brachial index has been criticized for not predicting healing in transmetatarsal amputation. may be done with secondary closures. There can be a drop of pressure from the ankle to the midfoot that would be sufficient to preclude healing at the midfoot level. of course. The index is to be measured at the proposed level of surgery. These usually can be controlled by the body's own defense mechanisms with the aid of appropriate antibiotics. ). and sural nerves can be reinforced with small amounts about the peri-incisional areas. In a recent personal communication. provided that the flaps have an adequate base to support the length. Kritter has developed a technique for irrigating wounds of this sort with closure. operation is now archaic because the residual limb has a scarred closure that is rarely suitable for use of a prosthesis.org/alp/chap16-01. It must be again emphasized that all factors should be taken into consideration when determining amputation level.). CLOSED TECHNIQUES All open wounds are eventually infected or colonized even with nonpathogenic bacteria. Guillotine amputation as the primary leg drainage to be followed by a definitive procedure. Regional anesthesia with perineural infiltration of the posterior tibial.oandplibrary. A small plastic catheter is drawn into the wound through a separate stab incision (see Fig 16A-11. Partial-Toe Amputation The toes can be excised from the tip to the base through any type of incision.asp[21/03/2013 21:55:22] . Cultures and sensi-tivity studies are virtually mandatory in selection of the proper antibiotics. His technique has virtually done away with open amputations in foot patients at Rancho Los Amigos Medical Center. as indicated. Several thousand thiopental (Pentothal) induction and inhalation anesthetics have been administered at Rancho Los Amigos Medical Center for diabetic and dysvascular patients with no intraoperative deaths for foot procedures. ANESTHESIA All types of anesthesia may be used. A paradox is thus created in leaving an amputation open when performed for severe infection. There is evidence in the literature that closed incisions do better than open incisions. Nutritional status has also been noted to be an important predictor of healing. superficial peroneal. Care must be taken with nephrotoxic and ototoxic antibiotics so that total amounts given do not exceed allowable limits. The flaps must close without tension. The wound is closed relatively loosely and slowly irrigated with an appropriate antibiotic solution for 72 to 96 hours. Infection should be controlled. With the great toe. Palpable foot pulses are not necessary. Articular cartilage is resistant to infection and need not be arbitrarily removed. the distal part of the foot is raised dorsally and divided from the plantar flap by an oblique incision. a disarticulation at the metatarsophalangeal joint is quite satisfactory. or fourth toe and ray. The residual foot is quite functional and produces a better gait than with a trans-metatarsal amputation. ). A Kritter irrigation tube is then introduced into the wound through a separate stab incision ( Fig 16A-11. third. The mobile pad appears to offer marked protection to the skin under the first metatarsal head ( Fig 16A-7. Complete removal of infected and necrotic tissue is important. The incision should not extend through hypoes-thetic areas or through infected areas. long dorsal flaps. scleroderma. but there should be no dependent rubor. The incision is carried sharply to bone. Ecker and Jacobs reported that only 2 of 18 closed wounds failed whereas 16 of 36 open wounds failed. all of the lateral rays have been removed with the great toe and first metatarsal left ( Fig 16A-8. fourth-. The wounds in such procedures are irrigated with antibiotic solutions when the removal has been for major infection. they are beveled or rounded on their inferior edge. For a single second. Transmetatarsal Amputation This amputation may be performed for deformities resulting from trauma to the toes. The periosteum is dissected distally. Toe Disarticulation If sufficient viable skin is not present to allow a partial-toe amputation. and the metatarsals are divided at the proximal level of the incision ( Fig 16A-10. ).35. a V-shaped wedge is removed. Enough bone must be removed so that flaps may be closed without tension. and fifth-metatarsal ray resections have been quite successful and leave a With the use of the ischemic index obtained by transcutaneous functional partial foot. and fixation of the long extensor tendon to the dorsal joint capsule aids in elevation of the metatarsal head. It continues on either side to half the thickness of the foot. arteriosclerosis. except in the fifth toe. thickening and rockering of the shoe aids in restoring function of the great toe. On occasion. We have left none open to granulate. the success rate has improved markedly. This has been well borne out in a recent article on great toes amputated for replacement of thumb loss. Wound irrigation is carried out to remove minor bits of debris from bone division. In the lesser toes. Venous filling should be less than 25 seconds. It goes across the plantar surface of the foot just proximal to the base of the toes ( Fig 16A-9..oandplibrary. It slants posteriorly to the lateral side approximately 15 degrees so that the residual foot will correspond to the break of the shoe. and infection or gangrene due to frostbite.org/alp/chap16-01. long plantar flaps. Postoperative Treatment and Function http://www.). Gangrene must be limited to the toes and should not involve the web space.). This closes well and leaves a symmetrical foot. Doppler ultrasound. transmetatarsal amputation in a diabetic in 1949. Metatarsal Ray Resection Third-.B). this does not seem to be as important. The flap is enclosed with a single layer of nonabsorbable sutures.45 and in the nondiabetics when it was over 0. Healing has occurred in over 93% of our diabetics when the ratio was over 0. After division of the bone.16A: Partial-Foot Amputations | O&P Virtual Library They may be side to side. To remove pressure points from the plantar surface of the metatarsal shafts.A). or any combination. fish mouth flaps. diabetes. A light compression dressing is applied. The patient should be free of pain.. Metatarsal head pressure can become more prominent. A long plantar flap provides more durable skin coverage. To these criteria. McKittrick et al. Stiffening.asp[21/03/2013 21:55:22] . loss of tissue. outlined the indications for rheumatoid arthritis. it is desirable to keep enough of the base of the proximal phalanx to preserve the attachment of the short flexor and extensor tendons. and similar conditions. Irrigation is performed with a physiologic solution when the wound has been noninfected. Technique A slightly curved incision traverses the dorsum of the foot obliquely at the level of the metatarsal necks ( Fig 16A-9. Their indications are as true today as they were then. we have added the transcutaneous Doppler ultrasound ischemic index. which then allows easier division of the metatarsal shafts. A Kritter tube is used to irrigate the wound postoperatively for 24 to 72 hours. without the need for cutting bone.16A: Partial-Foot Amputations | O&P Virtual Library The Kritter drain is removed in several days. In these cases. In the Chopart amputation. A http://www. the distal surfaces of the calcaneus are rounded to relieve potential pressure points. A light compression dressing is applied. and a walking cast is applied at 2 weeks. Lengthening of the Achilles tendon will lessen some of the equinus deformity. It is tailored to close without tension ( Fig 16A20. Stabilization can be performed at a later date in most cases. Lisfranc and Chopart Amputations Lisfranc and Chopart amputations were introduced before blood transfusions. second. the lever arm of the distal part of the shoe can raise the pressure at the end of the amputation. There is still marked drainage from a plantar ulcer. Postoperative Function The residual foot is shorter than that of a transmeta-tarsal amputation ( Fig 16A-22. Roentgenograms have shown osteomyelitis of the first. The proximal incision passes over the dorsum of the foot at the base of the metatarsals ( Fig 16A-16. If healing is sufficient at 2 weeks. This is continued until healing is secure and the patient begins shoe trials. Cultures have been taken during the procedure and aid in the postoperative antibiotic treatment. Occasionally. it is not wise to attempt tendon transfers at the time of the initial surgery. The plantar flap is long enough to fold up to the dorsum of the foot. In infected cases. On occasion. ). We have also had success at these levels by adding subcutaneous tenotomy of the Achilles tendon and subsequent use of a polypropylene ankle-foot orthosis to the basic technique ( Fig 16A-14. there is much less indication for their use at present. and most patients are able to use an ordinary shoe. After removal of the Kritter tube. and rockered. and third metatarsal bases. the sole is thickened.asp[21/03/2013 21:55:22] . no bone trimming is performed. stiffened. starting at the level of the short flexor muscles. to be performed as rapidly as possible. The fourth and fifth metatarsal bases are cut through with a motorized saw and left in the residual foot. it may be necessary to leave the third metatarsal base in place to provide a better surface to support the local soft tissues ( Fig 16A-18. the patient is then allowed to ambulate in a cast. The plantar incision is placed distally so that the infected material is removed but the flap is long enough that it may be tailored later to cover the ends of the resected bones ( Fig 16A-17. ). There are late complications associated with equinus deformity and resulting increased plantar pressure ( Fig 16A-13. ).oandplibrary. At Rancho Los Amigos Medical Center. depending upon the degree of preoperative infection ( Fig 16A-21. The residual foot heals rapidly. Bed rest and intravenous antibiotics have allowed regression of the surrounding cellulitis ( Fig 16A-15. The residual foot is then dissected from the plantar surface.org/alp/chap16-01. the patient is placed into a nonwalking cast. If these amputations are performed for an infected gangrenous foot. with soft-tissue instruments alone. ). antibiotics. and anesthesia were available. second. ). The wound is then checked for any residual infectious tissues. ). a further technique has been developed for the Lisfranc amputation in which the bases of the fourth and fifth metatarsals are divided from the distal metatarsal shafts and thus save the function of the peroneus brevis tendon. Some of the later problems may be prevented by transfer of the peroneus brevis to the cuboid and transfer of the anterior tibial tendon to the neck of the talus. In noninfected cases. ). ). and Fig 16A-19. They had been planned as disarticulations. On occasion. ). the anterior tibial tendon and extensor digitorum longus tendons are drawn down and incorporated in the skin closure so that they are attached to the plantar fascia and aid in dorsiflexion. Except in special circumstances. Technique-Lisfranc Amputation The procedure is demonstrated on a patient with diabetes mellitus who has a deformed infected forefoot. an ankle-foot orthosis is required (see Fig 16A-14. This will then imitate the action of the roll-off at the metatarsophalangeal joint ( Fig 16A-12. ). ). The tarsometatarsal joints are disarticulated at the first. and third metatarsal heads. Chopart Amputation-Technique Ablation of the forefoot at the talonavicular and calcaneocuboid joints closely parallels that of amputation at the tarsometatarsal joints. The flap is then beveled to the distal edge. 24:742-746. Revascularization procedures should be considered to allow lower amputations to be performed. 5:791-793. Knighton DR: Amputation prevention in a high-risk population through comprehensive wound healing protocol. Pasch AR. 17. Clifford EJ. Arch Surg 1986. Filling C. et al: Improved survival of the diabetic foot: The role of a specialist foot clinic. Weston GW. Elderly bilateral amputees do poorly with any level that does not save the knee. Rollins BF. South http://www. 11. Jacobs BS: Lower extremity amputations in diabetic patients. Calhoun JH. 9. 13:759. JAMA 1962.org/alp/chap16-01. J Bone Joint Surg [Am] 1984. as well as further lengthening of the Achilles tendon. Surg Gynecol Obstet 1976. et al: Results of in situ vein bypass to the foot. Edmunds ME. Carter SA: The relationship of distal systolic pressure to healing of skin lesions with arterial occlusive disease. 3. 16. If distal pressure ulcers arise despite rocker-ing of the shoe. et al: Conservative management of gangrene in the diabetic patient. 121:673. 13. J Vasc Surg 1987. Gibbons GW: The diabetic foot: Amputation and drainage of infection. The anterior tendons are sewn into the wound to aid in dorsiflexion. Scand J Clin Lab Invest 1973. 146:280-282. J Trauma 1984. 4. Cobos MD. Williams DM: Problems in the management of type III (severe) open fractures: A new classification of type III open fractures.asp[21/03/2013 21:55:22] . 5. Buchbinder D. 60:763-771. 15. Q J Med 1986. 19. et al: Treatment of diabetic foot infections: Wagner classification. Donovon DL. 18. Clin Orthop 1983. 7. Mendoza RM. Gustillo RB. all efforts should be directed toward partial-foot amputations if preventive measures are not successful. Gaenslen FJ: Split heel approach and osteomyelitis of the os calis.oandplibrary. Anderson L. 6. J Bone Joint Surg 1931. DeLee JC. Arch Phys Med Rehabil 1989. 70:780785. with special reference to diabetes mellitus. Diabetes 1970. Morris ME. 20. Ger R: Prevention of major amputations in the diabetic patient. Teget B. Ecker MD. 66:71-75. Burgess EM: Contralateral limb and patient survival after leg amputation. 14. Bessman AM. 8. 31(suppl 128):239. 4:550. 10. Klaborg KE: Forefoot amputation in rheumatoid arthritis. Am J Surg 1989. results and long-term follow-up. Am J Surg 1983. References: 1. Vlahose JG. it may be necessary to revise the residual stump by transferring the anterior tibial tendon into the center of the neck of the talus. Collins WS. 58:394-397. therapy and outcome. Efird WG: Amputations of the distal portion of the foot. Goodman J.16A: Partial-Foot Amputations | O&P Virtual Library percutaneous lengthening of the Achilles tendon is performed through three stab incisions: two medially and one laterally. 12. et al: Results of arterial reconstruction of the foot. Blundell MP. 181:692. Page CP: Nutritional status: Importance in predicting wound healing after amputation. Cantrell J. et al: Risk factors in local surgical procedures for diabetic gangrene. 2. 143:587. SURVIVAL OF THE CONTRALATERAL LIMB A high percentage of dysvascular patients will have an amputation on the opposite side within 3 to 5 years. File TM: Team approach in the management of diabetic foot infections. For this reason. Dobkin GB. 26(suppl):12-16. Ger R: Muscle transposition in the management of perforating ulcers of the forefoot. Additional rounding of the calcaneus may be necessary. 9:101-106. Peters PG. Postoperative Function A prosthetic device is necessary to allow standard shoe wear. Arch Surg 1985. J Foot Surg 1987. Claggett GP. J Pediatr Orthop 1984. Bottely KC. 175:186. 120:1317-1320. Doucette MM. Anderson JA. 158:502-505. Acta Orthop Scand 1987. Oppenheim LL: Syme amputation in children: Indications. Foot Ankle 1988. Dickhaut SC. 19:189. Hodge MJ. Frye RE. Many will not have survived. 30:585. 4:511516. Arch Surg 1973. 51. Holloway GA. Mosby-Year Book. Malone JM. Bessman AN: Mortality of diabetic patients treated surgically for lower limb infections and/or gangrene. Hobson RW. Zirul VT. 46. J Bone Joint Surg [Am] 1976. 191:232. 45. Kazamas TN. Corson JD. McCowen SA. Kirkendahl WM. 37. 29. Arch Surg 1984. 119:450-453. 122:53. et al: Guillotine amputation. Pinzur MS: Ray resection in the dysvascular foot. 95:549-552. Andersson GR: Partial amputation of the foot for diabetic arteriosclerotic gangrene-Results and factors of prognostic value. Sinnock T: Epidemiology of lower extremity amputations of diabetic individuals. Lynch TG. 122:931-934. 31:639. Surgery 1984.16A: Partial-Foot Amputations | O&P Virtual Library Med J 1989. Surgery 1988. 70:251. 32. 48. 112:567. Franklin DL: Blood pressure measurements with Doppler ultrasound flow meter. Carson JD. Mann RA. J Bone Joint Surg [Br] 1988. ed 3. Graham LM: Do operative results justify tibial artery reconstruction in the presence of pedal sepsis. LoGerfo FW. 256:44-49. J Bone Joint Surg [Am] 1989. Am J Surg 1988. 107:798. Clin Orthop 1971. Scher KS. Diabetes Care 1983. Wood D. 3:197-202. St Louis. 38. Hornby R. Mehta K. Clin Orthop 1977.org/alp/chap16-01. Shah DM. Sanders WE: Amputation after tibial fracture: Preservation of length by use of a neurovascular island (fillet) flap of the foot. Watkins DW: Laser Doppler measurements of cutaneous blood flow. Brewster DC. Burton AC. 58:833. 28. 47. Megerman J. Levin ME: Medical evaluation and treatment. 52. Liny RS. Hulnik A. Boutin FJ: Amputations for failure in reconstructive surgery. Kritter AE: A technique for salvage of the infected diabetic gangrenous foot. Laoka SG. 6:87-91. Poppen NK. 25. Wagner FW Jr: Neurocirculatory disorders of the foot. Roach JJ. McFarland DS: Resurrection of the amputations of Lisfranc and Chopart for diabetic gangrene. 35. J Bone Joint Surg [Br] 1978. Malone JM. Am J Surg 1987. Epstein PH. Arch Surg 1977. Burkus JK: Long-term follow-up of Syme amputations for peripheral vascular disease. Pyper A: The modified Chopart's amputation. Karmody AM. Katsanoris A. Karanfilian RG. Clin Orthop 1990. 26. J Bone Joint Surg [Am] 1949. 71:435. Gandor MP. 34. Rhodes GE Jr: Ankle level amputation. Clin Orthop 226:192-204. 147:510. Bailey SA. in Levin ME.oandplibrary. Nakhgevany KB. Am J Surg 1984. 82: 1138-1142. McKittrick JB.asp[21/03/2013 21:55:22] . 36:908. 33. et al: Optimal management of tibial arterial http://www. 22. 49. Larsson U. Clin Orthop 1984. Foot Ankle 1988. Jamil Z. et al: Prospective comparison of non-invasive techniques for amputation level selection. 23:287. 27. Mooney V. Steele FJ: Aseptic foot in patients with diabetes. Acta Orthop Scand 1984. Anderson GG. et al: Value of laser Doppler velocimetry and transcutaneous oxygen tension determination and predicting healing of ischemic forefoot ulcerations in diabetic and non-diabetic patients. 74:177. Deutsch A. 41. 69:306. Moore WS: Determination of amputation level measurement of skin blood flow with xenon-133. 55:227-233. Tsai T-M: Lower limb replantation: A report of nine cases. 50. Ruben RR. O'Kouskim M: Amputation of the great toe: A clinical and biomechanical study. 60:126. J Surg Res 1980. Pitluk SC. et al: The measurement of skin blood flow and peripheral vascular disease by epi-cutaneous application of xenon-133. 28:466-470. Holstein P: The distal blood pressure predicts healing of amputations on the feet. Most RS. Romano RL. 9:107-110. Hunter GA: Traumatic partial foot amputation in adults. 1983. et al: Transcutaneous oxygen tension and selection of amputation level. Letts M. Orthop Clin North Am 1973. J Invest Dermatol 1977. J Vase Surg 1986. 40. 104:661. 31. Kostuik JP. 21. Highsmith C. Burgess EM: Level selection in lower extremity amputations. 42. 36. pp 1-60. 154:179-184. 24. 156:144-147. 53. 43. 44. J Appl Physiol 1971. Circulation 1967. Mannick JA: Improved results with femoral-popliteal vein grafts for limb salvage. Millstein SG. et al: Fallability of Dop-pler ankle pressure in predicting healing of transmetatarsal amputation. 30. Wagner FW Jr. 39. 4:21. McKittrick LS. Kahn O. Risley TS: Transmetatarsal amputation for infection and gangrene in patients with diabetes mellitus. O'Neil LW (eds): Diabetic Foot. McIntyre KE. et al: Recommendations for human blood pressure determination by sphygmomanometers. Diabetes 1974. Foot Ankle 1983. Arch Surg 1987. Jupiter JE. 23. 130:826. Ann Surg 1949. the treatment of nonsalvagable lower extremity infections. Kutz JE. 65:599-604. 54. 61. Wagner FW Jr: Amputations of the foot and ankle. Harrington RM. Volpicelli LJ. Wagner FW Jr: Orthopedic rehabilitation of dysvascular lower limbs.oandplibrary.asp[21/03/2013 21:55:22] . J Bone Joint Surg [Am] 1983. 28:228-234. et al: Diabetic foot infections. Chapter 16A . 130:59. Chambers RB. et al: Failure of Doppler ankle pressure to predict healing of conservative forefoot amputations. Wagner FW Jr: A classification and treatment program for diabetic neuropathic and dysvascular foot problems.Atlas of Limb Prosthetics: Surgical. Lebermen DP. Welch GH. Br J Surg 1985. J Trauma 1988. et al: Transcutaneous oxygen tension as a predictor of success after an amputation. Wagner FW Jr: The dysvascular foot-A system for diagnosis and treatment. Henry M. Wagner FW: Ambulation levels of bilateral lower extremity amputees.org/alp/chap16-01.16A: Partial-Foot Amputations | O&P Virtual Library trauma. 72:888. Clin Orthop 1977. Instr Course Lect 1979. 146:1935. Contact Us | Contribute http://www. J Bone Joint Surg [Am] 1988. 70:203. 28:143. Wagner FW Jr: The use of transcutaneous Doppler ultrasound in prediction of healing potential and selection of surgical level in dysvascular lower limbs. 58. Burgess EM. Allen SD. 55. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 16A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Polluck JG. 60. Orthop Clin North Am 1978. 9:325. 2:64. Wyss CR. 59. Arch Intern Med 1986. 122:62. Wheat LJ. 62. 57. Prosthetic. bacteriologic analysis. Foot Ankle 1981. 56. West J Med 1979. Condie. The normal foot is an extremely complex structure.Atlas of Limb Prosthetics: Surgical. Rosemont. Prosthetic. This method of load transmission is commonly attributed to the "arch structure" of the foot. The specially adapted fatty tissues of the heel pad are ideally suited to the absorption of the high forces generated at impact and during the subsequent loading of the limb. which is a consequence of this movement. Melvin L. A more subtle but equally important role concerns the absorption of the longitudinal rotations of the lower limbs that occur with each stride ( Fig 16B-1. Internal rotation of the entire lower limb. Eng. During this phase the foot pronates about the subtalar joint axis. this load falls and localizes on the plantar surface of the hallux. 1992. the supporting forces are shared between the heel and the ball of the foot. the foot supi-nates about the subtalar joint axis to absorb this motion. which is initiated during the swing phase. Prosthetic. As body weight is transferred to the contralateral limb. Elevation of the lateral margin of the foot. Clearly the ability of the foot to alter its shape and alignment are of considerable importance in adapting to variations in the slope of the walking surface. is counteracted by supination of the forefoot through a combined motion of the rays. B. Stills. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.asp[21/03/2013 21:55:27] . and Rehabilitation Principles Partial-Foot Amputations: Prosthetic and Orthotic Management David N. Once the foot is flat and until the heel leaves the ground as push-off is initiated. Prosthetic. Joint Function The functions of the joints of the foot have been the subject of endless investigation. This discussion of the mechanics of normal foot function will be restricted to a brief consideration of load-bearing structure and the function of the foot joints during normal walking.Sc. Reproduced with permission from Bowker HK. continues after heel contact until the foot is flat. reprinted 2002. thus avoiding slippage occurring between foot and ground.16B: Prosthetic and Orthotic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 16B Chapter 16B . IL.oandplibrary. American Academy of Orthopedic Surgeons. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. and Rehabilitation Principles. The associated depression of the http://www. NORMAL FOOT FUNCTION The successful management of partial-foot amputation requires a clear understanding of the functions of the normal foot and the consequences of surgical ablation. ©American Academy or Orthopedic Surgeons.org/alp/chap16-02. After the foot is flat as the lower limb commences external rotation. even though it is now clearly understood that its effectiveness is a function of a number of both structural and neuromuscular mechanisms. Load-Bearing Structure The foot is the means whereby the ground reaction forces generated during physical activities are transmitted to the body structure. edition 2. the detailed function of which is still only partially understood. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. During normal level walking these loads are directed initially onto the heel. the increased ground force associated with push-off must be transmitted through the area defined by the metatarsal heads and the pulps of the toes. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).). CO. thus ensuring that ground contact is achieved across the entire forefoot. thereby maintaining the normal toe-out position of the foot. Once the heel leaves the ground. Click for more information about this text. C. with only a small contribution from the lateral aspect of the midfoot. asp[21/03/2013 21:55:27] . An alternative approach is the use of custom silicone rubber toes attached to the residuum with medical ad-hesives and held in place with a sheer nylon stocking. Inc. Can these tissues withstand both the direct and shear pressures that will occur during normal activity. A preferable solution consists of a simple insole to which toe fillers on spacers formed from orthopedic felt or foam are bonded (Muilenburg Prosthetics) ( Fig 16B-5. however. Custom insoles fabricated from pressure- http://www.16B: Prosthetic and Orthotic Management | O&P Virtual Library lateral margin of the foot is in this instance counteracted by pronation of the forefoot.. There are many factors to take into consideration in the management of the partial-foot amputee. Today the availability of moldable flexible materials permits the fabrication of partial-foot prostheses that are both functionally and cosmetically acceptable (Life-Like Laboratory. by doing so.). stiffens the long arch of the foot to prepare it for the higher dorsiflexion moment that it is subjected to after the heel leaves the ground. however. the resulting reduction in the area of the plantar surface available to transfer the forces encountered during physical activity may be significant. Once subtalar supination commences. THE DESIGN OF PARTIAL-FOOT PROSTHESES/ORTHOSES Devices used in the management of partial-foot amputations may be called orthoses or prostheses. the subtalar joint now reverses its direction of motion to pronate in conjunction with the forefoot. Patients may elect simply to use soft foam or cloth to fill voids left in the shoe. Traditional prosthetic solutions used for these patients were in general heavy and bulky. In addition. Ray amputations will also reduce the effectiveness of the pronatory/supinatory movements of the forefoot by impairing both its interaction with the subtalar joint and its role in responding to irregularities and slopes in the walking surface. this joint locks and. and Fig 16B-7.).). this technique is available at only a few specialized centers (Life-Like Laboratory) ( Fig 16B-6.). RAY AMPUTATIONS The biomechanical consequences of ray amputations will be largely dependent on the position and extent of the forefoot segments removed. however. During the initial loading phase this joint acts in concert with the subtalar joint. Dallas) ( Fig 16B-4. this effect will be aggravated by mediolateral instability and may result in more serious pressure problems. some consideration should be given to providing resistance to hyperextension of the first metatarsophalangeal joint area both to reduce the effect of the loss of the final element of push-off and to prevent uncomfortable shoe deformation. AMPUTATION OF THE TOES The functional requirement for this type of amputation is largely cosmetic. A final word should be reserved for the role of the midtarsal joint. once again enabling the maintenance of full forefoot loading. and this led to the widespread adoption of modified orthotic systems based on the ankle-foot orthosis commonly used to control ankle function (Muilenburg Prosthetics. and Fig 16B-3. perhaps most importantly the condition of the soft tissue in the weight-bearing areas of the residuum. if the hallux is absent. and how can the prosthesis be constructed to provide some degree of compensation? These issues and the associated biomechanical considerations will be discussed in the following description of the prostheses/orthoses currently in use for each amputation level. Houston) ( Fig 16B-2. particularly during push-off ( Fig 16B-8. external rotation of the limb continues. In the case of diabetic patients.org/alp/chap16-02.oandplibrary. however. it is desirable to resist deviation of the remaining toes toward the amputation site. After the heel leaves the ground. or does the load need to be transferred to a more proximal normal tissue? What will be the functional consequences of the loss of the foot joints. This ambiguity arises from the design of the various systems used.). hence transferring the area of support medially onto the first metatarsal head and finally the hallux as the foot loses contact with the ground. In those instances where the first or the fifth rays have been removed (with or without the intermediate rays). whereas for the more distal amputation levels the prostheses can be effectively interfaced with the stump by using suitable footwear. however. Alternative ankle-foot orthotic designs manufactured from thermoplastic materials are both lighter and more cosmetic. Laminated foam insoles may be used to increase longevity. Above-Ankle Designs Early prosthetic designs took a form similar to an ankle disarticulation (Syme) prosthesis.. Basically.). These insoles have a limited life expectancy since they are designed to gradually deform. the patient must adopt a modified pattern of hip motion. a more extensive socket is now indicated if relative motion between prosthesis and residuum is to be prevented when weight is applied to the forefoot.org/alp/chap16-02. Generally a softer. however. this may be incompatible with the stiffening required to prevent shoe hyperex-tension during normal push-off (Life-Like Laboratory) ( Fig 16B-12. In these designs the dorsiflexing moment created by forefoot loading is easily resisted by counterforces generated on the heel and at the anterior brim of the device ( Fig 16B-13. the device is constructed to encompass the entire residuum and extend some distance above the ankle. In these designs resistance to the dorsi-flexion moment is provided by the accurate fit of the socket on either side of the calcaneus ( Fig 16B-14. TRANSMETATARSAL AMPUTATION All those considerations referred to in connection with amputation of the toes also apply to the treatment of trans metatarsal amputations.asp[21/03/2013 21:55:27] . Fig 16B-10. as has previously been mentioned. For this. a variety of techniques are employed.O. these have been found to be bulky and heavy (see Fig 16B-2.. however. C. Ark). In the more traditional designs of prostheses (and some of the more recent ankle-foot orthotic solutions). Obviously some means must be provided for permitting entry and removal of the residuum. Collins Orthopedic Service.16B: Prosthetic and Orthotic Management | O&P Virtual Library sensitive materials may be used to distribute pressure evenly over the remainder of the foot. One of the principal problems encountered by the patient with a ray amputation is shoe fit.oandplibrary. the requirement to replace the anterior support area of the foot remains the same.. however. http://www. This design may also be constructed so as to provide axial load relief in the event that full plantar weight bearing is contraindicated. ). TARSOMETATARSAL AND TRANSTARSAL AMPUTATIONS With these more proximal amputations the prosthetic requirements become considerably more demanding. ). stiffer foam that will retain its shape longer is used for the base. Two basic biomechanical solutions are available.). and Fig 16B-15. this group of patients will experience some functional impairment due to the loss of normal forefoot mobility. to 16B-11). ). Since the subtalar joint remains free to function normally. All above-ankle systems will inevitable restrict subtalar joint motion.P. thereby eliminating the normal mechanism for absorbing the longitudinal rotations of the limb. the more significant loss of the loadbearing surface under the metatarsal heads that is experienced by these patients must also be addressed. Fig 16B-11.). Inc. . more conforming foam is used against the skin. thereby protecting the foot from excess pressures. If slippage between the foot and the ground is to be avoided. these are probably only indicated for those patients where it is necessary to transfer the weight-bearing forces above the ankle to unload fragile skin at the amputation site or to compensate for weakened ankle musculature (see Fig 16B3. while a more durable. most commonly by utilizing a shoe insert molded accurately under the remaining area of the longitudinal arch (see Fig 16B-5. Some flexibility in the construction of the forefoot filler to permit supination or pronation would be an advantage. More modern designs of prostheses of the slipper type enclose only the residuum and terminate around the ankle joint. Fayetteville. (Jack Collins. however. In more extensive amputations a foam insert may be used that will position the foot correctly in the shoe and avoid the necessity of purchasing split sizes of shoes (Life-Like Laboratory) ( Fig 16B-9. A spring steel is attached to the plantar surface of the socket and extends to within 1 in. The profile of the foot is restored by a soft or rigid buildup added to the socket.asp[21/03/2013 21:55:27] . of the toe (distal end of the finished prosthesis). ). These systems are fabricated over an exact model of the patients remaining foot. The Collins Orthopaedic Service Partial-Foot Prosthesis The socket for this prosthesis (see Fig 16B-15. 4. Semiflexible designs utilize a combination of materials generally having urethane elastomer or a silicone base. Rigid and semirigid partial-foot prostheses will generally require cushion heel and rocker sole modifications to the patient's shoes. These models are carefully modified to decrease pressure where required and increase pressure where tolerated.16B: Prosthetic and Orthotic Management | O&P Virtual Library Patients wearing above-ankle devices will have the further disadvantage of a reduced range of ankle motion. The resulting http://www. Permanent tooling is developed for each individual amputee and consists of a permanent polyester resin positive model and a negative mold of the finished artificial foot. these patients will be required to adopt compensatory hip and knee joint movements to cope with this restriction. Care is taken to ensure a tolerable distribution of pressure.org/alp/chap16-02. These fillers may simply fill the shoe shape or be carved to simulate the contours of an actual foot and toes. Modification of the socket to relieve excessive pressure is generally achieved by modification to the outside surface of the shell. The contours of the foot are filled out by using prosthetic foam that is foamed in place by using a plaster toe mold. callosities. The proximal edge of the socket opening is also thinned to avoid edge pressures. depending on skin tolerance. The Imler Partial-Foot Orthosis-Chicago Boot The socket for this prosthesis is vacuum formed over a modified plaster model in the manner of a University of California Berkeley shoe insert (see Fig 16B-17. Rigid Semirigid Semiflexible Flexible All of these systems are laminated or thermoformed about a positive model of the remaining foot. Reliefs are made for bone prominences. Rigid and semirigid systems incorporate a foam socket liner that acts as an interface between the walls of the socket and the surface of the skin. ) is fabricated over a modified positive plaster model of the stump. 3. Color is added during the foaming process or may be painted on to match skin tones at the time of fitting. Below-Ankle Designs There appear to be four basic types of construction currently in use: 1. ) manufacturing processing is somewhat complex. These liners may be of varying thickness and stiffness. or sensitive areas. Silicone is laminated into a cloth material and reinforced with woven glass if needed for increased durability. Material may be removed proximal to the calcaneus to improve the suspension of the prosthesis. Since the extent of the residuum precludes the use of a normal prosthetic ankle mechanism. Some examples of semiflexible prostheses include the following: Slipper-Type Elastomer Prosthesis The slipper-type elastomer prosthesis (STEP) ( Fig 16B-16. By reducing the socket thickness over the high-pressure area increased flexibility is achieved.oandplibrary. thereby maintaining the smooth integrity of the socket inner surface. The device is fabricated by using semi-flexible urethane elastomers. They are also prone to deterioration and will require replacement in time due to decreasing thickness and softness of the material. A toe filler is attached to the socket either during the foaming processing or by gluing in place later. This problem may be best addressed by the use of a rocker sole and cushion heel adaptation to the amputee's shoe. 2. The use of rigid and semirigid prostheses is today less common due to the availability of improved semiflexible and flexible designs. The choice of design to be employed will depend on the level of amputation. 12:19-23. Extensions above the malleoli are used to provide improved suspension of the prosthesis on the limb. Fig 16B-7. in Advanced Below Knee Prosthetic Seminar. Detailed coloring is done at the time of fitting to match the natural skin tones. ) is laminated over a modified plaster model in the usual manner by using a nylon-tricot cosmetic stockinette and Otto Bock silicone (Otto Bock Orthopedic Industry.. C. Campbell. The finished prosthesis extends just above the ankle and is retained by lace-up closures anteriorly. Subsequent experience has demonstrated that this design of prosthesis. and Fig 16B-12. Orthot Prosthet 1976. Staats T: The slipper type partial foot prosthesis. Fig 16B-9. The degree of flexibility is determined by the amount of reinforcement utilized in the socket walls. UCLA Prosthetic and Orthotic Education Program. and Fig 16B-12..16B: Prosthetic and Orthotic Management | O&P Virtual Library copolymer socket is inserted into a ure-thane elastomer (Lynadure. The socket is then bonded to a modified "Quantum" (Quantum Foot.. Fig 16B-11. A lost wax method is used to create a negative impression of the foot to be formed. This prosthesis extends just above the ankle and uses a zipper closure for retention. Inc. 1983..O. Medical Center Prostheses.oandplibrary. the condition of the remaining soft tissues. Fabrication Manual. Blackwell Scientific Publications Inc. Houston) cosmetic boot and is removable for adjustments.. Since this is the case. probably because silicone does not have the abrasive nature of the other materials traditionally used for socket construction (see Fig 16B-4. Fillauer K: A prosthesis for foot amputation near the tarsal-metatarsal junction. A zipper is added posteriorly. Collins SN: A partial foot prosthesis for the transmetatar-sal level. Boston. SUMMARY A comfortable socket and a balanced foot are the twin objectives of all partial-foot prostheses. Clin Prosthet Orthot 1977. Pure reinforced silicone is used to form the socket and the foot simultaneously. and a final silicone lamination is performed to finish the prosthesis. Wheeling. New materials and fabrication techniques have permitted the development of both cosmetically and functionally improved designs that may make partial-foot amputation a practical alternative to higher amputation where the pathology permits.. The use of above-ankle designs should be limited to patients who require assisted ankle function. or who cannot tolerate full plantar weight bearing.. in addition. These flexible partial-foot prostheses have worked particularly well on patients with adherent and fragile scar tissue. These four systems have all been used successfully in the management of the short partialfoot amputee. Inter-Clin Info Bull 1978. Lange Silicone Partial-Foot Prosthesis The socket for this prosthesis (Lawrence R. 4. Hossmer-Dorrance Corp.asp[21/03/2013 21:55:27] . Calif) or similar prosthetic foot shell. References: 1.. 30:9-11. thus ensuring that full forefoot contact is achieved when the foot is flat. and the status of the ankle. 3. . Pigment is added to the silicone to closely match the basic tissue color of the individual. Normal ankle and subtalar movements are theoretically possible for patients wearing belowankle designs of prostheses. ). Childs C. Fig 16B-8. Stills M: Biomechanics and prosthetic/orthotic solutions-Partial foot amputations. In the absence of such a design a simple measure adopted by some prosthetists is to wedge the forefoot of the prosthesis laterally. then the provision of some alternative means of achieving forefoot rotation would appear to be indicated. permits the successful restoration of balance and a more normal gait. Minneapolis). in Amputation Surgery & Lower Limb Prosthetics. Condie D. ) partial-foot prostheses constructed from reinforced silicone were originally introduced to provide cosmetic restoration only.org/alp/chap16-02. http://www.P. 2. WV) ( Fig 16B-18. Los Angeles. Flexible (see Fig 16B-4. who experience difficulties with suspension. Hayhurst DJ: Prosthetic management of partial foot amputee. Lange. 5. 1988. oandplibrary.P. Mosby-Year Book. Stills ML: Partial foot prostheses/orthoses. Imler CD: Imler partial foot prosthesis I. Curran Bldg.Atlas of Limb Prosthetics: Surgical. 8. Glasgow. 7. 6. 33:23-29. 640LS Scotland.org/alp/chap16-02. RECAL Literature Search.P. 1981.asp[21/03/2013 21:55:27] . James Rd. pp 322-325. Wilson MT: Clinical application of RTV elastomers. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 16B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Lunsford T: Partial foot amputations-Prosthetic and orthotic management. University of Strathclyde. 10. Prosthetic. Contact Us | Contribute http://www. Clin Prosthet Orthot 1987. 9." Clin Prosthet Orthot 1987. St Louis.F. Orthot Prosthet 1979. in Atlas of Limb Prosthetics. Chapter 16B .-"Chicago Boot. 12:24-28. 131 St. National Centre for Training and Eduation in Prosthetics and Orthotics. 12:14-18.16B: Prosthetic and Orthotic Management | O&P Virtual Library 17:11-15. revascularization procedures now permits its performance in previously nonoperable patients. American Academy of Orthopedic Surgeons. If one recognizes the many almost miraculous aids we now have in performing surgery. He performed approximately 60 to 70 more amputations of this sort in his lifetime. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.. This has not been the major experience at Rancho Los Amigos Medical Center nor in private practice. condition of the heel pad. he first performed the procedure on a 16year-old boy for probable tuberculous caries of the talus and calcaneus. but most of these are small series. IL. and Rehabilitation Principles The Syme Ankle Disarticulation: Surgical Procedures F. Shel-swell concluded that the Syme ankle disarticulation should not be performed in a pulseless foot.asp[21/03/2013 21:55:32] .oandplibrary. http://www. Rosemont. I regret having cut off many limbs that might have been saved by it. Three. He is remembered today mainly for his disarticulation at the ankle joint. the risk to life will be smaller. I think amputation of the ankle joint may be advantageously introduced into the practice of surgery. He pioneered many innovative procedures in general surgery and was regarded as one of the premier surgeons of Europe and the United Kingdom. and the absence of active infection at the operative site. edition 2. He reported the procedure in 1843.org/alp/chap17-01. Otherwise. They believed that good results could be obtained in other patients with proper selection of cases and proper surgical techniques. William Wagner. depends on vascular supply. a review of the literature shows mixed acceptance by various authors in various centers. THE CLASSIC SYME ANKLE DISARTICULATION Harris of Toronto has published two articles that describe the history. "For a male. ability of the patient to use a prosthesis. He listed three advantages over the transtibial level: "One. Prosthetic. There has been an occasional mention of aversion to the prosthesis in women. M.Atlas of Limb Prosthetics: Surgical. Click for more information about this text. development. no deviations are recommended.D. the Syme amputation is the best possible amputation stump in the lower limb. In 1842. reprinted 2002. the limb will be more seemly and useful for progressive motion. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). blood transfusion. Prosthetic. However. McKeever related satisfactory experience in a large series of military amputees. ©American Academy or Orthopedic Surgeons. anesthesia. or neuropathic foot problems. antisepsis and antibiosis. it is hard to realize that he did most of his work before the development of the science of bacteriology. Jr. and shall be glad if what has been here said in its favour encourages others to its performance. Srinivasan reported 20 cases performed for Hansen's disease and pointed out that a Level selection Syme residual limb could last with proper care even in an insensitive foot. on these grounds. a more comfortable stump will be afforded. Alldredge and Thompson stated that it should never be performed in patients with diabetes. . James Syme was a clinical professor of surgery at the University of Edinburgh from 1843 to 1869.17A: The Syme Ankle Disarticulation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 17A Chapter 17A . and Following trauma or in the case of congenital technique of the Syme ankle disarticulation. Reproduced with permission from Bowker HK. Two. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. 1992." Experience with many hundreds of cases at Los Angeles County University of Southern California (USC) Medical Center and Rancho Los Amigos Medical Center and in private practice has gone far to prove the value of his procedure. some deviation in the flap may be indicated by the altered anatomy. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. defects." Many authors report satisfactory experiences with the procedure and conclude that the residual limb is ideally suited for weight-bearing and lasts virtually the life of the patient when the procedure has been performed properly. Prosthetic. . and Rehabilitation Principles. and all of the modern mechanical adjuncts to the actual surgical procedures. Sarmiento and Warren reported 50% revision to a higher level in Syme ankle disarticulations in diabetic and dysvascular patients. peripheral vascular disease." The final statement of his article cannot be said better today: ". There are a few references to its use in the Increased experience with dysvascular patient. tumors.asp[21/03/2013 21:55:32] . or Since the modern Syme prostheses are Chopart levels are best treated at the Syme level. or similar nonabsorbable sutures ( Fig 17A-7.). wire.org/alp/chap17-01. No attempts should be made to trim the dog-ears since the vascular supply to the flaps might be endangered. polyethylene.5 cm of cartilage. To obtain the broadest surface.). a full-thickness segment is removed from the distal edge. The heel flap is now folded up into place for measurements. the Syme level has gained popularity and is assuming a justifiably important place in amputation through the lower limb. We have found no advantage to immediate ambulation and have allowed 7 to 10 days' healing before applying a weight-bearing plaster. The greatest portion of the subchondral bone provides excellent weight transmission. The tourniquet is released and hemostasis secured. Division of the Achilles tendon must be done carefully so that the posterior skin is not buttonholed. Inclusion of the plantar aponeurosis and the deep fascia in the tissues sutured provides excellent fixation. polypropylene. Trauma about the foot. Any possible pressure points are smoothed with rongeurs and rasp. and acquired deformities that are not suitable for procedures at the trans-metatarsal. This provides a weight-bearing surface that is parallel to the floor. The skin is closed with nylon. durable. Syme. this level is equally useful in men and women. With healthy plantar heel skin and the long lever arm of the virtually intact tibia and fibula. This allows gradual exposure of the flexor hallucis longus tendon. and allowed to retract. SURGICAL TECHNIQUE The incision ( Fig 17A-1. bone must be removed to allow closure without tension. The only further dissection is for tissues that appear nonviable. they have not been removed and are left in place. Dissection of the os calcis is started subperiosteal on the dorsal and lateral surfaces ( Fig 17A-3. We recommend suturing the flap to the tibia and fibula through drill holes ( Fig 17A-5. divided.). congenital anomalies. and Fig 17A-6. Opinion is divided as to the need to remove the plantar muscles. and then proceeds straight down across the sole. Surgical dressings may be soft or rigid.). divided. The anterior tendons are pulled down. On rare occasions. and allowed to retract. A moderate dead space is created and should usually be drained. Medial and lateral tendons are pulled down. divided. which is just lateral to the artery and nerves and aids in their protection. the osteotomy is made so that the dome of the plafond is left with approximately 1. Hart-man's or similar physiologic solution is used. adhesive taping. comfortable. and cosmetically acceptable. In recent years. Even in elderly diabetic patients. and the bones are palpated through the soft tissue. the durability of the operation has been demonstrated in finding that only 1 patient in 20 required revision when the Syme disarticulation was successful initially.oandplibrary. as indicated by skin perfusion tests. Subperiosteal dissection is continued medially to push the vital structures away from the body of the os calcis. Postsurgical hematoma is diluted and evacuated through a two-lumen tube (modified Shirley drain or modified Foley catheter) for 24 to 48 hours. Arteries are transfixed and large veins ligated. the two-stage method is preferred. volume plethysmography. It is not indicated with local infection or with inadequate circulation. http://www. The tibia and fibula are transected at right angles to the long axis of the weight-bearing line ( Fig 17A-4. If the flap is too large. Continued stripping of the os calcis distally completes the removal of the foot. recognized this problem after having severed the posterior tibial artery at the level of the ankle joint with resulting gangrene of most of the flap. Migration of an imperfectly anchored flap has been reported in some series. Smaller vessels are electrocoagulated. relatively light. near-normal gait is possible. For infection of the forefoot.17A: The Syme Ankle Disarticulation | O&P Virtual Library INDICATIONS The classic one-stage disarticulation is indicated in all circumstances when this level is the most distal effective amputation that will heal primarily. The malleoli and approximately 1 cm of the anteroposterior aspect of the tibia are exposed subperi-osteally. Lisfranc. The dog-ears gradually regress and smooth down with casting and then with use of the prosthesis. and allowed to retract.) begins at the tips of the malleoli. goes up across the ankle joint. Nerves are pulled down gently. Subcutaneous tissue is closed with a few absorbable sutures. In this series. Lactated Ringer's. and immediate casting. Various methods have been devised for fixation such as skewering the flap with a Steinmann pin in the distal part of the tibia. himself. The medial and lateral collateral ligaments are divided at their insertion into the body of the talus to allow it to dislocate ( Fig 17A-2. Care must be taken on the medial side not to damage the posterior tibial nerve and artery.). or the ischemic index as measured by Doppler ultrasound. ). describe waveforms.35 in others. The dorsalis pedis artery is ligated with a transfixing suture. related their experience with Hulnick's two-stage procedure at Walter Reed Hospital. This technique was first adapted to the diabetic foot at the Los Angeles County General Hospital in 1954 and at Rancho Los Amigos Hospital in 1969. Division of the plantar aponeurosis and subperiosteal dissection of the os calcis medially complete the excision of the forefoot. Care must be taken with the division of the Achilles tendon at its attachment to the os calcis. In the two-stage procedure. improvement in In technique. The joint is entered across the dorsum of the talar neck. The tube is then drawn into the cavity ( Fig 17A-12. and timing is started. Smaller vessels are coagulated.45. which was the distal pressure at several places in the lower limb divided by the brachial artery pressure. Subperiosteal dissection is started on the superolateral surfaces of the os calcis. serious consideration should be given to going to the next higher level. Present Indications The Syme ankle disarticulation performed in two stages is indicated in patients who have gangrene or infection of the forefoot. Care must be taken not to cut blindly across the medial malleolus because the posterior tibial neurovascular bundle may be damaged at this point ( Fig 17A-9. cut off.A. and the definitive amputation was performed 6 to 8 weeks later.org/alp/chap17-01. The superior function at the Syme level pushed the search for a method to allow its use in infected patients. and an intravenous tubing set is attached.5 cm distal and 1 to 1. Direct vision of the neurovascular bundle allows transection distal to the division into the medial and lateral plantar branches.oandplibrary. Larger arterial bleeders are transfixed. The heel pad should be intact. then the Syme procedure should be abandoned and the amputation carried out at the transtibial level. These wounds were almost impossible to heal. If there is no bleeding in the flap distally at 5 minutes. the success rate could approximate 90%. and allowed to retract. and refinement of clinical indications gradually led to a 70% success rate. the infected forefoot was removed through disarticulation at the ankle. The inferior incision courses directly down and across the sole and cuts all layers to the bone. the incisions are started 1 to 1.. The superior incision goes obliquely across the ankle joint. where it is virtually subcutaneous ( Fig 17A-11. ). Singlestage Syme ablations became infected in almost all cases. In 1975. ). are not suitable for a transmeta-tarsal amputation.. Penetration of the skin has led to failure of the amputation even though the laceration was repaired.45 or higher in the diabetic and 0. Irrigation is started with 1 L of Ringer's lactate solution with 80 mg of gentamicin or similar aminoglycoside. The tourniquet is released at this point.B). Spittler et al. and there should be no gross pus at the amputation site. Care must be taken not to exceed safe limits for ototoxicity and http://www. If the distal skin bled within 3 minutes. ). If the most distal skin has not bled within 3 minutes. The tip of the drainage tube is cut on a bevel. Continued dissection distally allows medial retraction of the bundle and medial dissection of the os calcis. The medial and lateral collateral ligaments are divided. Antibiotic prophylaxis is used preoperatively depending on bacterial cultures and sensitivity testing. 1970. First-Stage Technique To allow slightly longer skin flaps to cover the malleoli.asp[21/03/2013 21:55:32] . If the index was over 0. and contrast the distal flow with the brachial artery flow. Larger veins are ligated. These patients had massively infected forefoot wounds from sharpened bamboo slivers that had been smeared with human excrement and placed in the ground during the Korean episode. Doppler ultrasound was used to map blood flow.17A: The Syme Ankle Disarticulation | O&P Virtual Library THE TWO-STAGE PROCEDURE The classic Syme ankle disarticulation frequently failed in dysvascular and infected patients. A Shirley drain or Foley catheter is modified for irrigation and gravity drainage. The tendons are pulled down. A bone hook is driven into the body of the talus for traction on the ligaments and control of the foot during dissection ( Fig 17A-10. Experience.5 cm anterior to the tips of the malleoli ( Fig 17A-8. Either the Shirley air filter or the Foley balloon tip is removed. Bleeding is then assessed. ultimately allowing the talus to be dislocated ( Fig 17A8. Virtually 100% of these patients healed. the healing rate was around 80%. The patient should be a prosthetic candidate. The ischemic index should be 0. and have not responded to medical treatment or distal surgical care. A forceps is pushed through the soft tissue under the posterior tibiofibular ligament and then out posterior along the fibula and through a stab wound approximately 10 cm above the ankle joint. This led to the ischemic index. No tissue planes are dissected. a post-tourniquet reaction time was added. a transtibial amputation is performed. If it is excessive in length. the stump is wrapped in plaster. Closure The heel pad is tested by folding it against the malleoli and plafond. and no sign of residual infection. Deep fascia over the anterior portion of the tibia and the remnants of the collateral ligaments are sutured to the deep fascia of the sole. Second-Stage Surgical Technique Two elliptical incisions are made over the malleoli to remove the dog-ears ( Fig 17A-14. In the very low percentage of patients who do not heal after the first stage. the irrigation is continued. An occasional patient will be infected at the suture line and will require debridement along the suture line. Close dissection around the medial malleolus will protect the neurovascular bundle. The postoperative clinical course is also watched. good skin turgor. The skin is closed with nonabsorbable sutures or skin clips ( Fig 17A-13. The fat pad is usually adherent to the central cartilage. there will be deeper involvement. Division of the band and incision of the fat pad to provide a "nest" for the malleoli will hold the pad centered.org/alp/chap17-01. Upon removal of the tubing. A few subcutaneous sutures level the skin. unless the clinical course or late culture shows the presence of bacteria. the tip is cut off aseptically and sent for culture and sensitivity studies. The medial and lateral flares of tibia and fibula are then removed parallel with the shaft ( Fig 17A16. the skin and tissue should be removed until it closes with little or no tension. the malleoli are cut flush with the joint surface ( Fig 17A-15. and if there is fever or sign of local infection. Two pieces of felt with holes protect the dog-ears. The warning http://www. Irrigation is continued at approximately 1 L every 24 hours and is continued until the effluent is clear. and the pad is tested. this system has been left in place for 7 to 14 days. On occasion. They are observed in the outpatient clinic. Drainage is through gravity to a collecting bag. soft tissue must be removed from the ellipses until the pad is tight. Systemic antibiotics are continued according to preoperative cultures for 1 week.17A: The Syme Ankle Disarticulation | O&P Virtual Library nephrotoxicity in these compromised patients. Soft dressings are used for a few days and then replaced with plaster ( Fig 17A-18. ). Care must be taken not to fold the dog-ears and create pressure areas. ).oandplibrary. which is left intact. The malleoli are dissected subperiosteally to approximately 3 cm above the joint line. A compression dressing of fluffs is contoured over the stump and wrapped in place with a bias-cut stockinette. the pad may shift medially or laterally due to a fascial band pressing one or the other of the malleoli. The skin is closed with nonabsorbable sutures. On occasion. Occasionally. similar to a urine bag. Irrigation is continued for 48 to 72 hours. the patients are usually independent in walking casts. Every 2 to 3 hours. Weight bearing is begun for those who have a firm heel pad. If it is too loose. ). a week or more in a walking cast is needed. This leaves the anterior and posterior flares of the tibia and fibula for suspension and a moderate narrowing and flattening of the sides of the stump ( Fig 17A-17. the exit tube is clamped for 5 minutes to distend the cavity with irrigating fluid. Postoperative Care On discharge from the hospital. and casts are changed at 2-week intervals. ). When the patient is clinically stable. The amount of tissue removed should be equal to the volume of the malleolus. Occasionally. Approximately 50% of the patients are weight bearing after the first stage while awaiting the second stage. crutch ambulation is allowed. ). Care must be taken on the posteromedial aspect not to damage the posterior tibial nerve and artery.asp[21/03/2013 21:55:32] . depending upon the degree of preoperative infection. Second Stage Healing is usually secure enough at 6 weeks to perform the definitive amputation. After subperiosteal dissection. ). The deep fascia of the sole is clamped with a towel clip to the periosteum of tibia. On removal. Closure is adapted to anchor the pad to bone. A few subcutaneous sutures will level the skin edges. and the malleoli must be removed to allow closure over a further irrigation system. as well as to the periosteum. It is then sutured through two drill holes in the tibia and fibula. Care must be taken not to fold the dog-ears upon themselves because circulation may be compromised. as described by Harris. Function at the Syme level is superior to any other major amputation in the lower limb. 13. 4. 6. Roberts JR. Nakhgevany KB. and controls and maintains apposition of the heel pad. and the first prosthesis is fabricated. References: 1. 37:110. 9:107. Stuyck J. The classic procedure. report of a case. McElwain JP. Brennan JJ. Jac-quelin Perry. Vandenberk P. J Bone Joint Surg [Am] 1973. et al: Syme amputation: Success in elderly diabetic patients with palpable ankle pulses.Amputation surgery. 7. J Bone Joint Surg [Br] 1967. J Bone Joint Surg [Br] 1967. McKeever FM: A discussion of controversial points. The plaster cast has been an invaluable aide inasmuch as it mobilizes the patient. Payne JW: Syme amputation performed in two stages. 9. J Bone Joint Surg [Br] 1956. ) than patients with more proximal amputations. Shelswell JH: Syme's amputation. The two-stage technique has proved successful in patients with forefoot infections that preclude distal partial-foot procedures. has performed function tests that show the Syme amputee to have greater stride length. 12:237. Thomsen S. Pirogoff and Syme amputations. 28:415. J Bone Joint Surg [Br] 1969. 16. 49:144. Can J Surg 1985. Reynders P: Syme's amputation. remains the preferred procedure in cases without infection or dysvascular problems. protects the healing wound. Berkus JK: Long-term follow-up of Syme amputations for peripheral vascular disease associated with diabetes mellitus. 6:44. Wethelund JO. J Bone Joint Surg [Am] 1954. Dale GM: Syme's amputation for gangrene from peripheral vascular disease. 21. J Bone Joint Surg 1946.asp[21/03/2013 21:55:32] . Stableforth PG: Syme's amputation. 38:614.oandplibrary. 2. greater velocity. under the direction of Dr. faster cadence ( Fig 17A-19. 10. 20. 36:37. Artif Limbs 1961. a long term review. 95:549. et al: Antibiotic prophylaxis in lower http://www. 55:568. Mazet RR: Syme's amputation. A review of sixty-seven cases. Acta Orthop Belg 1990. 14. 49:142. Thompson TC: The technique of the Syme amputation. 56:535. Jamy RS. Baker GCW. Lancet 1954. Rosenman LD: Syme amputation for ischemic disease in the foot. Clagett PL. 51:482. Alldredge RH. Srinivasan J: Syme's amputation in insensitive feet. 5. Foot Ankle 1988. 129:799. 17. A survey of twentyone cases. Acta Orthop Scand 1966.org/alp/chap17-01. Artif Limbs 1961. 82:495. 6:4. 50:1549. Warren WB: Reevaluation of lower extremity amputations. The Syme ankle disarticulation is actually a partial-foot ablation because of retention of the heel with its excellent weight-bearing characteristics. Harris RI: Syme's amputation. Spittler AW.17A: The Syme Ankle Disarticulation | O&P Virtual Library is given to stop weight bearing and to return immediately if any pistoning should occur due to stump shrinkage. CONCLUSIONS The Syme ankle disarticulation provides a long-lasting. Lindqvist C. English E: Syme's amputation in adults. Ratliff AHC: Syme's amputation: Results after forty-four years. and less oxygen consumption per meter traveled ( Fig 17A-20. Francis H III. 15. Rhoads JE Jr: Ankle level amputation. Surg Gynecol Obstet 1946. the stump has matured. ). Am J Surg 1969. Harris RI: The history and development of Syme's amputations. J Bone Joint Surg [Am] 1968. 12. The Gait Laboratory. Surg Gynecol Obstet 1969. Sarmiento A. 28:203. 18. durable residual limb. 118:194. aides in the muscular venous pump action of the leg. 2:1296. 3. Riska EB: Chopart. Hunter GA. Surgery 1984. Revascularization of the distal portion of the limb in patients with arteriosclerosis has allowed performance of the Syme procedure in patients who would be faced with a higher-level amputation. 11. At about 8 weeks. 8. even in diabetic patients. J Vase Surg 1990. Catterall RCF: Syme's amputation by Joseph Lister after sixty-six years. 19. Jakobsen BW. 17A: The Syme Ankle Disarticulation | O&P Virtual Library extremity amputations due to ischemia. 37:156. 22. J Bone Joint Surg [Am] 1976. Chapter 17A . ed 5. Mosby-Year Book. New York.asp[21/03/2013 21:55:32] .oandplibrary. Thayer TR. Wagner FW Jr: The dysvascular foot. 29. Warren R. et al: The Syme amputation in peripheral arterial disease. Antonelli D. 2:64. 109:72. 26. 2:93. Perry J. et al: Energy costs of walking of amputees: The influence of level of amputation. Foot Ankle 1981. Syme J: Amputation at the ankle joint. Grune & Stratton. 25. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 17A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www. Yaojst (eds): Gangrene in Severe Ischemia of the Lower Extremities. 27. Instr Course Lect 1979. Arch Orthop Trauma Surg 1990. St Louis. 23. Wagner FW Jr: Amputations of the foot and ankle. a system for diagnosis and treatment. 28:143. Clin Orthop 1977. in Mann RA (ed): Surgery of the Foot. Wagner FW Jr: The diabetic foot and amputations of the foot. Waters RL. Achenbach H. Buggs H: Use of Doppler ultrasound in determining healing levels in diabetic dysvascular lower extremity problems. neuropathic and dysvascular foot problems.Atlas of Limb Prosthetics: Surgical. p 131. Surgery 1955. A report of six cases. 1978. 24. Prosthetic. p 421. Wagner FW Jr. in Bergen JG. 28. Lond Edinburg Monthly J Med Sci 1843. Wagner FW Jr: A classification and treatment program for diabetic. 122:62.org/alp/chap17-01. 1986. 58:42. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. 1992. A prosthesis of this type was developed and is being used by the Canadian Department of It is commonly called the "Canadian Syme prosthesis" ( Fig 17B-1. Although articulated joints have been used in the past. C.). and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Surgical modifications have been introduced to make the stump neater and less bulky.O. John W. 2. 10. 5. In addition to producing the artificial limb. it was necessary to substitute ep-oxy resins for the polyesters before adequate strength was obtained. Early use of polyester-fiberglass laminate with an opening for entry of the residual limb materially reduced bulkiness. Prosthetic. to increase the strength of the socket. Reproduction of Ankle Joint Motion The limited space available between the distal portion of the residual limb and the floor severely constrains the design of foot mechanisms for the Syme prosthesis. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists SOLUTIONS TO PROBLEMS INHERENT IN THE DESIGN AND MANUFACTURE OF SYME PROSTHESES Weight and Bulkiness Until 1940. Disarticulation at the ankle has challenged the prosthe-tist since the procedure was first introduced by Syme in 1842. ©American Academy or Orthopedic Surgeons. reprinted 2002. 6. However. 8. American Academy of Orthopedic Surgeons. 3. difficult fasteners Adjustability to relieve pressure along a sensitive scar line Cosmesis Reproduced with permission from Bowker HK. C. the usual prosthesis was a leather socket reinforced with steel straps and with an anterior tongue and lacer.17B: Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 17B Chapter 17B . Reports in the literature of "new prosthetic approaches" attest to the fact that the final perfect prosthesis has not yet been designed. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. The ankle was frequently a single-axis joint with bumpers. Transmission of body loads Light enough to wear comfortably Ability to supply the equivalent of foot and ankle function Lengthening of the limb to adjust for loss of the talus and os calcis Distribution of the high forces developed in the ankle area Provision of rotary stability about the long axis Provision of shock absorption Suspension during swing phase Readily donned without requiring multiple non-cosmetic.Ed. allow more room for the ankle joint. M. Click for more information about this text. A satisfactory end-bearing Syme limb demands a prosthesis with the following characteristics: 1. These protect the tissues during the healing phase and hasten contouring of the stump (see Fig l7A-18). the pros-thetist may aid in postoperative management by applying walking casts.org/alp/chap17-02. edition 2. and Rehabilitation Principles. Rosemont..O. multiple problems still exist in the design of the "ideal" prosthesis.oandplibrary. they were plagued by chronic wear and tear http://www. 9. 11. Despite the advantages provided by the long lever arm of the essentially intact tibia and fibula and the virtually full end-bearing capabilities of the heel pad. Veteran Affairs. and produce a more cosmetic prosthesis.P. Michael.Atlas of Limb Prosthetics: Surgical.P.asp[21/03/2013 21:55:37] . 4. Prosthetic. Prosthetic. and Rehabilitation Principles The Syme Ankle Disarticulation: Prosthetic Management Richard Voner. 7. IL. You can help expand the O&P Virtual Library with a tax-deductible contribution. a modified solid-ankle. while the limited space for the heel cushion limited the shock absorption at heel strike as compared with the SACH foot designed for higher-level amputations. Because of the bulbous form. High forces in the ankle area require sufficient material to absorb the stress. low-profile style suitable for the Syme amputee..oandplibrary.org/alp/chap17-02.B).. Strength is most easily obtained by using high strength-to-weight ratio plastics that can be molded easily over a plaster positive model. cushion-heel (SACH) foot was the only available Although clinically successful. posteriorly. but reliability and specific indications have yet to be determined.17B: Prosthetic Management | O&P Virtual Library and have been largely abandoned. the rigidity of the wooden keel added significant option.). Provision of Pressure Relief Along a Sensitive Scar Line Direct end bearing can be reduced by proximal loading of the prosthesis along the tibial flares. or similar material bridges the narrow portion of the stump above the heel pad and maintains a total-contact. Carbon Copy II and the Seattle Litefoot both have plastic spring keels that add a measure of dynamic response to the prosthesis while incorporating an abbreviated cushion heel to simulate plantar flexion following heel strike. close about the end and provide suspension ( Fig 17B-3. http://www. As a result. there will be a certain bulky appearance to any prosthesis design.asp[21/03/2013 21:55:37] . It has a flexible anterior keel that allows an easier rollover and reduces the ground reaction forces on both prosthesis and More recently. or posteromedially ( Fig 17B-2. There is a constant problem then between thickness requirements for strength and thinness required for appearance. Silastic foam. Patient acceptance of these newer alternatives has been favorable thus far. In an effort to overcome these shortcomings. Plastic prostheses have windows either medially. several dynamic-response feet have become available in a residual limb. Flex-Foot and the similar Springlite design are also available for the Syme level. Distribution and Absorption of Stresses Developed During Stance Phase Uniform distribution of loads along the tibia is necessary during push-off or rollover.A and C). Provision for Donning Provision for donning is necessary to allow the bulbous distal end to pass the narrow shank portion of the prosthesis. several more flexible foot options are now available. stresses to the prosthesis and was not suitable for some vigorous activities. Closed double-wall prostheses with flexible inner walls allow expansion so that the The elasticity is sufficient to bulbous end is inserted past the expandable portion. A double wall with an elastic panel also provides enough expansion ( Fig 17B-3. stumpsocket wall relationship ( Fig 17B-4. almost all contemporary Syme prostheses utilize a nonarticu-lated foot. Careful molding is necessary along the tibial crest. For many years. Provision of Rotary Stability About the Long Axis A patellar tendon-bearing shape of the proximal part of the brim will stabilize against the mediolateral flares of the tibia. 2.). Flattening of the posterior portion of the brim adds to a triangulation effect. Older prostheses had an anteriorly opening corset that could be laced. A flexible inner socket of Kemblo rubber. Both designs utilize a carbon composite spring heel and keel to simulate ankle motion. The following are some of the methods of providing the different diameters: 1. The Quantum foot from England provides similar function by using fiberglass-reinforced spring keels/ heels and has also been adapted for Syme prostheses. 4. A special version of the stationary-ankle flexible-en-doskeleton (SAFE) foot has been used with the Syme prosthesis for the past decade with good results. 3. The cuplike contour for the stump end must extend superiorly enough to prevent motion between the socket and the stump in an anteroposterior direction. When the amputation stump has a bulbous and irregular distal end.C). Dispersion of force encountered at heel contact is accomplished through contact from the heel to the upper gastrocnemius.. In bilateral amputees. which flexes just after heel contact. A good share of the impact force is dissipated in the heel. The closed rigid shell with a flexible removable inner socket may allow even earlier donning of the limb without undue difficulty. The contour of the distal part of the socket must be in intimate contact with the residual limb in its most bulbous portion. PROSTHETIC CONSIDERATIONS Indications for each of the described types of prostheses will depend primarily on the physical characteristics of the residual limb.17B: Prosthetic Management | O&P Virtual Library Provision of Suspension During Swing Phase The bulbous distal end and the flare of the tibia and fibula provide sufficient surface. Stabilization against rotary forces about the long axis. Comfortable Transmission of Stump-Socket Forces Through a Satisfactory Socket Socket design must provide the following: 1. this is not a problem.asp[21/03/2013 21:55:37] . or other outside paraphernalia for closure. 3. the distal portion of the stump is squared slightly. 2. but some load must be assumed by the knee. However. Most patients can be fitted with a closed double-wall prosthesis with attached flexible inner walls fabricated with expandable material. they are thicker just above the ankle ( Fig 17B-3. Three-point or triangular stabilization against the flares of the tibia plus a flattening across the posterior portion of the gastrocnemius will provide a good share of stability. The closed prosthesis presents a much neater appearance and is particularly desirable for women. If the distal end is especially narrow and has minimal flare. Because of this.. it is not always possible to use as thick a heel cushion as desired for shock absorption. buckles.C and Fig 17B-4. and such improvements as a five-way ankle may be used. often seen in older amputees and after trauma. Sweating in a Plastic Prosthesis Porous plastic laminates have been introduced but have not proved completely satisfactory to date. Weight support can be distributed between the end of the prosthesis and the proximal portion of the socket brim. it may be necessary to fabricate one or more windows in the http://www. This possibly aids in preventing rotation about the long axis. Provision of Shock Absorption The cushioned heel of the SACH foot is smaller than in a transfemoral or transtibial prosthesis. In the two-stage method. Cosmesis Plastic laminates provide a thinner wall. Correction of Limb Length Discrepancy A thinner SACH foot must be used for the Syme ankle disarticulation than that used for transtibial or trans-femoral amputations. Dispersion of forces against the proximal surface of the leg at push-off can be accomplished through careful fitting against the mediolateral surfaces of the tibia.oandplibrary. a suprapatellar suspension strap may be added.org/alp/chap17-02. Substitution of several layers of prosthetic socks may provide better moisture distribution. Air-cushion types that require no window and doublewalled types with an inner elastic panel are less unsightly because they require no straps. Atlas of Limb Prosthetics: Surgical. 50:1549. 3. lighter in weight. 4. J R Coll Surg Edinb 1975. 8. use of prosthetic stockings. Murdoch G: Syme's amputation. Finnieston A: A new surgical-prosthetic approach to the Syme's amputation. 5. Institute of Engineering Research. Chapter 17B . 2. Gilmer RE Jr. Almost without exception. Ardizzone J: SACH foot prosthesis. Burgess EM: The Syme's amputation: A new prosthetic approach. Contact Us | Contribute http://www. issue 30. Surgeons performing the Syme ankle disarticulation can often simplify prosthetic considerations by careful attention to bone contour and heel pad positioning.oandplibrary. 7. 10:52. 6. and simpler and less costly to manufacture. 12:99-108. free from malfunction of mechanical components. Inter-Clin Info Bull 1972. Most patients state that it will take a day or two to get used to the limb. 9.17B: Prosthetic Management | O&P Virtual Library prosthetic shell to allow the terminal tissues to slide past the smaller and narrower proximal area. Gordon EJ. 1956. JBone Joint Surg [Am] 1968. Improvements in design and materials have allowed amputees using old-style prostheses to convert successfully to using the modern limbs now available. Prosthetic. Radcliffe CW: The biomechanics of the Syme prosthesis. and daily maintenance of the prosthesis. series 11. Sarmiento A. Zettl JH. Lower extremity amputee research project. JBone Joint Surg [Am] 1960. SUMMARY Modern plastic materials and construction techniques permit manufacture of Syme prostheses that are improved in appearance and durability. 42:226. In addition. Berkeley. After delivery of the prosthesis. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 17B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Foort J: The Canadian type Syme prosthesis. Mazet R Jr: Syme's amputation. the patient is taught stump hygiene. Artif Limbs 1961. Artif Limbs 1961.asp[21/03/2013 21:55:37] . PHYSICAL THERAPY The Syme ankle disarticulate has usually walked in a plaster cast with a rubber heel or artificial foot prior to delivery of the definitive prosthesis. 6:52. 11. The prosthetist may need to innovate and deviate from standard designs in certain unusual circumstances.org/alp/chap17-02. Warner R. University of California. 11:1. 12:7. Artif Limbs 1966. Romano RL. Marx HW: An innovation in Syme's prosthetics. instructions are given for donning and doffing. 6:76. A preliminary report. Daniel R. all prostheses will be fitted with the SACH foot described earlier. References: 1. Orthot Prosthet 1969. Virtually no training is required during the cast period except for occasional use of crutches or a pickup walker at the outset. Michael JW: Component selection criteria: Lower limb disarticulations. Wilson AB: Prostheses for Syme's amputation. 23:131. 10. Leswing AL: Another new prosthetic approach for the Syme's amputation. 21:15. Clin Prosthet Orthot 1988. Inter-Clin Info Bull 1972. Calif. and Rehabilitation Principles. These studies strongly suggest that the notion that diabetics do best with a primary transfemoral amputation for foot lesions should be discarded. Another singular advantage of transtibial over transfemoral amputation is markedly reduced perioperative mortality. transfemoral gait is borne out by several studies of prosthesis usage. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). It was long taught that diabetics should have a primary amputation at the transfemoral level because of their supposed inability to heal at more distal levels. unilateral transtibial amputation may be followed by loss of the opposite limb with progression of vascular disease. between transtibial amputations. Rosemont. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. in a series of 171 amputations. each with at least 50 patients.5%. American Academy of Orthopedic Surgeons. Boontje. on average.B. and Rehabilitation Principles Transtibial Amputation: Surgical Procedures and Immediate Postsurgical Management John H. noted a 28% failure of transfemoral healing as compared with 35% for transtibial cases. (Gen Surg) Among major amputations in the lower limb. analysis of four studies covering the transtibial prosthesis usage rate of 73. http://www. Eighty-four percent wore their prostheses more than 13 hours a day. Healing at that level. Sports were played by 72%. Bertram Goldberg. 92% healed their wounds. the patients in these studies had peripheral vascular disease. These series did not separate diabetics with or without ischemia from those with ischemic disease alone. Data were combined from four series that compared the healing rate of transtibial amputations in diabetics with that in patients with purely ischemic disease. Pradip D. the transtibial (below-knee) amputation is the most common.Atlas of Limb Prosthetics: Surgical. They were reviewed 2½ years following surgery as regards their function and life-style. reprinted 2002. edition 2. M. The combined mortality of three studies for transtibial amputation was 9. and 84% drove automobiles. This is because energy consumption for the transtibial amputee. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.D.asp[21/03/2013 21:55:42] . IL.7% for transfemoral amputation. it was found that 70% of transtibial amputations healed primarily and 16% secondarily for a total healing rate of 86%. is far from certain. Click for more information about this text. In ischemic conditions. Two additional series of 100 diabetics each reported transtibial healing rates of 99% and 90%. Reproduced with permission from Bowker HK. who noted a fall in mortality rate from 24% to 10% that was directly related to the reversal of their transtibial-to-transfemoral ratio from 1:2 to 2:1. Prosthetic. Prosthetic. One study of 80 patients noted an interval The risk of contralateral limb of 23 months. is far less than for amputees with a transfemoral level. due to The preservation of the knee joint. Many series report a ratio of at least two transtibial amputations to every It is important to note that it is the most proximal level in transfemoral (above-knee) one. transfemoral amputations were preferred to transtibial ones because it was felt that primary healing is easier to obtain at the thigh level. Another detailed study was made of 25 unilateral transtibial amputees who were all under the age of 45 years at the time of amputation for trauma. Combined data from 13 studies from 1943 through 1983 showed an average In contrast.5%. Most of same period disclosed that transfemoral prosthesis usage averaged only 26. M. Virtually the same findings were reported by Sarmiento and Warren.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 18A Chapter 18A . Bowker. M. M.org/alp/chap18-01.S. 72% could walk a mile if necessary. Of 194 diabetic patients. By pooling the data from eight reported series totaling 942 cases.. Prosthetic. In contrast.5% as compared with 29.B.S. Poonekar. respectively.D. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. the lower limb at which near-normal function is available to a wide spectrum of lower-limb amputees.oandplibrary. The most notable finding was that 84% of these unilateral transtibial amputees regarded themselves as minimally or nondisabled. For many years. ©American Academy or Orthopedic Surgeons. however. only 75% of 188 patients with purely ischemic disease healed. relative ease of transtibial vs. 1992. therefore. In contrast. In view of the high risk of later contralateral amputation. infection of peripheral nerves with Mycobacterium leprae will cause foot insensitivity. Although the population of diabetics appears to be growing.). physical. pain. it may be difficult to distinguish the relative importance. increased longevity related to better treatment. It allows younger patients to continue a vigorous life-style and elderly patients the opportunity to walk as opposed to wheelchair confinement. 30% to 75%) had diabetes mellitus as the primary or secondary causal factor in amputation. which can be initiated by presumably minor trauma. Smoking appears to be related to this increase. Severe tissue destruction from fungal infection may occur in the presence of normal sensation. Infection in diabetics may be difficult to combat at the tissue level due to decreased leukocyte activity in the hyperglycemic state. or persistent infection. thereby preventing chronic invalidism. may require transtibial amputation ( Fig 18A-2. or intractable claudication. When reconstruction after trauma has resulted in an unsatisfactory limb due to deformity. In Hansen's disease. In summary. The precipitating cause of amputation may be gangrene.asp[21/03/2013 21:55:42] . thereby rapidly spreading the infection along tissue planes. Another series reported that 58% of 110 transtibial amputees were smokers. It is certain. in causation of gangrenous changes. Patients often continue to walk on infected feet due to a loss of deep pain sense. infection. usually related to diabetes mellitus.). In cases of severe foot infection. Adherence to this approach will preserve the patients fiscal. that an increasing percentage of lower-limb amputations is being done in diabetics.org/alp/chap18-01. this level is suitable if there is sufficient vascularity present at the level selected. Stewart found a significantly higher incidence of smokers as compared with the general population (82. Progressive loss of bone and soft tissues. Pooled data on 137 patients showed that 77% of bilateral transtibial amputees were able to attain functional ambulation.4% vs.A and B). nonunion. In a review of 51 male lower-limb amputees in the United Kingdom.. trauma has been replaced by peripheral vascular disease as a leading cause of lower-limb amputation. In cases of trauma to the foot and leg.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library loss is 10% per year. transtibial amputation is indicated when the process requiring ablation cannot be effectively eliminated by lesser procedures. This should be done as soon as it becomes apparent that further attempts at salvage have little likelihood of success. however. In addition. transtibial amputation should be favored over the transfemoral level whenever there is a reasonable http://www. and psychological assets. transtibial amputation will provide a good solution ( Fig 18A-4.oandplibrary. every effort should be made to preserve at least a transtibial level at the first amputation. Neuropathic arthropathy. the vast majority of amputations are related to various types of foot injury secondary to peripheral sensory neuropathy. if there has been warm ischemia of the leg and foot for more than 6 hours following severe vascular injury to the lower limb. the importance of preserving the knee joint cannot be overemphasized. combined data from 17 studies published between 1961 and 1988 showed that an average of 52% of patients (range. or other factors.). a primary amputation should be consid-ered. with often minor foot damage providing a portal for infection. For example. may also lead to amputation if the foot and ankle skeletal structure becomes severely damaged ( Fig 18A-1. a 1956 study showed diabetes as a factor in only 16% of cases. In peripheral vascular disease with distal gangrene. With sufficient longevity. INDICATIONS In general. Although diabetics often develop atheromatous disease at an earlier age than the general population does. In diabetes mellitus. as in mycetoma or "Madura foot" ( Fig 18A-3. a long transtibial level can almost always be saved even if the proximal spread of infection precludes a partial-foot amputation or Syme ankle disarticulation (see Chapter 16A and Chapter 17A). transtibial amputees often face the prospect of opposite lower-limb loss. aggravated by intractable deep infection following skin ulceration. The chances of ambulation as a bilateral transtibial amputee therefore become a major concern. it is conjectural whether this is due to earlier detection. of atheromatous changes seen in larger vessels and more peripheral small-vessel disease. transtibial amputation should be done initially if there is such severe destruction of soft tissue and bone that reconstruction or a more distal amputation is not feasible (see Chapter 2C). 55%). CAUSAL CONDITIONS With aging of the general population. Finally. the infection that has led to the need for amputation often totally disrupts diabetic control. they must be approached simultaneously for optimum effect. If they are needed. Following initial aerobic and anaerobic wound cultures. Patients undergoing amputation for trauma. arrhythmias. Care should be taken to avoid nephrotoxic drugs where possible.). should lead to consideration of a primary transfemoral amputation. although usually young and healthy. disarticulation at the ankle joint will preserve end weight-bearing capability and allow a moderate increase in length over time (see Chapter 35). and diabetes for optimum results. Special attention must be directed to control of congestive heart failure. They include gram-positive. they advocated prompt drainage of abscesses. dehydration. These are largely related to the reason for amputation. Even if they are not prosthetic candidates. Severe rest pain in the proximal portion of the calf may indicate the need for a primary transfemoral amputation as well. and anerobic organisms. hypertension. Hemiparetic patients can often manage household ambulation with a transtibial prosthesis. or viscera. PREOPERATIVE CARE There are several very important aspects to the preoperative management of prospective amputees. CONTRAINDICATIONS Inadequate vascularity at amputation sites between the knee and ankle. A relative contraindication to transtibial amputation is prolonged nonambulatory status. with the emphasis on rapid preoperative treatment. for any reason. however. In these cases. is an absolute contraindication to transtibial amputation. If they are able to comprehend and follow instructions. electrolyte imbalance. Even poor knee control can be managed easily with a hybrid "prosthosis" that combines a transtibial prosthesis with orthotic knee control componentry. A knee flexion contracture severe enough to prevent use of a transtibial prosthesis may be best served by a knee disarticulation. maintains that the tibial portion of the limb will still be useful in transfer and wheelchair sitting activities and is reluctant to remove it on the basis of nonambulation alone. gram-negative. Since the control of infection and of hyperglycemia are interdependent. Pedersen et al. While its use has been suggested in selected cases. occasionally singly but more http://www. broad-spectrum antibiotic therapy should be started. There are several conditions mistakenly thought of as relative contraindications to transtibial amputation. provided that flexion or extension patterning is not extreme and that reasonable balance is present. Persson. One study found that 76% of 70 patients coming to transtibial amputation had various other degenerative diseases.asp[21/03/2013 21:55:42] .org/alp/chap18-01. With good prosthetic fitting and regular observation of the skin for areas of pressure. A careful evaluation must be done to rule out injury to areas other than the affected limb. soft tissues. whether gradual or sudden in onset. bronchitis. provided that the skin at that level is viable and will heal primarily. A wide range of bacteria may be associated with foot infections in diabetics.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library possibility of ambulation. When dysvascularity related to peripheral vascular disease with or without diabetes mellitus leads to amputation. condemned this practice and stated that following icing. A knee disarticulation can be a good choice in this situation because it provides much better sitting balance than a transfemoral residual limb does. In cases of diabetes mellitus. they can do quite well ( Fig 18A-5. the presence of associated disease must be assumed. If the patient is bed bound. This will interfere with the growth of the residual limb and make its relative length less in adulthood. followed by appropriate antibiotics and bed rest. Icing of a necrotic/infected limb to control local and systemic effects of the infectious process remains controversial. the amputee should do extremely well. A diabetic or a patient with Hansen's disease (leprosy) need not be denied a transtibial level on the basis of insensate skin.oandplibrary. often have concomitant injuries to other skeletal parts. pending bacterial sensitivity studies. Children with congenital foot deformities requiring revision for use of a prosthesis are not well served by transtibial amputation. a knee flexion contracture will very likely develop. renal function should be closely monitored. a transfemoral amputation is unavoidable. aerobic. sitting and kneeling activities will be enhanced by leaving as much of the leg as possible. Instead. Dependent rubor or gangrenous changes about the upper portion of the tibia. The inability to reach consensus on the best test or tests for level selection clearly shows that the best test. they should be introduced to the team members who will be caring for them postoperatively.). a unique opportunity exists to influence the surgical outcome insofar as patient compliance is concerned. Although level selection is multifactorial. The addition of nutritional supplements such as ascorbic acid. These include the serum albumin level as an indicator of nutritional status (normal. a level that will heal and be durable and optimally functional should be chosen. with preservation of limb length secondary ( Fig 18A-7. would be one that predicts failure with 100% accuracy and thus guides the surgeon away from that level. 3. LEVEL SELECTION There are several aspects to correct selection in the individual case. there remains an intermediate gray zone of unpredictability. The more traditional methods of level selection are considered in this chapter. Assessments of wound healing potential are also indicated. Third. In dys-vascular cases. tissue glycosylation secondary to chronic hyperglycemia. suboptimal surgical technique. and level of amputation can be very beneficial. Fearon et al.). In practice. preferably by oral intake. If failure then occurred. ray. the exact length of recon-structible tissue distal to the knee is usually predetermined by the accident and treatment to that point ( Fig 18A-6. level selection by either http://www. the reader is referred to Chapter 2C. Reversal of the catabolic state associated with infection should be initiated preoperatively. the proximal extent of infection along tissue planes may determine whether a ray or transmetatarsal amputation or a Syme ankle disarticulation is feasible.asp[21/03/2013 21:55:42] . the amputated limb. In trauma. If purulence has extended proximal to the ankle. Second. The physical therapist can initiate a preoperative program to condition the entire body. If time and the patients' condition allow. and ferrous sulfate should present no additional clinical problem. or poor postoperative wound management. prevent contracture of the hip and knee on the side of (see Chapter 23). Tumor surgery requires that adequate margins free of disease be the surgeon's first concern.500/mm ). sex. either entirely or with limited loss at the toe.org/alp/chap18-01. infection.5 g/dL or more) and the total lymphocyte count as a measure of immu-nocompetence (at least 1. A psychologist experienced in dealing with amputees can encourage them to express their anxieties regarding both the surgical and prosthetic phases of care. one may expect difficulties with primary wound healing. increase in both wound infection and reamputation rates in lower-limb amputees who smoked cigarettes. an open ankle disarticulation with fascioto-mies and compartmental debridement is indicated to preserve length. Although both clinical evaluation and objective laboratory measurements of vascularity are reasonably predictive of success or failure at both the high and low ends of measurement spectra. A preoperative visit by a trained amputee peer counselor matched with the patient by age. operative factors other than tissue blood flow should be sought.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library often in various combinations. and Proteus vulgaris to be most common. evidence of genitourinary and pulmonary infections should be sought. In cases of foot infection. the surgeon should first determine that the limb is not salvageable by reconstructive vascular surgery. A reasonably detailed account of the expected course through prosthetic fitting should be given. Streptococcus hemolyticus. cultured more than 15 different bacteria in a series of diabetic gangrene cases. Specifically. it should be determined whether a transtibial level has a reasonable chance of healing. but significant caloric enhancement will require matching increases in hypoglycemic agents. If these values are abnormal.oandplibrary. Hoar and Torres found Staphylococcus aureus. many studies have tried to oversimplify the problem by basing success or failure solely on one criterion. or transmetatarsal level. This would avoid imposing higher levels of amputation on patients who could heal at the transtibial level but were eliminated by overly strict application of criteria that include a built-in failure rate for reasons that are not determined by the study method. and teach safe ambulation with a walker or crutches Because the patient looks to the amputation surgeon for guidance. such as poor nutritional status. Systemic infection secondary to wet gangrene or infections independent of the foot must also be controlled preoperatively. For a detailed discussion of laboratory tests designed to give more objective measurements of limb and tissue blood flow. This is also an opportunity for the surgeon to promote wound healing by strongly A Danish study showed a 50% discouraging smoking preoperatively and postoperatively. zinc. which does not yet exist. Ken-drick. Harris. Arteriography has been found to bear little correlation to the healing potential of transtibial Arteriography is now used chiefly amputations. with a bony level as distal as the junction of the proximal and middle thirds. In summary. however. Although 65% of these patients had no popliteal pulse felt. which results in a cylindrical stump. effectively limits length to approximately 15 cm since the leg begins to taper beyond that point. however. Marsden recommends limiting the length to 15 cm on the basis that the prosthetist will have less trouble fitting a prosthesis. gross infection. bone length at the junction of the middle and distal thirds will provide a very functional residual limb. Modern prosthetic components can be easily matched to these more distal levels. the addition of a femoral pulse increased the success rate to 81%. they may still be present but obscured by edema. and the presence of indolent ulcers. This position is supported by work showing that transtibial amputees with longer limbs require less energy to ambulate. Once the decision has been made to amputate at the transtibial level. In a series of 113 transtibial amputations. ANESTHESIA http://www. Regarding the evaluation of peripheral pulses. expressed over several decades that cast doubt on this certitude. there is no longer an ideal length or site of amputation. flatly stated that the longer the residual limb. skin warmth and texture. an equally important choice must be made as to the exact length to be retained ( Fig 18A-8. If they cannot be felt. compatible with healing should be retained. Many surgeons have relied on the trial skin incision. although recommending a short transtibial amputation in his paper of 1944. The data from six papers were combined and analyzed regarding the relationship of healing rate to the presence of a palpable popliteal pulse.org/alp/chap18-01. or lymphangitis. 82. the ideal length for optimal prosthetic function has not been determined. however. the surgeon should immediately move proximally. The shortest useful amputation must include the tibial tubercle to preserve knee extension by the quadriceps. A distal trial incision that bleeds. noted no correlation between bleeding of a trial skin incision and healing potential. noted that a long transtibial amputation is stronger than a shorter one. Despite this recognized functional advantage. The basic question of how distally the initial trial skin incision should be made remains unaddressed. Flexion at this level is provided by the semimembranosus and biceps femoris. all transtibial amputations in this series healed. or obesity.). McCollough et al. if they can be easily felt. The profunda femoris artery. the better the gait. it should heal at that level. In cases with good blood flow to the ankle. correlating it to function and the prosthetic components to be used. Even with the development of more sophisticated tests. The amputation method advocated by Burgess. hypotension. to determine the feasibility of vascular reconstruction.asp[21/03/2013 21:55:42] . With palpable popliteal or pedal pulses. while not specifying what they considered optimal length. most surgeons continue to rely on factors that can be easily evaluated by touch and sight. on a par with reliance on palpable pulses. The presumption is that if the skin bleeds within 3 minutes after incision at the proposed level. color of the foot dependent and elevated. however.5% These findings point out the difficulty in evaluation of healed at the transtibial level.oandplibrary. 57% healed with only an aortic pulse present. This is attested to by the varying ratios of transtibial to transfemoral amputations performed in similar institutions in different parts of the world and even in various parts of the same country or city. should encourage the surgeon to proceed at that level. including peripheral pulses.. In dysvascular cases with an absent popliteal pulse.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library approach remains somewhat idiosyncratic and is based on the attitudes and prejudices of the surgeon as well as those of the prosthetist regarding the level under consideration. Beyond universal agreement as to this shortest possible functional level. if the skin does not bleed. he recommended a short residual limb due to the skin complications seen in longer amputations from wearing the prostheses with plug-fit sockets Moore stated that the greatest length and thigh corsets that were available at that time. which may be the only major vessel providing collaterals to the calf. There are a number of opinions. tissue necrosis. they are usually there. hair growth. while Epps stated that the basic rule was to save all length possible. A significant number of transtibial amputations will heal despite the absence of palpable pulsation at any given level. including the superficial femoral level. is inaccessible to the palpating finger. amputation in the proximal half of the leg would seem reasonable. collateral circulation by palpation. if he is fit to receive any type of anesthetic. -In the healthy patient undergoing amputation for trauma. the skills and experience of the individual anesthetist. As more functional goals for the transtibial amputee have been appreciated.oandplibrary.asp[21/03/2013 21:55:42] . If hypotension occurs. Transtibial amputations may be classified as follows: 1. -This technique has little effect on the pulmonary system. transtibial amputations. 4. function. 3. The posterior flap is then drawn with its length equal to the distance from the original reference point to the anterior third of the tibia. The placement and measurement of flaps must be accurately related to the cross-sectional area of the leg at the bony level selected. leg at the junction of the anterior two thirds and posterior third of the leg diameter at the level selected for bone section. A second and equally important criterion is the proper technical management of tissues during the procedure. transtibial amputation should be performed or directly supervised by an experienced surgeon and not delegated to the least experienced surgeon-in-training to do unsupervised. however. The agent is injected along the proposed incision line and deeper tissues infiltrated as necessary. Closed amputations 2. Open amputations Closed Amputations Long Posterior Myofasciocutaneous Flap In 1943. with a local anesthetic. it is corrected with fluid administration and/or vasopressors. but rather as a reconstructive procedure to restore ambulatory function. the choice of anesthesia depends on the patient's condition. The anterior and posterior flaps meet in a small half circle that will eliminate the "dog ear. and the patient's choice. -For patients with severe cardiopulmonary compromise. The senior author's technique. Regional anesthesia.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library The various types of anesthesia useful in transtibial amputation may be classified as follows: 1. it can be quite safe and effective. Agents containing epinephrine are avoided. Nerves. may be attributed to the educational efforts of Burgess. but only inflated if bleeding is problematic during surgery. as discussed above. General anesthesia. Local anesthesia. End weight-bearing amputations 3. can be problematic. however. the surgeon must be willing at times to do staged procedures. a sciaticfemoral block can be very effective. new techniques have To achieve optimal been developed in an attempt to enhance function at that level. It can be supplemented. To achieve this end. especially the posterior tibial. The ultimate goal is a residual limb that will interface well with a prosthesis.5 cm in length. Otherwise. -An extremely ill or even moribund patient can have a transtibial amputation done without pain under local anesthesia. follows: reference points are marked medially and laterally on the adapted from Wagner. are individually injected prior to any manipulation and section. either the bone will need to be shortened to avoid closure under tension. Use of a thigh tourniquet is recommended in cases of amputation for trauma. Successful use of a variety of flap configurations has shown that incision placement is not crucial so long as the incisional scar is not adherent to the underlying bone. or redundant soft tissue will have to be excised. if necessary. The two points are joined to form an anterior flap that is convex distally and no more than 0. There are two criteria for the primary healing of transtibial residual limbs. 2. First. Low spinal anesthesia. If the patient has severely compromised cardiopulmonary function. is proper selection of level. a tourniquet may be in place. SURGICAL TECHNIQUE Amputation is no longer to be considered as purely the ablation of a useless or debilitating part. In summary. Bickel reported on the use of a long posterior myofasciocutaneous flap in 110 The major impetus for the acceptance of this concept. it may not be the best choice. In dysvascular cases." http://www.org/alp/chap18-01. however. Control of blood pressure. This line passes slightly anterior and then gradually posterior to pass around the posterior aspect of the leg and is completed in a similar fashion on the opposite side ( Fig 18A-9.). the flap edges can be trimmed further to obtain a good fit. There are several anatomic reasons for this. and the skin is closed with interrupted nylon sutures widely spaced. with the technique becoming progressively easier in more distal amputations ( Fig 18A-16. thus resulting in minimal muscle excision to allow closure. or it may be dissected out and lightly cauterized. The absolute indication for equal anterior and posterior flaps is to conserve bone length when relatively little bone remains ( Fig http://www. With distal tapering of the calf. At this point. Starting from a midlateral apex on either side. the skin is cut to form equal anterior and posterior flaps. ). The long amputation knife is used to create a posterior myofasciocutaneous flap. A long amputation knife is passed behind the tibia and fibula and drawn distally to create a tapered myofasciocutaneous flap ( Fig 18A-11. the length of each flap is equal to half the diameter of the leg at the level of bone transection ( Fig 18A-18. This and the superficial peroneal nerve and the neurovascular bundle are managed as described in the previous section. It should be made equal to or slightly shorter then the tibia to prevent undue distal tibial prominence as seen in a conical rather than cylindrical residual limb ( Fig 18A-10. in cases of severe dysvascularity in which the blood supply to the muscle appears compromised. and the posterior investing fascia ( Fig 18A-14. The anterior investing fascia and the muscle of the anterolateral compartment are then cut down to the anterior tibial neurovascular bundle. ). The deep calf musculature is excised to reduce the bulk of the posterior flap ( Fig 18A-12.asp[21/03/2013 21:55:42] . It is then cut transversely with a saline-cooled power saw. widely based posterior flap.org/alp/chap18-01. the veins ligated. In these cases. The peroneal and posterior tibial arteries are clamped. ). The intervals are reinforced with adhesive paper strips ( Fig 18A-15. The artery should be doubly ligated. The wound may be closed by using either a myodesis or myoplasty technique. No subcutaneous sutures are necessary. The drain tube is run between the layers of cast padding out the top of the cast so that it can be removed after 24 to 48 hours without disturbing the cast ( Fig 18A-17. A heavy absorbable suture works well for this. and the veins are singly ligated. The posterior tibial nerve may be ligated to secure its intrinsic vessels. and the nerve cut under slight tension. Both bone cuts are now carefully smoothed and contoured with a bone file ( Fig 18A-13. control of venous bleeding is simplified because of fewer venous plexuses distally. Following placement of a suction drain. thus preventing later retraction. ). and doubly ligated. The fibula is cleared with an elevator and cut obliquely to form a facet facing posterolateraly. ). and this results in a much shorter. and myoplasty is carried out by suturing the investing fascia and myofascia of the posterior and anterior flaps together over the end of the bone. It is contraindicated. The nerve is then cut and allowed to retract proximal to the bone end. the cross-sectional area of the leg decreases. The lesser saphenous vein is found in the posterior flap and ligated while the adjacent sural nerve is cut under tension. the gastrocnemius (or tapered Achilles tendon in the case of a long transtibial amputation). ). drill holes are placed each side of the tibial crest bevel. Myodesis provides firm fixation of the posterior muscle padding to the tibia. All bone detritus must be carefully washed from the wound after drilling.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library The subcutaneous tissue and investing fascia are cut in line with the skin incision. Distal muscle bulk is much less. The tibia is beveled and contoured with a bone file. The medial and lateral portions of investing fascia and muscle flap are sutured with further interrupted absorbable suture. Finally. Less tissue mass also results in less tendency for "dog ear" formation. To effect myodesis. myoplasty will be sufficient. divided. The tissues joined to the bone by these sutures include the anterior investing fascia. The cast is made as light as possible to allow the patient greater mobility in bed and on crutches. A posterior myofasciocutaneous flap can be formed down to the distal extent of the soleus muscle.oandplibrary. The wound is irrigated. Equal Anterior and Posterior Flaps In this technique. The tibia is stripped of periosteum only to the level of transection to reduce the chance of bone spur formation. The cooled power saw is now used to cut a bevel in the anterior end of the tibia. ). ). ). the greater saphenous vein is ligated and the superficial peroneal and saphenous nerves transected under slight tension to cause them to retract into the soft tissues. however. The tibia and fibula are cut as noted before. A bulky soleus may also be tapered further to contour the distal tibia padding. The vessels and nerves are dealt with as described. the myodesis sutures are inserted. The anterior compartment muscles are carefully divided to expose the neurovascular structures. A well-padded plaster or fiberglass cast is applied with the knee in full extension. If necessary. Other holes may be placed medially and laterally as well. The second reason is that the resultant flaps are widely based and very short. another covers the bone better and provides good spontaneous drainage. advantage is that the sagittal flap configuration allows the skin to be more easily cut proximal to any anterior or posterior damaged skin. The nerve is folded into the soft tissues of the residual limb.A and B and Fig 18A-22. . Persson also stated that a side-to-side myoplasty In trauma cases.oandplibrary.org/alp/chap18-01. Its chief disadvantage is the sacrifice of 10 cm of bone length. but to a much lesser extent in the civilian population. The open circumferential technique. the creation of anteromedial and posterolateral flaps is suggested. both initially and in revision surgery.A and B). The proximal attachment of these osteoperiosteal flaps is preserved as the remainder of the amputation is performed. This method has been employed in the American military.A-C). The flaps are less apt to become necrotic in dysvascular cases for two reasons. with the posterior tibial nerve left in continuity. This applies equally in traumatic amputations and in cases of infection in which an attempt will be made to preserve maximum limb length below the knee to enhance prosthetic function.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library 18A-19. . thus helping to preserve bony length ( Fig 18A21. . If the posterolateral flap is seen to have very poor blood supply at the time of skin incision. but the posterior tibial nerve and foot should be intact. The resultant amputation has end weight-bearing capability. and a posterior tibial-popliteal arterial anastomosis is done. To take advantage of this fact. The heel pad is then sutured over the end of the residual limb to provide end weight bearing after healing. Skew Flaps This approach is designed for the severely dysvascu-lar patient in whom all major vessels are occluded. which will ossify to form a sturdy weight-bearing bone bridge ( Fig 18A-24. and the anteromedial flap is sewn to its lateral aspect. particularly in cases where there is sufficient mobile soft tissue present to cover a greater length of tibia. whereby each http://www. The indications are limited. and the surgery is precise. Open Amputations Primary open amputation is indicated whenever primary closure of the wound is likely to result in initial or continuing infection and/or necrosis. The "guillotine" amputation in which all soft tissue and bone is transected at the same level should be reserved for emergency situations and then done only at distal levels to leave enough proximal tissue for a functional transtibial amputation at the time of revision. This approach combines features of the long posterior flap and sagittal flaps ( Fig 18A-23. From thermographic and intradermal radioisotope studies it has been shown that collateral circulation through small arteries accompanying the saphenous and sural nerves will provide blood supply to flaps that incorporate these nerves and their vessels. The heel pad and sole tissues are dissected from the skeleton of the foot. End Weight-Bearing Transtibial Amputations Osteomyoplasty (Ertl Procedure) This procedure was designed for revision of transtibial residual limbs in the war wounded. They are then sewn to each other to create an osteoperiosteal tube joining the ends of the bones. Equal Medial and Lateral (Sagittal) Flaps The advantages of this approach were outlined by Persson. thus enhancing their viability ( Fig 18A-20. It has been recommended as a useful technique in young traumatic amputees. The first is that the placement of flaps medially and laterally automatically reduces the amount of poorly vascularized anterior skin that is left. . ). Singer Procedure This is another approach to end weight bearing in transtibial amputation for trauma. Tibial diaphyseal bone loss must be extensive enough to preclude skeletal reconstruction. Once the amputation has been completed.asp[21/03/2013 21:55:42] .A and B). it can be shortened. criteria are strict. the lateral flap is sewn to the medial aspect of the fibula. .A-C). Two osteoperiosteal flaps are elevated from the anteromedial and lateral aspects of the tibia beginning approximately 10 cm distal to the proposed level of bone transection. or "dog ears" that will not promptly atrophy. It is therefore generally accepted that muscle should not be dissected from its overlying investing fascia. In cases of irreparable loss of foot vascularity and sensation associated with segmental tibial fracture. redundant skin. . all viable tissue is preserved by forming rough myofasciocutaneous flaps whose length and orientation are dictated by the trauma or infection. this portion will be removed at the time of closure. it may be left because it will probably fibrose in time. Available skin can be rotated to cover the anterodistal part of the tibia.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library successive layer is cut and allowed to retract before cutting deeper layers. If tissue planes In cases of severe foot infection. which would prevent dissipation of shear forces generated at the socket-skin interface. Of these three. This.A and B and Fig 18A-27. It is not necessary in these cases to shorten the bones to the level where full coverage by skin is possible.org/alp/chap18-01. SPECIAL CONSIDERATIONS DURING TRANSTIBIAL AMPUTATION Treatment of Skin In order to have a successful amputation. have to be revised to allow a good soft-tissue envelope reconstruction over the end of the bones. they may be easily opened medially and/or laterally to thoroughly debride the infected compartments ( Fig 18A-30. . this last technique preserves the maximum amount of bone length ( Fig 18A-25.A and B and Fig 18A-29. It will. skin edges can be everted for closure by the suturing needle. an open ankle disarticulation is useful. Healing can occur following the complete http://www. however. . the site where the greatest stress occurs during prosthetic walking. This condition appears most commonly in the anterior compartment.A-D). In trauma cases. skin with forceps. . Treatment of Fascia The crural or investing fascia should be cut at the same level as the skin and subcutaneous tissue. Muscle may be trimmed to provide sufficient padding for the end of the tibia without unnecessary bulk. Complete closure of the fascia also prevents scarring of skin directly to bone. or gloved fingers. In closing a myofasciocutaneous flap. considerable shrinkage will occur before closure is feasible. The residual limb should not be left with inverted scars. It should never be separated from the surrounding soft tissues in order to prevent damage to any small perforating vessels serving the skin. hence. more difficult to accurately oppose and more prone to necrosis.A-C).oandplibrary. the one tissue structure that must heal is the skin. These segments can be fixed to the proximal part of the shaft by internal or external fixation to provide a longer residual limb ( Fig 18A-26. If muscle tissue is merely pale.A-C). . . At no time should the skin be traumatized by grasping Instead. allows the use of fewer skin sutures. in turn. A much better technique utilizes open flaps. The remainder of the muscle is covered with a split-thickness skin graft ( Fig 18A-28. proximal to the ankle are involved. Any ischemic or necrotic muscle should be excised. There should be no separation of layers in the creation of myofasciocutaneous flaps because this may interfere with the blood supply to the skin. In dysvascular cases. which may contribute to less skin necrosis. While such flaps may appear excessively long initially. Simple interrupted sutures are widely spaced and alternated with adhesive paper strips to contain subcutaneous fat. If the flaps are so long that some distal viability is lost. In this case.asp[21/03/2013 21:55:42] . The skin must be precisely approximated without closure tension.A and B). hooks. there may be instances in which there is enough muscle to adequately cover the bones but insufficient skin to completely close the wound. The skin-subcutaneous incision should be made at 90 degrees to the surface to avoid having portions of skin unsupported by subcutaneous tissue and. care should be taken to ensure that the crural fascia is indeed found and firmly sutured both to ensure maximal wound strength and to take tension off the overlying skin. Treatment of Muscle Muscle is considered to carry at least some blood from the deep arteries of the leg to the skin. has the advantage of less exposure of the deeper soft tissues and bone and perhaps conserves some bone length. the sutures are kept in place for 3 weeks to allow for the slower healing that is common in these cases. there may be segments of tibial shaft that are still well attached to soft tissue which can be closed secondarily to form a good soft-tissue envelope. the surgeon wishes to avoid fluid splattering. and posterior tibial. Dellon et al. the fibular head may produce pain by its ball-like presence in the socket ( Fig 18A-31. the splint is not broken and the wrapping is firm. can move about in bed quite easily. A soft dressing. improved sense of wellIn another series. demonstrated that nerve ends surgically buried in muscle show no tendency toward neuroma formation. the wound should be generously irrigated to wash away bone detritus. hospital stay was being. a Gigli saw may be used instead to cut the tibial shaft from posterior to anterior.org/alp/chap18-01. IMMEDIATE POSTOPERATIVE MANAGEMENT A rigid dressing from the end of the residual limb to midthigh with the knee in full extension meets a number of worthwhile goals.5%) by a standard infusion pump at the rate of 2 to 3 mL/hr over the first 72 hours. ). Another advantage of the rigid dressing is that it protects against falls onto the residual limb while the patient is learning to manage a walker or crutches. Removal may also be beneficial in a very short transtibial amputation at the level of the tibial tubercle where. The catheter is easily removed where it exits the postoperative cast. Various authors have suggested a bevel of 45 to 60 degrees as being optimal. If it is necessary to look at the wound. Both bones should be carefully filed to remove all sharp edges and points. however. A posterior plaster splint will keep the knee straight so long as reduced from 14 to 7 days. however. deep peroneal. One randomized study comparing soft and rigid dressings showed that rigid dressings resulted in less pain. it can be secured with a waist belt. Treatment of Bone Beveling of the tibia combined with careful smoothing of the bone edges will prevent damage to the skin in its position between the hard bone surface and the firm prosthetic socket. If necessary. if left in place. Careful attention to the patient's general status. It does not. on the other hand. 0.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library removal of necrotic muscles so long as the skin remains viable. offer any protection to the wound from trauma. if the rigid dressing is light enough. The best approach appears to be simple The cut proximal end retracts into the sharp division following mild traction on the nerve. the fibula may be cut with a bevel facing posterolaterally. it is directed proximally to cut the bevel.25% to 0. All bone If cutting with a power saw should be done with saline cooling to prevent thermal necrosis. and edema formation is limited. Treatment of Nerves The nerves to be specifically found and transected during transtibial amputation include the superficial peroneal. A variety of methods have been advocated to inhibit neuroma formation by traumatizing the proximal cut end of the nerve. allows easy access to the wound for inspection and for motion of the knee with or without the guidance of a therapist. Malawer et al. Prior to closure. nor does it prevent knee flexion contracture if the patient does not move the knee on a regular basis. Bleeding from the tibia or fibula can be controlled by electrocautery and closure of the wound. As the saw enters the anterior cortex. The cast is worn for 3 weeks with weekly changes for wound inspection and full range of motion of the knee. http://www. sural. and enhanced prosthetic fitting progress. have advocated the control of postoperative pain in the residual limb by intraoperative placement of a small Silastic catheter within or next to the posterior tibial nerve sheath for the continuous administration of local anesthetic (bupivacaine. The fibula should be no more than 0. Bone wax should not be used because of its tendency to provoke a foreign-body reaction and its interference with firm healing of the muscle flap to the bone. Total removal of the fibula may be required in cases of fibular osteomyelitis or bony necrosis due to circumferential muscle loss or abscess formation. Knee flexion contracture is prevented during the first few painful postoperative days.5 to 1 cm shorter than the tibia if a conical shape of the To prevent distal residual limb with a prominent distal end of the tibia is to be avoided.asp[21/03/2013 21:55:42] . complaints of soft-tissue impingement during prosthesis use. will inform the surgeon of any indication for removal of the cast such as an otherwise unexplained fever or evidence of excessive drainage. The patient is generally comfortable and.oandplibrary. saphenous. soft tissues where the inevitable neuroma will be protected during prosthetic gait. The only disadvantage is that the wound cannot be readily inspected. The posterior tibial nerve may present sufficient intrinsic vascular supply to warrant ligation or cauterization of its vasa nervorum. the wound is protected from bed trauma. educational. sex. Infection prevention is an important aspect of postoperative management that is met in most cases with perioperative intravenous antibiotics. All further care. proprioception. Selection of length is based on etiologic factors and on clinical and laboratory evaluation. the patient should be sitting out of bed with the residual limb elevated to the level of the chair seat. Alternatively. including prosthetic fitting and follow-up. they will stay until these goals have been achieved or abandoned as unrealistic. one or more antibiotics chosen from organism sensitivities should be continued for 2 to 5 days postoperatively. and recreational outlet. and amputation level can be of inestimable help. If infection was an overriding factor in the amputation. functional end organ that will interface well with a prosthesis. this is no longer financially feasible. the rigid postoperative If an immediate postoperative prosthesis has been applied. Amputee/ consumer peer support groups can be extremely helpful in smoothing the amputee's transition to the community. On the first postoperative day.oandplibrary. The aim of amputation surgery is a well-healed. Transtibial amputees are often discharged from the hospital 4 to 5 days after surgery unless they have failed to achieve their maximum level of independence in transfers and one-legged ambulation. bilateral concomitant lower-limb amputations. habituation should not occur. contribute to prevention of pain. This is followed by the use of crutches or a walker as conditioning and balance improve (see Chapter 23). Most patients with dysvascular limbs have one or more significant associated diseases calling for detailed preoperative management and skilled care in the immediate postoperative period. In the past. especially by providing a comfortable social. many patients remained in the hospital or rehabilitation center following surgery until they had healed. Visits by a trained amputee peer counselor matched with the patient by age. and thoroughly trained in its use. therapy can be switched to oral narcotics or nonsteroidal anti-inflammatory drugs. As much length as possible should be preserved. The psychological needs of the amputee must also be met.asp[21/03/2013 21:55:42] . and cognition to accurately determine the weight applied. In that case. The cost of hospital stay has become a major issue in recent years. provides the amputee with the possibility of near-normal function in regard to ambulation and overall life-style. compatible with disease eradication and good prosthetic function. however. The patient should be made mobile as soon as possible to prevent the deconditioning that may occur within just a few days. In the United States. by saving the knee joint. By the next day. Meticulous management of http://www. advanced age. the patient should be in the physical therapy department beginning ambulation on the parallel bars. the majority of major lower-limb amputations are now being done at the transtibial rather than the transfemoral level. In this way. Further need for antibiotics can be determined by direct evaluation of the wound. Atelectasis may be prevented by positioning and by deepbreathing exercises using various types of incentive respiration devices. a small Silastic catheter may be inserted at the time of surgery within or next to the posterior tibial nerve sheath for the administration of local Avoidance of wound dependency will also anesthetic for the first 72 hours postoperatively. been fitted with a prosthesis. Hospitalization for prosthetic gait training can be justified in cases of marked deconditioning. Counseling by various team members can be quite helpful in allaying anxiety regarding the prosthetic phase of care. Diabetes is now seen to be a primary or secondary cause of amputation in at least 50% of cases. With the availability of new information on the efficacy of transtibial amputation and improved methods of determining potential healing levels in a limb.org/alp/chap18-01. a better plan is to make a strong posterior hemicylinder by removing the anterior half of a full cast. The issue that most concerns patients in the immediate postoperative period is pain control. sen-sate. limited weight bearing on cast. SUMMARY Transtibial amputation. or great distance from the center. Early mobilization has been enhanced in recent years with the introduction of the immediate postoperative prosthesis and its more commonly used component.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library however. After this. the residual limb can start almost immediately provided that the patient demonstrates sufficient strength. They should be given an amount of narcotics sufficient for good pain relief every 3 to 6 hours or by means of an on-demand machine for a maximum of 5 days. is accomplished on an outpatient basis. balance. Arch Surg 1963. et al: Below-knee amputation. et al: Belowand through-knee amputations in ischaemic disease. ed 2. Gonzalez EG. Browse NL. Shurr DG: The healing of below-knee amputations: A comparison of soft and plaster dressings. 131:195-201. Ann R Coll Surg Engl 1983. 27. 28. Early prosthetic weight bearing has great value in selected cases if closely monitored. Amputee Clin 1970. References: 1. 16. 55:111-119. 15:38-41. Moshein J. 1990. 25. Castronuovo JJ. Jain AS. Jacobs BS: Lower extremity amputation in diabetic patients. Hoar CS. DeLee JC. Barnes RW. 14. Root R. Baker WH. et al: Improved results with diabetic below-knee amputees. Am J Surg 1977. Dickhaut SC. et al: The fate of the below-knee amputee. Eraklis A. Ann Plast Surg 1984. http://www. 133:716-718. Diabetes 1970. Prosthet Orthot Int 1980. Deffer PA: More on the Ertl osteoplasty. 4. Burgess EM: The below-knee amputation. 4:596-604. Block MA. Myodesis is advocated in cases in which local dysvascularity is not a problem.org/alp/chap18-01. 9. Boontje AH: Major amputations of the lower extremity for vascular disease. Corcoran PJ. Eur J Nucl Med 1989. N Engl J Med 1963. Rauwerda JA. 19:189-195. Deterling RA. Reyes RL: Energy expenditure in below-knee amputees: Correlation with stump length. 19.asp[21/03/2013 21:55:42] . McPhail NV. Fleurant FW. MacKinnon SE. infection. Is the effort to preserve the knee joint justified? Arch Surg 1980. 21. 10:19-25. 26:339-341. Clin Orthop 1978. 120:777-780. Krause RJ. 2. 87: 682-689. Nielsen K. with special reference to evaluation of assistive devices. Churchill Livingstone Inc. 63:475-479. Arch Phys Med Rehabil 1974. Whitehouse FW: Below-knee amputation in patients with diabetes mellitus. 269:933-943. et al: Fate of the vascular patient after belowknee amputation. Postoperative rigid dressings are strongly recommended because of local protection of the wound and the prevention of edema and knee flexion contractures. Alexander J: Below knee amputation and rehabilitation of amputees. Bickel WH: Amputations below the knee in occlusive arterial diseases. Deane LJ. et al: Below-the-knee amputation for arteriosclerosis obliterans. Can J Surg 1983. 3. Ralston HJ: Measurement of energy expenditure during ambulation. 13. Surg Gynecol Obstet 1980. 40:415-420. Alter AH. Elconin KB. Pestronk A: Implantation of sensory nerve into muscle: Preliminary clinical and experimental observations on neuroma formation. Chilvers AS. et al: A prospective study of lower limb amputations. Strasser RS. Lancet 1987. 7. 11. Bagdade JD. 22. Optimal amputee management is best achieved through a team approach beginning even before surgery.oandplibrary. 39:355-360. Early mobilization prevents deconditioning. 20. 115:1184-1187. 23. et al: Below-knee amputation using the sagittal technique: A comparison with the coronal amputation. et al: Host defense in diabetes mellitus: The feckless phagocyte during poor control and ketoacidosis. Bard G. 98:77-80. 218. 10. Randall P. 2:7-8. 6. 12. Campbell DR. et al: A modified scintigrafic technique for amputation level selection in diabetics. Chirurgie 1949. Arch Surg 1985. Br J Hosp Med 1970. in Evarts CM (ed): Surgery of the Musculoskeletal System. 26. Epps CH Jr: Amputation of the lower limb. 58:824-826. AAOS Instr Course Lect 1990. Br J Surg 1971. New York. Dwars BJ. Cheng EY: Lower extremity amputation level: Selection using noninvasive hemodynamic methods of evaluation. 23:982-994. Bull Prosthet Res 1968. and vascular disease.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library tissues will lead to preservation of the length obtained at surgery. Bowker JH: Surgical techniques for conserving tissue and function in lower-limb amputation for trauma. Barber GG. Arch Surg 1969. van den Brock TAA. 15. Fearon J. Briggs J. 8. Walker WF. 19:364. de Cossart L. J Bone Joint Surg [Am] 1984. Ecker ML. 65:230-232. 20:2-12. Arch Phys Med Rehabil 1982. Scobie TK. Surg Clin North Am 1943. thereby allowing early discharge to an outpatient status. 17. 4:87-89. Wheeler B: Below-knee amputations in patients with severe arterial insufficiency. 151:41-44. Diabetes 1970. Brodie IAO: Lower limb amputation. Cumming JGR. 12:30-40. Ertl J: About amputation stumps. Turner P. Cranley JJ. 2:613-615. 66:71-75. Arch Phys Med Rehabil 1959. Dellon AL. 24. 18. Page CP: Nutritional status: Importance in predicting woundhealing after amputation. 5. 12:9-18. Blaisdell FW. Lange R. 33. et al: Is the outlook for the vascular amputee improved by striving to preserve the knee? J Cardiovasc Surg 1988. et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. Hanse S. Arch Surg 1961. 61. Schwartz SI. Pedersen HE. Hobbs MST: Decline in rate of death from ischaemic heart disease in The United Kingdom. 266:440-443. Schwartz JA. 85:461-463. Arch Surg 1984. 36. Flye MW: Factors affecting the resuits of below knee amputation in patients with and without diabetes. Bodtker S: The influence of smoking on complications after primary amputations of the lower extremity. Lepantalo M. Heller RF. 51. Khurana JS. LaMont RL. 53. et al: Postoperative infusional continuous regional analgesia (PICRA): A technique for relief of postoperative pain following major extremity surgery. J Bone Joint Surg [Am] 1972. Torres J: Evaluation of below-the-knee amputation in the treatment of diabetic gangrene. 38. Int Surg 1980. Lim RC. 42. 54:1217-1223. Robinson K: Long-posterior-flap myoplastic below-knee amputation in ischaemic http://www. 43. Buch R. 55. 86: 199-202. McCollum PT. Wolma FJ. Kotb M. 20:32-36. Ramsey RH: Below-knee amputation for gangrene. Pohjolainen T. Kyllonen L: Can the failure of a below-knee amputation be predicted? Ann Chir Gynaecol 1987. 54. 29:741-745.asp[21/03/2013 21:55:42] . 39. Moore TJ: Amputations of the lower extremity. Walker WF. Kendrick RR: Below-knee amputation in arteriosclerotic gangrene. N Engl J Med 1962. Kramhoff M. Harris RI: Amputations. 59. Hall AD. Surg Gynecol Obstet 1967. Hannon MA: How successful is below-knee amputation for injury? Injury 1989.oandplibrary. 1981. Englund R. Mclntyre KE Jr. Louie TJ. Prosthet Orthot Int 1977. Loon HE: Below-knee amputation surgery. Surg Gynecol Obstet 1982. et al: Lower extremity amputation: The control series.org/alp/chap18-01. Spence VA. 56:110-114. 1988. 60. Harris PD. 30:392-393. Philadelphia. Matsumoto R: Above vs. Jennings JJ. Harris WR: Below-knee amputation: A technical note. et al: Below-knee amputation for ischemic gangrene. 40. 31. 47. Lynn RB: Major amputations for oblitera-tive peripheral vascular disease with particular reference to the role of below-knee amputation. 65:265-267. Keagy BA. Comparative results of conventional operation and immediate postoperative fitting technique. Ann Intern Med 1976. 52. 9:95-99. Persson BM: Sagittal incision for below-knee amputation in ischaemic gangrene. 119:450-453. pp 341-368. South Med J 1964. 25:203-208. Bach A. 286:260-262. J Vasc Surg 1986. 50. 41. 4:321-326. Hampton FL: Below-knee amputation. 44:13-17. 45. 30. 44. Tally FP. 125:493-501. 10:168-171. 47:384-392. Pros-thet Orthot Int 1985. Hayward D. 57. et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. 57:820-825. Perry T: Below-knee amputations.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library 29. 34. Kacy SS. Marsden FW: Amputation: Surgical technique and postoperative management. DeWeese JA: Midcalf amputation for peripheral vascular disease. 37. 35. Hall AD. 49. 58. Aust N Z J Surg 1977. Sarmiento A: Bilateral be-low-the-knee amputation in patients over fifty years of age: Results in 31 patients. Rizzo RL. Artif Limbs 1961. Harris JP. 267:211-217. 155:513-518. Murray DG: Below-knee amputations in the aged: Evaluation and prognosis. 266:227-237. Bailey SA. 6:86-99. et al: A rationale for skew flaps in below-knee amputation surgery. 26:626-634. Am J Surg 1972. 56. Malawer MM. in Atlas of Limb Prosthetics. 20:1033-1038. Malone JM. Can J Surg 1987. Arch Surg 1963. Purry NA. 82:381-383. 32. Geriatrics 1965. Moore WS. Isoniemi H. Paloschi GB. below knee amputations: A retrospective analysis. Mosby-Year Book. Clin Orthop 1991. J Trauma 1985. J Bone Joint Surg [Br] 1974. Harris AR. Hoar CS. St Louis. 124:127-134. Alaranta H: Lower limb amputations in southern Finland. Prosthet Orthot Int 1988. 46. JB Lippincott. et al: Guillotine amputation in the treatment of nonsalvagable lower-extremity infections. Lind J. 76:119-123. Can J Surg 1967. J Bone Joint Surg 1944. Murdoch G: Amputation surgery in the lower extremity. Page S. McCollough NC III. McCollough NC. in Chapman M (ed): Operative Orthopaedics. Br J Surg 1956. Br Med J 1983. 48. 1:7283. Bartlett JG. Clin Orthop 1991. Lim RC: Below the knee amputation for ischemic gangrene. Goldstone J: Below-knee amputation: A modern approach. 64.asp[21/03/2013 21:55:42] . Morrison WA. Thornhill HL. 65. Perry J. Chapter 18A .oandplibrary. Bivins BA. 62. Yaramenko D. Sarmiento A. Ann R Coll Surg Engl 1991. Singer DI. Calif. Aust NZJ Surg 1988. Acta Orthop Scand 1977. 73:155157. Rush DS. et al: Energy cost of walking amputees: The influence of level of amputation. Contact Us | Contribute http://www. Antonelli D. 58:42-46. 69:554-557. Warren WD: A re-evaluation of lower extremity amputations. Br J Surg 1982. 47:36-39. 2:193-195. 68. Stewart CPU: The influence of smoking on the level of lower limb amputation. Rancho Los Amigos Medical Center. J Bone Joint Surg [Am] 1976. 72. et al: Operative and late mortality rates of above knee and below knee amputations. Arch Phys Med Rehabil 1986. 67. 71. Brodzka W. Am Surg 1981.org/alp/chap18-01. Surg Gynecol Obstet 1969. 73. Waters RL. Prosthetic. Smith BC: A twenty year follow-up in fifty below-knee amputations for gangrene in diabetics. 10:125-128. Robinson K: Skew flap myoplastic below-knee amputation: A preliminary report. 63. Prosthet Orthot Int 1986. 69. 58:817-823. 70. Am J Surg 1977.Atlas of Limb Prosthetics: Surgical. Huston CC. 11:113-116. et al: The fillet foot for endweight-bearing cover of below knee amputations. Moore WS. et al: Bilateral below-knee amputations: Experience with 80 patients. Lancet 1972. Prosthet Orthot Int 1987. Termansen NB: Below-knee amputation for ischaemic gangrene. 74. 134:153-158. Surg Gynecol Obstet 1956. 103:625-630. Andruhova RV: Below-knee amputation in patients with vascular disease and prosthetic fitting problems. Roon AJ. 67:159-163. Wagner FW Jr: Resident Training Manual.18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library disease: Review of experience in 1967-1971. McCann JJ. 66. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 18A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Robinson KP: Skew-flap below-knee amputation. 129:799-802. Jones GD. 48:311-316. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. elastic bandages and residual limb shrinkers still play an important role in the conditioning of an amputated limb. a foot. the intermediate prosthesis is often preceded by rigid dressings or immediate postsurgical fittings. an elastic bandage or shrinker may be the most practical and economical form of residual limb conditioning. reprinted 2002. which ensures that alignment changes can be made as needed throughout the intermediate period. shrinkers or elastic bandages should be worn whenever the patient is not wearing a prosthesis. and for a period of perhaps 1 month has not had to add prosthetic socks to accommodate limb shrinkage. In addition to gait training. weightbearing tolerance.P. and limb shrinkage. C. or other circumstances that delay prosthetic fitting. For patients with wound complications.P. To accomplish this. This is a considerable advantage since the needs of the patient can be constantly reassessed and accommodated as his ability to use the prosthesis improves. For example. Atrophic changes may stabilize after only 4 months. Bandaging is beneficial whenever the new amputee is not wearing the prosthesis. These goals are often accomplished with the help of an intermediate (or preparatory) prosthesis coupled with gait training. prosthetic wearing time. however. Even after initial prosthetic fitting. 1992. It is not unusual for the patient to progress through several intermediate sockets within the first year following amputation. and regular inspection of the limb for any sign of excessive pressure. Click for more information about this text. ©American Academy or Orthopedic Surgeons. Prosthetic. edition 2. American Academy of Orthopedic Surgeons. the application of shrinkers or elastic wraps. Once fitted with an intermediate prosthesis. and a method of suspension. The decision to proceed with definitive fitting. Residual limb shrinkers. a pylon. the process continues for 12 months or more. and residual-limb volume.org/alp/chap18-02. The intermediate may be worn for a few months or as long as a year. In contrast. largely subjective. residual-limb hygiene. Donald Cummings. the goals of rehabilitation become limb maturation and return to normal activity. Prosthetic. a residual limb shrinkage program. depending upon the pace of residual limb atrophy. A patient's readiness for a definitive fitting varies depending on his activity level. a young active amputee who has worn an intermediate prosthesis is probably ready for definitive fitting when he can tolerate full weight bearing. http://www. wears the prosthesis all day. Alignment and socket fit are adjusted by the prosthetist as needed. delayed healing. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). and Rehabilitation Principles Transtibial Amputation: Prosthetic Management Susan Kapp. rigid dressing. it is recommended that the patient be instructed in the use of prosthetic socks. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. IL. It is usually applied when edema is diminished and the patient's residual limb has atrophied sufficiently to allow independent donning and doffing of a prosthetic socket. or some other compressive device. is based on the overall perception that the patient has reached a plateau in activity level. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. may be used in place of elastic bandages. It aids in residual limb shrinkage through pressure atrophy of subcutaneous fat and by externally supporting veins and lymphatic channels to allow blood return through muscular contractions. an elderly patient with other Reproduced with permission from Bowker HK. Once the patient has completed the postoperative phase of treatment and adequate wound healing is established.18B: Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 18B Chapter 18B . More likely. For the recent amputee. the patient may progress in physical therapy to full weight bearing.Atlas of Limb Prosthetics: Surgical. and close supervision by the clinic team. Prosthetic. and Rehabilitation Principles. Rosemont. C.oandplibrary.asp[21/03/2013 21:55:48] . An intermediate prosthesis consists of a socket. before it is replaced with a definitive prosthesis. An intermediate prosthesis is generally constructed on an endoskeletal pylon. which are composed of a series of elastic bands sewn together to form a cylinder with a padded distal end. Each technique. While preparatory systems are intended to accommodate the multiple changes experienced by a recent amputee. skin grafts. The distal portion of the PTB socket may incorporate a soft pad that in theory prevents distal edema by aiding venous and lymphatic return from the distal part of the residual limb. the patient and the clinic team is faced with a wide variety of choices due to numerous innovations in prosthetic components. or a predisposition to breakdown. The medial wall is modified with a slight undercut in the area of the pes anserinus on the medial flare of the tibia. 5.org/alp/chap18-02. Reliefs or modifications can be located with exactness. To make a PTB socket. When deciding upon an appropriate prosthesis. or it may differ dramatically depending upon the goals that have emerged during rehabilitation. Contours within the socket do not compress or pack down with use. except in some postoperative prostheses or when pathologic conditions require an alternative socket. alignment. Advantages: 1. but is nevertheless ready for definitive fitting because a degree of con-sistancy in activity level and residual-limb condition has been achieved. because the patellar ligament is not the only major weight-bearing surface utilized by the PTB socket. materials. Less bulky at the knee than with an insert. The term patellar tendon bearing can be misleading. The lateral wall provides a relief for the head of the fibula and supports the fibular shaft. A soft socket liner may be used for added protection or comfort. and techniques during the last several decades. suspension system. The PTB total-contact socket is appropriate for virtually all transtibial (below-knee) amputations. THE PATELLAR TENDON-BEARING SOCKET The patellar tendon-bearing (PTB) socket ( Fig 18B-1. 3. scarring.) is rigid plastic and therefore has specific advantages and disadvantages when compared with a socket with a soft liner or distal pad. prosthetic wearing schedules. The anterior wall of the socket usually extends proxi-mally to encapsulate the distal third of the patella. Easy to keep clean. 4. and component has specific advantages and disadvantages that can be balanced to provide the optimum combination for the patient's unique needs. Just below the patella located at the middle of the patellar ligament is an inward contour or "bar" that utilizes the patellar ligament of the residual limb as a major weightbearing surface. A definitive prosthesis may closely resemble the intermediate prosthesis that preceded it. This style of socket is primarily indicated for a residual limb with good soft-tissue coverage and no sharp bony prominences. however. Perspiration does not corrode the socket. It is not recommended for residual limbs with thin skin coverage. This wall also acts as a counterpressure to the medial wall.18B: Prosthetic Management | O&P Virtual Library health problems may use a walker and wear the prosthesis only 4 to 5 hours daily. http://www. It can be suspended in multiple ways. The posterior wall is usually designed to apply an anteriorly directed force to maintain the patellar ligament on the bar. Together they control rotation. an impression taken of the patient's residual limb is modified to achieve an intimate. contain soft tissue. socket configuration. SOCKET INTERFACES The PTB Hard Socket The hard socket ( Fig 18B-2.) consists of a laminated or molded plastic socket. and residual-limb changes have all stabilized. and may provide some mediolateral knee stability. The medial and lateral socket walls extend proximally to about the level of the adductor tubercle of the femur. 2. thus utilizing another major pressure-tolerant surface. The posterior wall is flared proximally to allow comfortable knee flexion and to prevent excessive pressure on the hamstring tendons.oandplibrary. a definitive prosthesis differs primarily in that its design and components are geared toward the goals of the patient after activity levels.asp[21/03/2013 21:55:48] . which are discussed later. total-contact fit over the entire surface of the residual limb. A few special instances may not call for these protective pads. Protects the distal portion of the residual limb when it settles into the socket as a result of volume loss. 2. Disadvantages: 1. 4. Increases the weight of the prosthesis. Provides increased comfort.) are fabricated over the modified cast to fit inside the socket. Flexible Sockets With Rigid External Fra New plastics and materials have enabled prosthetists to offer patients the benefits of a flexible inner socket that is inserted into a rigid frame ( Fig 18B-4. 2. Soft Liners Soft liners ( Fig 18B-3. Increased weight. Rebound in the liner may aid circulation by providing a "pumping action" and by providing intermittent pressure over bony prominences. Not as sanitary as a hard socket because liners tend to absorb fluids. but most often they are standard.org/alp/chap18-02.oandplibrary. 5. The added protection of a soft liner may also benefit the highly active patient. The liner may compress over time with resultant loss of intimate fit. Silicone and similar materials may also be used to create an air seal against the patient's skin so that the liner can provide suction suspension. 2. protective socket interface. Soft liners are recommended for patients with peripheral vascular disease. 2. bony prominences and soft tissues not http://www. Is appropriate for the majority of residual limbs. They are often fabricated from a 5-mm polyethylene foam material. Facilitates future modifications of the distal end of the socket. 3. They act as an interface between the limb and socket to provide added comfort and protection for the residual limb by moderating impact and shear.asp[21/03/2013 21:55:48] . The inner socket is fabricated from polyethylene or a similar material and the frame from laminated plastic or thermoplastic material. 3. Occasionally silicone gel is used for the more sensitive residual limb. Is easily modified. Provides a soft. Not as easily modified as a socket with a liner. Increases bulk around the knee and proximal circumference of the prosthesis. the distal portion of PTB sockets generally incorporate a soft pad. sensitive. The frame provides coverage only over the primary weight-bearing areas. 3. for thin. Distal Pads To improve overall comfort and to help prevent edema.. The bilateral transtibial amputee may prefer liners to protect the distal portion of the tibia when rising from a chair or during stair and incline climbing. and for patients with peripheral neuropathy. Disadvantages: 1. or scarred skin and sharp bony prominences. 3.18B: Prosthetic Management | O&P Virtual Library Disadvantages: 1. Difficult to fit bony or sensitive residual limbs. 3.e. 2. Added fabrication time. May be less hygienic due to absorption of fluids. i. while the more pressure-sensitive areas. May aid in venous and lymphatic return. Advantages: 1.). Materials may deteriorate over time. 4. 4. Requires extra skill in casting and modification. Advantages: 1. Advantages: 1. Ease of donning and doffing by the patient. and anterior walls extend higher and fully encompass the femoral condyles and the patella.asp[21/03/2013 21:55:48] . It encircles the thigh and purchases over the femoral condyles and proximal part of the patella. 2. lateral. 5. Patients with mild mediolateral knee instability or those who cannot tolerate a supracondylar cuff can also benefit from PTB-SCSP suspension.18B: Prosthetic Management | O&P Virtual Library requiring rigid support. Cuff suspension is appropriate for average-length residual limbs with good knee stability. Disadvantages: 1. During casting and modification. PTB Supracondylar Suprapatellar Suspension The PTB supracondylar. The area just proximal to the patella may also be contoured inward to create a "quadriceps bar. It is not recommended for short residual limbs since they generally require increased surface area contact and rotational control through more proximal trim lines. Patients http://www. This type of suspension is particularly recommended for patients with short residual limbs since it encompasses more surface area to share weight bearing and resist torsional forces. May not be as cosmetic as conventional prostheses. May restrict circulation. More difficult and time-consuming to fabricate." which provides added suspension over the patella and resists recurvatum. 2. Cannot completely eliminate socket pistoning. This technique often results in a more comfortable socket and can be utilized in en-doskeletal or exoskeletal systems. 2. 4. Improved heat dissipation. particularly the medial condyle. Provides no added mediolateral stability. 3. Advantages: 1.) was designed originally as an alternative suspension and as a means of providing increased mediolateral and anteroposterior stability of the residual limb.oandplibrary. 2. The posterior wall is unchanged. suprapatellar (PTB-SCSP) socket ( Fig 18B-6. are enclosed only in the flexible socket. 3. the proximal mediolateral dimension just superior to the femoral condyles is reduced to provide purchase over the femoral condyles. Easily replaced. Decreased weight. 4. Increased comfort. Adjustability.) is generally fabricated from da-cron and lined with leather. Attachment points on the socket are slightly posterior to the sagittal midline in order to resist hyperextension forces at the knee and to allow the limb to withdraw slightly from the socket during knee flexion. During knee flexion. may pinch soft tissue between the posterior proximal end of the socket brim and the cuff. SUSPENSION VARIANTS Cuff Suspension The cuff ( Fig 18B-5. 3. Disadvantages: 1. Adequate suspension for the majority of transtibial amputees. The inner socket may be replaced to accommodate anatomic changes.org/alp/chap18-02. Provides moderate control of knee extension. This socket style generally cannot provide adequate purchase over the femoral condyles for obese or very muscular patients. 4. This socket differs from the standard PTB socket in that the medial. Excessive scarring or sensitive skin in the area in contact with the cuff may be another contraindication. May be less cosmetic and more destructive to clothing because higher trim lines protrude when the knee is flexed. and pressure distribution. as is the PTB-SCSP socket. Advantages: 1.oandplibrary. Suprapatellar and PTB Supracondylar Sockets The PTB-SCSP socket usually incorporates a removable soft liner with a foam wedge buildup over the medial femoral condyle that compresses sufficiently to allow the amputee to push his residual limb past the supracondylar undercuts and into the prosthesis. As the name implies. The anteroproximal part of the socket brim can also be made to encompass the patella in the fashion of a PTB-SCSP socket. It is contraindicated. The socket with a removable medial brim ( Fig 18B-8. Disadvantages: 1.). Laminated into the proximal brim is a steel bar that fits into a channel on the medial aspect of the socket. http://www. Does not provide a knee extension stop. 3. May make kneeling easier. 4. but anteriorly they dip downward to form a more traditional trim line near the distal end of the patella. the need for a soft liner. Is less restrictive to circulation than a cuff or thigh corset. 3.).asp[21/03/2013 21:55:48] . 2. 3. A third variant is the removable medial wedge ( Fig 18B-9. Disadvantages (as compared with the PTB-SCSP socket) 1. 2. May be more cosmetic. the supracondylar area between the limb and the medial socket wall is filled by a Plastisol or crepe wedge that "keys into" the proximomedial portion of the socket brim. thus allowing the medial brim to be removed and then replaced in its original position. Advantages (over the PTB-SCSP socket) 1. 2. PTB Supracondylar Suspension The major difference between this and the PTB-SCSP socket is that the patella is not enclosed ( Fig 18B-7. Variants of the PTB Supracondylar. The medial and lateral brims purchase over the femoral condyles. and patient preference.18B: Prosthetic Management | O&P Virtual Library with moderate to severe ligamentous laxity usually require the added stability of metal joints and a thigh corset rather than supracondylar suspension alone. durability. Enclosure of the patella can inhibit comfortable kneeling. Modifications over the patella and femoral condyles must be precisely located. May provide less effective suspension than a PTB-SCSP since there is no suprapatellar purchase and because the absence of patellar encapsulation makes the medial and lateral walls more flexible. Aids in knee stability. Once the patient has inserted his residual limb into the socket. The selection of supracondylar methods depends upon patient needs such as cosmesis. It is then replaced to provide purchase over the medial femoral condyle. the proximal medial brim is removed to allow the residual limb to be inserted into the socket. ease of donning and doffing. Reduces pistoning. This suspension may be indicated when a patient wishes to do a lot of kneeling or cannot tolerate the quadriceps bar or encapsulation of the patella. The quadriceps bar and its knee extension control are thus eliminated. for patients with moderate to severe ligamentous laxity who require the added stability of metal joints and a thigh corset. 2. rotational control.org/alp/chap18-02. The patient must have a stable cruciate ligament with no need for an extension stop at the knee. Suspension is an inherent part of the socket. Less mediolateral stability than the PTB-SCSP.) is another type of supracondylar suspension. This liner is worn directly against the skin and dramatically reduces shear forces created by socket pistoning. Improved suspension. 2. 2. but they also provide excellent auxiliary suspension during sports and recreational activities for those who normally use supracondylar suspension. Ann Arbor. Some patients may have difficulty in donning the liner. 4. Sleeves may restrict full knee flexion and require good hand function to don and doff.oandplibrary. The silicone liner is used strictly to provide suspension. Must be replaced regularly. 3. The socket utilizes a "silicone liner" either custom-made or prefabricated. they are often combined with waist belt suspension. lined socket depending on the amputee's needs. and longitudinal tension in the sleeve. Does not create proximal constriction. which is noisy and soon wears the joints down. 4. Simple and effective means of suspension. Although joints and a corset may be the sole form of suspension. Silicone Suction Socket The silicone suction socket (3-S) ( Fig 18B-11. Suspension is greatly decreased if the sleeve is punctured. 5. It may be used with a hard socket or with a soft. Three suspensory forces attributed to the sleeve are described by Chino (1975): negative pressure created during the swing phase. ) has been in use since 1968 when it was introduced at the University of Michigan. 2. Patients whose activities require kneeling may find the sleeve less durable and may need to replace them frequently due to punctures of the sleeve material. a posterior "check strap" is usually http://www. Sleeves are contraindicated as the sole suspension for very short limbs or those that require more proximal trim lines for added knee stability. 2. They fit snugly over the proximal aspect of the prosthesis and are rolled up over the patient's thigh 2 or 3 in.18B: Prosthetic Management | O&P Virtual Library Sleeve Suspension The suspension sleeve ( Fig 18B-10. Disadvantages: 1. Good auxiliary suspension. Advantages: 1. Sleeves are prefabricated from thin latex rubber or neoprene and come in a variety of sizes. ) or Icelandic roll-on suction socket (ICEROSS) was conceptualized and developed by Ossur Kristinsson with further development by Durr-Fillauer Orthopedic.asp[21/03/2013 21:55:48] . is fastened snugly around the distal two thirds of the patient's thigh and is attached to the socket by metal joints with vertical support bars. Helps minimize socket pistoning. humid climates may find that the sleeve creates perspiration and hygiene problems. Sleeves may serve as the sole means of suspending a prosthesis. Perspiration may build up under the sleeve and create skin irritation or hygiene problems. In order to prevent the joints from reaching full extension. traditionally made of leather. Joints and Thigh Corset The thigh corset ( Fig 18B-12. the sleeve converts the socket into a sealed chamber. Suspension is achieved by the inherent suction capabilities of a silicone material against skin and a shuttle lock mechanism at the distal end of both liner and socket. Some patients living in hot. Advantages: 1. Provides no added knee stability. ). friction between the residual limb and the socket. Decreased shear on residual limb. 3.org/alp/chap18-02. 3. Increased range of motion in flexion. By making contact with the patient's skin. Inc. Disadvantages 1. Punctures or tears in the silicone can dramatically decrease suction suspension. proximal to the prosthetic socks. 6. it frequently contributed to marked atrophy of the thigh musculature. if adjusted properly. The waist belt is not recommended for patients with severe scarring or sensitive skin in the regions in contact with the belt. 3. Can provide maximum prevention of recurvatum. 2. 3. Prior to 1958. they are still appropriate when maximum mediolateral or anteroposterior stability is required. could effectively prevent recurvatum. and the use of a hyperextension check strap. Joint centers must be precisely located to minimize motion between the leg and the prosthesis. Advantages: 1. Requires more fabrication time. The standard system consists of a belt situated above the iliac crests or between the iliac crests and the greater trochanters. Enables patients to loosen the supracondylar cuff or other form of suspension. Much of the weight of the prosthesis is distributed proximally over the iliac crests. Not very cosmetic. 2. The trade-off. The corset also provides some degree of shared weight bearing and is useful when partial unloading of the residual limb is necessary. the main purpose of the thigh corset was to utilize the thigh to share weight bearing and reduce torque forces about the residual limb. While modern total-contact socket designs (and suspension systems) have greatly reduced the need for joints and thigh lacers. Fastened to this buckle is a strap that attaches to a PTB cuff or inverted "Y" strap connected to the prosthesis. Good auxiliary aid when other types of suspension are inadequate. 2. Increases proprioceptive feedback. The elastic strap provides some knee extension assistance. 8. 3. however. The elderly or debilitated patient may prefer the added security of a waist belt. 4. It also affords good auxiliary suspension for sports prostheses.org/alp/chap18-02. Waist Belt Suspension The waist belt ( Fig 18B-13. Adds weight and bulk to the prosthesis. Knee joint instability is a common indication. because the corset bound the thigh tightly and reduced muscular demands. 5. was that the lack of total contact combined with a tightly laced corset often resulted in chronic distal edema. It is also recommended when all proximal constriction must be eliminated due to skin or vascular conditions. Can contribute to distal edema. Redistributes some weight bearing and torque forces to the thigh. 4. Also.asp[21/03/2013 21:55:48] . On the amputated side. ) can be used as an auxiliary suspension or as a sole means of suspension. Patients who perform exceptionally heavy-duty work may benefit from the added stability of joints and corset suspension. Usually requires additional suspension of a fork strap and waist belt. Provides maximum mediolateral stability. an elastic strap extends distally to a buckle at midthigh. The check strap can be adjusted to limit knee extension to varying degrees. 7.oandplibrary. Since sockets were open ended and did not fit as intimately as today's total-contact sockets.18B: Prosthetic Management | O&P Virtual Library added between the corset and socket. Leather is not very hygienic. Disadvantages: http://www. Tends to atrophy thigh musculature. depending upon the patient's needs. The extended lever arm of the joints and corset provided maximum me-diolateral stability. the thigh corset combined with a waist belt was probably the most common form of transtibial prosthetic suspension. 4. Waist belt suspension is often used on postoperative or intermediate prostheses because it maintains suspension regardless of residual-limb volume changes. Disadvantages: 1. Advantages: 1. cushion-heel) feet. 4. the plantar flexors may actually "push off" and assist in propelling the weight of the body forward. During running or rapid walking. -The foot must absorb the impact of heel strike and weight acceptance without transmitting excessive forces to the residual limb. ) include a solid wood or aluminum internal keel that extends to the toe break and is surrounded by a molded external foam foot with cosmetic toes and a cushioned heel wedge available in different densities. the importance of cosmesis cannot be overlooked. the talocrural joint allows plantar flexion and dorsiflexion. and pediatric sizes. A successful.oandplibrary. Joint simulation. although forces in the coronal plane are dampened by compression of the rubber sole. 3. During midstance and heel-off. multifaceted component of the transtibial prosthesis. postoperative uses. a few specialized feet actually provide some degree of dynamic "push-off" during late stance. Cosmesis. Too much shock absorption. might fail to generate the normal knee flexion moment when the foot is flat and result in an unacceptable gait pattern.asp[21/03/2013 21:55:48] . the SACH foot has been the traditional foot of choice for children and for the majority of adult patients with transtibial or ankle disarticulation amputations. They are SACH (solid-ankle. Does not provide even suspension through swing phase (the tension of the elastic is proportional to the degree of knee flexion). so joint motion is simulated by the rubber surrounding the keel. The primary purpose of the prosthetic foot is to serve in place of the anatomic foot and ankle. the prosthetic foot should provide the following functions: 1.-While function of the prosthetic foot is of primary concern to the prosthetist. in contrast. These motions are vital to normal energy-efficient gait and are particularly important during ambulation on uneven ground. In addition. http://www. Syme's fittings. The primary way in which a prosthetic foot substitutes for muscle activity is through stance-phase stability (substitution for the plantar flexors). some prosthetic feet allow controlled plantar flexion and dorsiflexion. Ankle dorsiflexion is not available in the SACH foot. the dorsiflexors eccentrically lengthen to prevent foot slap after heel strike. the plantar flexors stabilize the ankle joint and resist the powerful dorsiflexion moment that occurs during these phases of gait. 4. A stable weight-bearing base of support. and the other joints of the foot (in particular. 2. They are available for multiple shoe styles and heel heights. -In the normal human foot and ankle. The SACH foot has no movable components. and cosmesis of the SACH foot make it the single most frequently recommended prosthetic foot. energyefficient gait with a prosthetic foot is therefore largely dependent upon the ability of the foot to compensate for the absence of normal joint function. Neither inversion nor eversion of the ankle is provided. In doing this. 2. external-keel "waterproof' fittings. Shock absorption. PROSTHETIC FEET The prosthetic foot is an important. Although recent innovations in prosthetic foot design may change this. Discomfort of wearing a belt. -In normal human gait. No mediolateral stability is provided by waist belt suspension alone. There are essentially four different designs of prosthetic feet available for use with transtibial prostheses. thus simulating both dorsiflexors and plantar flexors.18B: Prosthetic Management | O&P Virtual Library 1. Forefoot dorsiflexion is simulated by the flexible toe portion distal to the end of the internal keel. The design of a particular foot may enhance or diminish its cosmetic appeal. Through dynamic response principles. SACH Foot The light weight. Plantar flexion is replaced by the compression of the heel wedge.-This is important during stance phase or when the amputee is standing. Each will be discussed in detail. the metatarsophalangeal joints) allow smooth rollover during heel-off and toe-off. the subtalar joint allows inversion and eversion. Muscle simulation.org/alp/chap18-02. The fork strap does not provide any resistance to knee extension. 3. low cost. 5. and flexible-keel-dynamic-response feet. multiaxis feet. Standard SACH Feet Internal-keel SACH feet ( Fig 18B-14. durability. single-axis feet. Other SACH Foot Types The Syme SACH foot ( Fig 18B-16. which makes the postoperative foot very shock absorbent. the rubber portion of the foot is affixed to the keel.asp[21/03/2013 21:55:48] . However. The second determining factor is keel length. the more stable the base of support. The SACH foot has excellent stability due to several determinants. Softer heel cushions produce less resistance to this motion and may diminish the stability of the weight-bearing base in the sagittal plane. is lower in height than the SACH foot in order to accommodate this minimal ground clearance. It is used for exoskeletal prostheses only. wearing temporary. which prevents ankle dorsiflexion. The heel cushion may loose elasticity. 3. This factor is probably more significant for bilateral amputees who lack a sound foot for balance control and proprioception. 4. Since there is no motion in the ankle. 5. and since no shoes are worn. its primary use is on postoperative or temporary prostheses. ) was designed to provide the ankle disarticulation amputee with the advantages of a SACH foot. It is dependent upon the density of the heel cushion and the superincumbent weight of the patient. 4. intermediate. No moving components. The invertors and evertors are simulated to a small degree by compression of the rubber sole.org/alp/chap18-02. Instead. Good shock absorption for moderately active patients. This foot is recommended for a Syme prosthesis when an internal-keel foot will not accommodate a minimal leg length discrepancy. therefore. The heel cushion deteriorates over time. the junction between the foot and shank can be reduced to a barely perceptible line. ) is designed so that the patient can walk without shoes or in slippers. the heel cushion is also reduced and therefore less shock absorbent. The postoperative SACH foot ( Fig 18B-15. Limited plantar flexion and dorsiflexion adjustability. Because the foot height is reduced. Plantar flexor muscle simulation in the SACH foot is accomplished by the presence of the solid keel and ankle. shortening of the leg. In the external-keel SACH foot ( Fig 18B-17. Heavier patients require firmer heel cushions. A longer keel will increase the toe lever arm but may result in excessive hyperextension forces at the knee during late stance. the heel cushion provides resistance when the patient "rocks" backward on the heel. The molded rubber foot and heel are softer. Moderate weight.oandplibrary. Minimal maintenance. External-keel SACH feet are more stable in the coronal plane because of the widened keel. a difference between the materials of the shank and foot is often still visible. The third determining factor is keel width. 3. As the name implies. which absorbs plantar flexion forces during heel strike and foot flat. Good durability. Since an ankle disarticulation in an adult results in only an average I½ in. ) the keel portion is not incorporated within the rubber foot. Use of a keel that is too short will reduce stability and lead to early heel rise and a shortened stance phase on the prosthesis. The wider the keel. This level requires a special design. Disadvantages: 1. Resistance to dorsiflexion in the SACH foot is proportional to the length of the keel. 2. or definitive transtibial prostheses. Cosmesis of the SACH foot is good. The need for optimum cosmesis at the ankle on an exoskeletal prosthesis may also be an indication for an http://www. During standing activities. young and old. It has no heel rise. The SACH foot is indicated for virtually all patients. The standard SACH foot is contraindicated for ankle disarticulation amputees. the space available for the addition of a prosthetic foot is limited. 2. Advantages: 1. Important to note is the thinner heel cushion. The rigid forefoot provides poor shock absorption for high-output activities.18B: Prosthetic Management | O&P Virtual Library Shock absorption at heel strike in the SACH foot is good. the postoperative foot has a wider sole than a standard SACH foot to provide more stability. The Syme foot. The dorsiflexors are simulated by the cushion heel. although an attempt should be made to gain stability through prosthetic alignment first. However. because of its ability to absorb forces in all planes the multiaxis foot reduces torque on the residual limb that might occur on uneven terrain. Although transverse rotation is not truly an anatomic ankle joint motion. the foot may be considered less stable statically. it provides motion in all three planes. Because the foot plantar-flexes after heel strike.18B: Prosthetic Management | O&P Virtual Library external-keel SACH foot. thus dampening knee flexion moments. a rubber plantar flexion bumper. Joint simulation is achieved by the various bumpers. SINGLE-AXIS FOOT The single-axis foot ( Fig 18B-18. but its increased weight and maintenance may overshadow its advantages. with added true simulation of the invertors and evertors through the corresponding rubber bumpers. eversion. It is a good option for patients who traverse frequently over uneven terrain. The foot's wider keel makes it ideal for patients who require added stability. those for which cosmesis is a priority. 3. 4. Less cosmetic." Multiaxis Foot This foot ( Fig 18B-19. Plantar flexion resistance can be varied. a metal singleaxis joint. 2. Cosmesis is comparable to the single-axis type due to the space required between the ankle block and foot. Minimal inversion and eversion occur through the flexibility of the rubber sole. Toe dorsiflexion is simulated by the flexibility of the rubber toe section. which makes it particularly suitable for patients who walk on uneven terrain. a molded foam rubber shell. or those with limited access to prosthetic follow-up. http://www. which is available in multiple durometers. Its components include a solid-wood internal keel. Increased weight. Advantages: 1. and since it is in contact with the ground for a longer period of time. and a dorsiflexion stop. stance-phase stability is excellent. although some amputees prefer the sensation of ankle motion. Tendency to "squeak. Its components include a solid wood internal keel.oandplibrary. and transverse rotation. Ankle plantar flexion and dorsiflexion are provided in a limited way by rotation about the ankle joint. 2. ) provides more ankle motion than any other prosthetic foot. Disadvantages: 1. Because of the many motions it allows. it reduces shear forces transmitted to the residual limb and is an alternative to a rotation unit. The degree of compressibility and rebound of these individual components determines the degree of shock absorption during various gait phases. a molded rubber foot. The single-axis foot offers shock absorption at heel strike through the plantar flexion bumper. ) is available for exoskeletal or endoskeletal prostheses. Muscle simulation is the same as that of the single-axis foot. and a transverse ankle joint that provides inversion. a central rubber rocker block that allows sagittal-plane motion. Relatively high maintenance due to moving components. The plantar flexion capability provides increased knee stability at heel strike and foot flat and may lessen the difficulty of descending inclines.org/alp/chap18-02. The external-keel SACH foot also permits the prosthesis to be made waterproof. Shock absorption is excellent in the multiaxis foot because of the many bumpers. It is not recommended for patients who are weak and debilitated.asp[21/03/2013 21:55:48] . Available for endoskeletal and exoskeletal prostheses. Single-axis feet have specific application in transfem-oral (above-knee) prosthetics and are rarely necessary for transtibial amputees. In addition. and gives some degree of push-off that the rigid keel cannot provide. alignment. the feet allow a more fluid motion. thereby absorbing energy that is released during push-off. Increased maintenance. there is an increase in the dorsiflexion moment. provides a smoother gait.18B: Prosthetic Management | O&P Virtual Library Advantages: 1. 2. Biomechanics of Transtibial Socket Fit The prosthetic socket is the primary connection between the patient's residual limb and the prosthesis. As a patient's cadence increases. This need has promoted research and resulted in a new generation of feet ( Fig 18B-20. ) that aid the more active amputee. which produces a more normal gait. May provide less stability than other feet on smooth surfaces.Dynamic-Response Feet Prosthetic feet are primarily designed for walking. casting. 4. These feet incorporate a shock absorption mechanism in the form of a flexible keel that dissipates energy. Allows motion in all planes. and aids in propelling the patient forward. The successful resolution of these forces can come about only through careful attention during patient evaluation.oandplibrary. this dorsiflexion moment allows the keel to compress or distort. and Fig 18B-21. 3. yet many lower-limb amputees have the desire to be more active and therefore require the use of a prosthetic foot that will allow them increased activity. Disadvantages: 1.org/alp/chap18-02. Increased weight. foot function. Adjustability. and flexible rubber. Through the use of new designs and materials. some bony portions of the residual limb like the distal part of the tibia or the head of the fibula cannot be compressed as much as soft-tissue areas. a socket that simply makes equal contact with the surface area of the residual limb may cause more pressure over bony http://www. These forces are continually changing during both static and dynamic use of the prosthesis. while the amount of time spent on the forefoot increases. Since soft tissues are displaced during axial loading. For example. As such it must provide comfort and function to the patient under the duress of two force systems: the weight of the body due to gravity and the forces applied to the residual limb through contact with the socket. Decreased cosmesis. ). the amount of time spent on the heel decreases. which generally result in a lighter-weight foot. Biomechanical factors in transtibial prosthetics can be divided into four broad categories: socket fit. and socket modification to the following details. and suspension ( Fig 18B-22. polyurethane elastomer. and considerably more forces are exerted on the forefoot. Delrin. 2. Displacement and Pressure Tolerance of Residual-Limb Tissues (Total Contact) In theory. BIOMECHANICAL VARIABLES IN TRANSTIBIAL PROSTHETICS The successful fitting of a transtibial prosthesis requires a thorough understanding of the biomechanical variables involved and the ability to achieve an appropriate compromise between these variables to meet the unique needs of each patient. In actual practice this is complicated by differences in tissue displacement and tissue pressure tolerances.asp[21/03/2013 21:55:48] . Flexible-Keel. Reduces torque on the residual limb. residual-limb/socket pressures could be maximally reduced by ensuring that every square centimeter of the residual limb is in contact with the socket and is sharing an equal portion of the load. 3. Kevlar. Since relatively more time is spent. Some of the materials currently in use include graphite composite. Mediolateral forces occur during single-limb support on the prosthetic side when floor reaction forces may result in varus or valgus forces. and the anterior and posterior compartments. Shear forces can occur in any plane. For example. In contrast. or neuromas. peroneal nerve. The problem is increased when patients have unusually thin skin. Areas within the socket that require relief ( Fig 18B-23. Patients with sensitive skin.asp[21/03/2013 21:55:48] . and lateral stabilizing pressure over the anterior compartment (pretibial muscle group) ( Fig 18B26 ). or gait deviations. scars. the prosthetic socket must accommodate these forces. lateral stabilizing pressure along the shaft of the fibula. therefore. sharp bony prominences. http://www. floor reaction forces produce moments at the joints of the lower limb. Rotation units or "torque absorbers" are another option. lateral tibial flare. Anteroposterior forces are generated from heel strike to foot flat while a powerful knee flexion moment exists.org/alp/chap18-02. These forces can be reduced by a soft. This proximal and distal motion creates shear forces between the residual limb and the socket. As a result. only to be driven back to its correct position during heel contact. must provide even pressure distribution in the popliteal area and anterodistal relief coupled with anterior. Other dynamic forces created within the socket that may present prosthetic problems include torque and shear. Shear occurs whenever the socket moves in a direction opposite to residual-limb motion. hamstring tendons. But distolateral forces can create excessive pressure on the transected end of the fibula. such as diabetic or burn patients. even if pressures are equalized over the surface area of the residual limb. ) are the tibial crest. skin breakdown. and the patella. if a patient's suspension is too loose. ). Similar forces exist during ambulation with a prosthesis. medial tibial shaft.oandplibrary. ) are the patellar ligament. Proprioception and sensory feedback with the prosthesis are increased when the socket is in intimate contact with the residual limb. Knee stability is maintained by contraction of the quadriceps. Socket modifications to prevent this include relief for the distolateral aspect of the fibula. Excessive shear forces result in discomfort or skin breakdown. forces are generally increased over the proximomedial and disto-lateral aspects of the residual limb. Further. other areas of the residual limb such as the medial tibial flare or the patellar ligament can tolerate a great deal of pressure with no pain or skin breakdown. may be especially susceptible to skin breakdown from shear forces. If excessive torque exists. They can be used in transtibial prostheses when the patient uses the prosthesis for activities such as golfing that generate an unusually high amount of torque or to protect fragile skin. tissues are selectively loaded through inward contours over weight-bearing surfaces and reliefs over sensitive areas. With normal foot inset. the socket tends to change its angular relationship with respect to the residual limb. In order to apply greater pressure to pressure-tolerant areas and less to pressure sensitive areas. The socket. The resulting forces between the socket and residual limb are concentrated on the an-terodistal portion of the tibia and posteroproximal soft tissue ( Fig 18B-25. the prosthesis tends to drop away from the limb during swing phase. The major dynamic forces to be considered are anteroposterior and mediolateral forces. distal tibia fibular head. Proximomedial forces are not a significant problem because they are focused upon the pressure-tolerant medial femoral condyle and medial tibial flare. socket insert or a nylon sheath worn directly over the skin. medial tibial flare.18B: Prosthetic Management | O&P Virtual Library anatomy and less pressure over soft tissue. but they are applied through the prosthetic socket to the enclosed residual limb. These forces upon the residual limb must be managed to achieve socket comfort and prevent skin breakdown. Pressure-tolerant areas ( Fig 18B-24. medial. lateral fibular shaft. some bony or sensitive areas may be unable to tolerate these forces. the tendency of the socket to rotate in relation to the residual limb may cause discomfort. Modification for Dynamic Forces In normal human locomotion. Most fitting problems can be accommodated through appropriate socket design. These forces can be reduced if the foot is moved laterally. Biomechanics of Transtibial Prosthetic Alignment This is the second broad category of biomechanical factors in transtibial prosthetics. A certain amount of shear is unavoidable because some motion between the socket and the underlying tissues will always occur. but since foot inset is desirable in most cases. tibial tubercle. and lateral counterpressures to prevent excessive pressure over the distal end of the tibia. This general rule may not apply if the patient exhibits pelvic obliquity. 27. thereby approximating the 5 to 7 degrees of normal anatomic toe-out. if the toe-out attitude of the prosthesis does not match that of the contralateral limb. of course. The toe lever arm diminishes at the toe break but includes the entire length of the foot. Foot rotation can also affect prosthetic function. places the quadriceps muscles "on stretch" to give them a mechanical advantage for control of the prosthesis. However. mediolateral tilting of the socket. congenital leg length discrepancy. There is a cosmetic trade-off. Dynamically it will duplicate the normal genu varum moment at midstance and provide optimum loading of the medial tibial flare during stance phase. This unit allows for anteroposterior foot positioning. decreased energy expenditure. Biomechanics of Prosthetic Feet It is essential to have a thorough understanding of prosthetic foot biomechanics because often foot selection alone can determine the ultimate success or failure of a prosthesis. length of the toe lever arm. During stance phase the tendency of the body to fall over the foot is resisted by the counterforce of this lever arm.2 . The appropriate amount of foot inset is determined for each patient with the understanding that there will always be a trade-off between energy expenditure and torque on the residual limb. This initial alignment results in a slight external rotation of the prosthetic foot. It is necessary to note that optimum foot inset is related to the length and condition of the residual limb. They are alignment (previously discussed). mediolateral foot positioning. Dynamically this will result in a smooth. 27. Proper anteroposterior socket tilt will result in an attitude of initial flexion statically. and fit of the prosthetic foot within the shoe.18B: Prosthetic Management | O&P Virtual Library Alignment refers to the spatial relationship between the prosthetic socket and foot.4 . thus loading those areas that are pressure tolerant.1 . smooth rollover with a limited recurvatum tendency.asp[21/03/2013 21:55:48] . There are six possible variables to be considered when choosing a prosthetic foot. Proper mediolateral foot positioning will result in loading of the proximomedial and distolateral aspects of the residual limb statically. energy-efficient gait pattern. Proper height will result in a smooth and symmetrical gait with no excessive trunk lean to either side. This overall lever arm can be shortened or lengthened by moving the foot http://www. Such cases must be taken individually. Foot inset results in appropriate loading of the medial tibial flare. but decreased torque on the residual limb because the genu varum moment is limited or eliminated.3 . and heel-off prior to initial heel contact on the contralateral foot. Proper anteroposterior foot positioning will result in even weight distribution between the heel and toe portion of the foot statically. The net effect of externally rotating the foot is to increase stability by widening the base of support. 27. Fig 18B-27. The most convenient method to determine the correct height of the prosthesis is through clinical comparison of the iliac crests or the posterior superior iliac spines.5 . 27.6 summarize prosthetic alignment deviations and their causes and gives corrective measures. or unilateral femoral shortening. Dynamically proper flexion not only improves the weight-bearing characteristics of the socket but also allows for a smooth gait pattern. and rotation of the prosthetic foot. this position may need to be altered during static and dynamic alignment so that foot position during ambulation matches that of the sound limb. Proper foot rotation is important both cosmetically and functionally. Prosthetic toe-out refers to the angle between the line of net forward progression and the medial border of the prosthetic foot. and often the best indicator of correct length is through gait analysis and patient comfort. anteroposterior tilting of the socket. flexibility of the keel. A short residual limb may require that foot inset be reduced. a narrow-based gait pattern. including controlled knee flexion after heel strike. durometer of the heel cushion. width of the keel. It also provides for a more cosmetic appearance to the prosthesis. and increased torque on the residual limb due to the normal genu-varum moment at mid-stance. A transtibial prosthesis is initially aligned so that the medial border of the foot is parallel to the line of progression. height adjustment.oandplibrary. increased energy expenditure. Rotation of the foot therefore directly affects the length and the direction of force exerted by the lever arm. Reduced foot inset results in a wide-based gait pattern. and limits recurvatum forces during midstance and terminal stance. A common misconception when discussing foot function is to confuse toe break location with toe lever-arm length. 27. How this occurs may be understood if the keel of the foot is viewed as a lever arm.org/alp/chap18-02. Correct dynamic alignment may be determined by the prosthetist as the patient ambulates on an adjustable alignment unit. lighter patients will generally require mediumor soft-density heel cushions to avoid creating an excessive heel lever arm. that the function of a prosthetic foot can be enhanced or decreased by the shoe within which it is fitted.asp[21/03/2013 21:55:48] . as well as the indications for http://www. a soft crepe heel enhances the shock absorption qualities of a SACH foot. Heavier patients are more likely to require a firm heel cushion to provide sufficient heel leverarm force during loading response. For example. Conversely. Once a prosthesis has been aligned and fabricated. The function of prosthetic feet varies so greatly today that it is important to mention the differences between rigid and flexible keels. The selection of heel cushion density or resistance obviously involves a trade-off between shock absorption and forces acting to flex the knee or rotate the socket upon the residual limb. In contrast. Geriatric patients or household ambulators often require soft heel cushions to limit knee flexion forces and maximize shock absorption. It is essential that shoe heel height match the built-in heel rise of the foot. Shoe heel height is probably the single most important factor of shoe fit as regards prosthetic foot function. When a solid-ankle foot is forced into a tight-fitting shoe. a hardwood or rubber heel will tend to increase the knee flexion moment during loading response. The team should be familiar with socket designs. the ability of the foot to compress and bend during ambulation is diminished.18B: Prosthetic Management | O&P Virtual Library anterior or posterior in relation to the socket. This will ensure that socket alignment in the sagittal plane is not altered and that the keel of the foot maintains the correct position with respect to the floor.oandplibrary. Keel widths are determined by the manufacturers. Women's high heels may compromise stance-phase stability and are not recommended for weak. and shoe fit as related to foot motion. and extends as it operates throughout the gait cycle. It compresses. shoe heel material and shape. Increased heel stiffness results in greater knee flexion forces at heel strike and decreased shock absorption. It should not be surprising. (Some flexible-keel-dynamic-response feet do not have a definite toe break but rather a gradually diminishing resistance from midfoot to the toe tips.org/alp/chap18-02. shanks and feet. PRESCRIPTION OF TRANSTIBIAL PROSTHESES When making decisions about a prosthetic prescription the clinic team must analyze available patient information to formulate a plan for prosthetic treatment. Attention must be given to shoe heel height. then the greater is the probability that the patient will benefit from a softer heel. In comparison. The more susceptible the residual limb is to pain or skin breakdown.) Dynamic alignment is of course still necessary to determine the optimum foot position. the choice must be based upon the patient's needs. Keel flexibility provides for a smoother gait pattern with a less pronounced transition at toe break. lower heel stiffness results in lower knee flexion forces and increased shock absorption. however. The heel cushion absorbs shock and helps initiate knee flexion during loading response. rebounds. The prosthetic foot is designed to function under the stress of ambulation. A wider keel provides greater medial lateral stability during stance phase by widening the base of support. thereby decreasing the knee moment at heel strike. If such heels present a problem. the patient should not significantly increase shoe heel heights unless an appropriate wedge is added inside the shoe. externalkeel feet and the Carbon Copy II have wider keels than other feet do. then. it is appropriate to round or bevel the posterior corner of the heel. is rarely significant enough to be the sole rationale for prescribing these. Very active patients may prefer a firm heel cushion since more rapid cadences increase the net loading on the foot. As in similar prosthetic decisions. To optimize resistance of the forefoot during the late stance phase. The difference. but the position of the toe break in relation to the foot remains constant. suspension systems. the prosthetic foot is designed to fit inside a shoe. flexes. The material and contours of the heel of the shoe can make a significant difference in the way the prosthetic wearer ambulates. With the exception of postoperative feet and those designed for barefoot ambulation. the flexible-keel-dynamic-response foot can be moved anteriorly or slightly plantar-flexed during alignment of the prosthesis. debilitated patients. For example. At times it may be necessary to modify the foot or the shoe configuration to ensure optimum function. It is always better to fit the shoe slightly looser on the foot so that maximum flexibility is achieved. A younger patient tends to be active and therefore usually requires a durable prosthesis that will function for many activities. including the patient. jogging. conditions or complications associated with certain pathologies may influence the choice of components. Flexible-keel-dynamic-response feet are an example of the trend toward meeting the desire of patients to return to a more active life-style. Geographic Location The patient's geographic location may be very important. Date of Amputation When the amputation is recent. may have other concurrent health problems. The prosthetic prescription should represent a consensus between all the members of the health care team. may prefer the cosmesis of an endoskeletal prosthesis with a high-heel SACH foot and sculpted toes. The following factors influence the prescription recommendation. A woman with an amputation may place cosmesis at the top of her list of concerns.org/alp/chap18-02. components that require frequent maintenance are not practical. A patient who is very athletic requires a sturdy. and other sports. If the amputation occurred years ago. In comparison.18B: Prosthetic Management | O&P Virtual Library each. the patient's present physical status may give an idea whether he is progressing normally with the prosthesis or whether some problem or complication may be present. Type of Employment If the patient works outdoors or on uneven terrain. humid climate where perspiration is a chronic problem.oandplibrary. Medical Condition The patient's general health and specific medical condition are major factors to consider in the recommendation for a prosthesis. Previous Prosthesis http://www. Activity Level The patient's activity level affects the components prescribed. An elderly patient will often have a lower activity level. an exoskeletal prosthesis with a multiaxis foot may be appropriate. Age This can only serve to give a general idea about the patient's activity level. leather liners or rubber suspension sleeves may be questionable options since both can create skin or hygiene problems. whereas a male may prefer function even at the expense of cosmesis. on the other hand. If the patient lives in an extremely hot. Sex Again. If the patient lives in a rural community and has difficulty returning for follow-up. the results of any previous prosthetic fittings should be discussed. Transtibial prosthetic components and techniques are available for swimming. it is becoming more common for patients to request a prosthesis designed for sports.asp[21/03/2013 21:55:48] . durable prosthesis. this category can only provide a general guideline based on stereotype. a household ambulator will require a lightweight prosthesis designed for a less-strenuous activity level. Sports As materials and techniques are improved. A businesswoman. skiing. and will generally require a lightweight prosthesis with a protective socket interface. perhaps with specialized components. Although prostheses are not prescribed according to disease categories. Condition of Bony Anatomy A soft liner may be indicated to provide protection to bony prominences. If the patient has a flexion contracture of greater than 25 degrees. If these or other muscle groups are weak. the patient may require physical therapy for strengthening.org/alp/chap18-02. Bone spurs or unbeveled bones that present a fitting problem should be brought to the attention of the physician for possible surgical correction. Subcutaneous Tissue Residual limbs with prominent bones and thin subcutaneous tissue will probably require the added protection of a soft liner in the socket. If this occurs. nonremovable plaster of paris prosthesis to be utilized until the distal circumference of the residual limb has decreased enough to allow donning and doffing of the socket. Skin Problems Skin problems such as blisters. this will probably decrease as the patient uses the prosthesis. A cylindrical residual limb is probably the ideal shape since pressure and stabilizing forces can be applied evenly. Allergic skin reactions caused by materials can be remedied by choosing an alternate material. Distal Padding If distal coverage is thin.asp[21/03/2013 21:55:48] . Because of their inherent protective padding. a new distal pad must be fabricated to restore total contact. a minimum of 35 degrees of knee flexion is necessary for normal ambulation.18B: Prosthetic Management | O&P Virtual Library In many cases the patient will already be wearing a prosthesis and should be asked what he likes or dislikes about the present prosthesis. Often. If ligament laxity is present.oandplibrary. One solution is a temporary. has a larger circumference distally than proximally. residual limbs with heavy subcutaneous tissue can often be fitted with hard sockets and a distal end pad. which is often present shortly after amputation. the patient will be unable to don or doff the prosthetic socket. controlled gait. Residual Limb Shape This helps identify potential fitting problems. Patient Goals The patient's personal goals should be taken into consideration and prosthetic design tailored to those goals whenever possible. and the limb may actually lose contact with the distal pad in the socket. If the difference between circumferences is large enough. cysts. Range of Motion The patient should ideally be able to achieve full knee extension and flexion. A bulbous residual limb. If distal soft tissue is very heavy. and abrasions usually occur as a result of an ill-fitting prosthesis and can generally be resolved by socket or alignment modifications or by a new prosthesis. Condition of the Thigh Musculature In transtibial prosthetics the quadriceps are probably the most important muscles for a smooth. ulcerations. verrucose hyperplasia. A conical residual limb is characteristic of a long-term prosthetic wearer and should not present a fitting problem. Condition of the Knee Joint The stability of the knee joint is very important to the prosthetic prescription. If an extension contracture is present. supracondylar or joint and corset suspension is recommended. an awareness of problems with the old prosthesis can help avoid difficulties with the new prosthesis. the length of the socket and the fit of the distal pad are of critical importance. prosthetic http://www. Presently the data collection methods include digitized passive plaster impressions. Burgess EM: Amputation surgery and postoperative care. 65:1493-1497. BIBLIOGRAPHY Abrahamson MA. This results in a qualitative evaluation of socket fit rather than a more objective quantitative evaluation. Orthot Prosthet 1983.F. Charles C http://www. et al: Prescription options for below knee amputees. Each of these methods provides residual-limb topography from which residual-limb changes can be monitored and documented. it is now evident that CAD will become a very useful tool for the prosthetist-orthotist. Baltimore. as the technology has evolved. Campbell JW.E. Williams & Wilkins.org/alp/chap18-02. Transtibial prostheses of today are designed and fabricated by using subjective techniques that can be difficult to teach and reproduce. 13:25-32. Childs CW: The S. A clearer understanding of what constitutes a well-fitting socket could have a profound effect on prosthetic practice. Burgess EM.S. Matsen FA. a well-fitting socket is difficult to produce and analyze.asp[21/03/2013 21:55:48] . St Louis. an optical shape sensor that rotates about the limb to collect data points of the high-contrast silhouette. COMPUTER-AIDED MANUFACTURE Computer-aided design-computer-aided manufacture (CAD-CAM) is beginning to play a role in the practice of prosthetics and orthotics. Government Printing Office. Effney DJ. Zettl JH: The Management of Lower Extremity Amputations. the data are then sent to a numerically controlled milling machine where a positive model is carved from a plaster blank. Data collected by computers could be used to create a data base from which ideal socket shapes might be developed. Contractures that cannot be reduced will have to be accommodated in the prosthesis. and molded plaster impressions to gain data regarding residual-limb size and shape. Orthopedics 1985. and experimental use of ultrasound to gain information regarding a patient's residual limb. COMPUTER-AIDED DESIGN. 111. Orthot Prosthet 1980. and a new socket is fabricated by incorporating the changes. it is hoped that the time and effort of the prosthetist can be greatly reduced. Without quantitative information. The traditional process is also time-consuming because of the trial-and-error method that even the most experienced prosthetist must use. Burgess EM. Friedmann. National Academy of Sciences.A. foot. Burgess EM. U. Mosby-Year Book. in Bonjeree SN (ed): Rehabilitation Management of Amputees. palpation. et al: The Seattle prosthetic foot-A design for active sports: Preliminary studies. Skinner HB. 1982. DC. 1971. the patient may be referred for physical therapy. Once the desired shape is complete. 8:210-225. When contractures exist. Hittenberger DA.18B: Prosthetic Management | O&P Virtual Library fitting will be difficult. Once the data are stored in the computer. 1981. Springfield. Washington. Forsgren SM. If the patient should require socket modifications. Software packages offer a variety of features with which to manipulate shapes. Committee on Prosthetic-Orthotic Education: The Geriatric Amputee Principles of Management. they are made on the electronic model. III: Current concepts: Vascular disease. This method of data gathering and documentation can potentially be applied to most levels of amputation as well as to many limbs requiring orthotic care. The traditional methods are labor intensive and use calipered measurements. From this point traditional fabrication and fitting techniques are utilized. Although early CAD systems were greeted with some skepticism. Washington. LW: The Surgical Rehabilitation of the Amputee. laser shape sensing.oandplibrary. Atlas of Limb Prosthetics: Surgical and Prosthetic Principles. As more accurate methods of data collection are developed through CAD. / Bone Joint Surg [Am] 1981. 1969. 34:3-17. DC. the prosthetist makes modifications to the threedimensional image on screen. Orthot Prosthet 1986. in Atlas of Limb Prosthetics.C. Middleton L. 1983. interim prosthesis for below knee amputees. Gerhardt JJ. McBride E. Bern.Atlas of Limb Prosthetics: Surgical. Lower Limb Prosthetics. McCollough NC III. Temple University. 1981. 1981. Stills M: Manual for Ultralight Below Knee Prosthetics. Andrews BG. et al: Comparison of postoperative stump management: Plaster versus soft dressings. 1982 revision. et al: Scotchcast P. New York. 1982. p 18. in Fisher SV. Harris AR. 58:365-368.18B: Prosthetic Management | O&P Virtual Library Thomas Publishers. Bull Prosthet Res 1981. Balliere Tindall. Staats TB: Advanced prosthetics techniques for below knee amputees. Rehabilitation Engineering Center. 1981. Prosthetic. Mensch G. Mooney V. Kostuik JP: Amputation Surgery and Rehabilitation: The Toronto Experience.V. New York University Medical Center. J Bone Joint Surg [Am] 1979. Lower Limb Prosthetics Including Prosthetists Supplement. Harvey JP Jr.asp[21/03/2013 21:55:48] . et al: An innovative removable rigid dressing technique for belowthe knee amputation. 33:1-19. Staros A. Gonzalez E. 1982 revision. 3:58-63. Krick HJ. Williams & Wilkins. 40:17-23. St Louis. New York. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 18B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Churchill Livingston Inc. Mier RH III: Amputations and prosthetic fitting. Pritham C: Suspension of the below knee prosthesis: An overview. Mosby-Year Book. Pritham C. St Louis. Weiss J. Switzerland. Orthopedics 1985. Robert K Krieger Publishing Co Inc. Brncick MD. Williams & Wilkins. et al: Amputations and Prostheses. Zettl JH: Amputations: Immediate and Early Prosthetic Management. 40-45. Orthot Prosthet 1983. 1982. Ellis P: Physical therapeutic management of lower extremity amputees. 8:210-225.org/alp/chap18-02. London. Contact Us | Contribute http://www. Hittenberger DA: The Seattle Foot. Krick HJ. King PS. Selected articles from Artificial Limbs January 1954 to Spring 1966. Chapter 18B . J Bone Joint Surg [Am] 1976. 1978. 1982. Warner H Green Inc. 1978. Keagy RD. Mosby-Year Book. in Bonjeree SN (ed): Rehabilitation Management of Amputees. St Louis. Robinson K. Levy WS: Skin Problems of the Amputee. Baltimore. 6:724-729. 10:36. Philadelphia. Wu Y. Moss Rehabilitation Hospital. Hans Huber Publishers. 1970. New York University Post-Graduate Medical School. pp 227-314. Orthot Prosthet 1979. 1982. in Atlas of Limb Prosthetics. Baltimore.oandplibrary. Wilson BA Jr. Vitali M. 1984. 1977. Helm PA (eds): Comprehensive Rehabilitation of Burns. Hampton FL: Below knee amputation. et al: The thigh corset: Its effect on the quadriceps muscle and its role in prosthetic suspension. Goralink B: Lower limb prosthetic systems. Wu Y. The retained femur tends to grow at a slower rate than the contralateral femur. (4) decreased surgical blood loss and. Knee disarticulation maintains femoral length in growing children by preserving the growth potential of the distal femoral epiphysis.Atlas of Limb Prosthetics: Surgical.asp[21/03/2013 21:55:54] . 1992. You can help expand the O&P Virtual Library with a tax-deductible contribution. Click for more information about this text. somewhat unstable.A and B). and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). so these patients rarely develop early or late hip joint contracture. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists USE IN THE NONWALKER Nonwalking patients often develop knee flexion contractures following transtibial (below-knee) amputation or hip flexion-abduction contractures following transfemoral amputation due to muscle imbalance. Prosthetic. ©American Academy or Orthopedic Surgeons. and often damage overlying clothing. IL.D.oandplibrary. knee disarticulation (through-knee amputation) has the potential benefits of (1) durable end weight bearing (direct load transfer). Knee flexion contracture may lead to distal stump ulcers in the transtibial amputee ( Fig 19A-1. Prosthetic. (5) resistance to infection by maintaining the cartilage barrier to infection. powerful. If a standard transfemoral (above-knee) prosthetic knee joint is used in a knee disarticulation prosthesis. edition 2.). This amputation level is infrequently used in adults for both cosmetic and functional reasons. The residual limb is perceived to be unsightly due to its length and distal bulbousness. A large surface area for weight bearing and balance while sitting and for turning in bed is provided as well as a long lever arm for transfers ( Fig 19A-3.. its knee center will be far distal to that of the contralateral normal knee center. It also avoids the risk of appo-sitional bony overgrowth inherent in pediatric transosseous amputation. The residual limb in the knee disarticulation amputee is muscle balanced. Development of the polycentric prosthetic knee joint has allowed the prosthetic knee joint center to approach that of the normal knee. eventually allowing the prosthetic knee joint center to approach the same level as the normal knee. weightbearing platform comfortably allows direct load transfer. muscle-stabilized femoral lever arm.org/alp/chap19-01. Prosthetic.).19A: Surgical Procedures | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 19A Chapter 19A . Reproduced with permission from Bowker HK. and Rehabilitation Principles. American Academy of Orthopedic Surgeons. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. This may be limited with some techniques for knee disarticulation in which the soft-tissue envelope covering the femoral condyles and interfacing with the prosthetic socket consists only of skin. The knee disarticulation technique described by Wagner provides a softtissue envelope over the femoral condyles that is composed of a mobile nonadherent gastrocnemius muscle flap and full-thickness skin. External knee hinges improve sitting cosmesis somewhat but are cumbersome. M. nonsalvageable trauma. This cushioned. (2) retention of a long. and Rehabilitation Principles Knee Disarticulation: Surgical Procedures Michael S. unsightly. Rosemont. shear-absorbing. (3) ease of prosthetic socket suspension due to the bulbous end. The residual limb of the transfemoral amputee with hip joint contracture provides only a small posterior thigh platform for sitting and a short lever arm for transfer ( Fig 19A-2. Its use in growing children has generally been confined to the treatment of congenital anomalies. malignant tumors. PROSTHETIC CONSIDERATIONS FOR THE POTENTIAL WALKER The active walker should benefit from the direct load transfer possible following knee disarticulation. reprinted 2002. Pinzur. When compared with transfemoral amputation. or infection. thereby smoothing out the gait pattern and making the procedure a more reasonable option in adults. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. which is preferable to the http://www. The weight-bearing capacity of the distal end of the femur allows fabrication of a prosthetic socket with direct load transfer. asp[21/03/2013 21:55:54] . The distal portion of the femur can be narrowed and/or shortened to cosmetically decrease the bulbous end. load transfer. USE IN THE TRAUMA OR INFECTION PATIENT Push-off at the terminal stance phase of gait is accomplished by advancement of the limb against a stable foot and ankle. nonresilient skin due to pistoning and shearing within the transtibial socket is minimized in knee disarticulation because an intimate total-contact prosthetic socket fit is not essential when the end bearing of direct load transfer is utilized. Hip flexion contractures can frequently be corrected by having the patient lie prone for periods sufficient to stretch out the deformity. but at the expense of decreased surface area and increased pressure concentration for weight bearing. and muscle contractility with electrical stimulation. but when the contracture approaches 50 degrees. these patients may be better served by provision of an adequate soft-tissue envelope at the knee disarticulation level ( Fig 19A-4. Patients amputated at the level of the tibial tuberosity with retention of the patellar tendon insertion retain a functional knee joint and transtibial amputee gait. Prosthetic accommodation of a hip flexion contracture also becomes difficult when that contracture exceeds 30 degrees. This should generally be reserved for young trauma patients and avoided in dys-vascular patients where the added dissection may well compromise surgical wound healing. The risk seen in severely dysvascular transtibial amputees for the development of pressure ulcers in weightbearing areas with tenuous. the residual limb has a bulbous distal shape. When a knee flexion contracture approaches 50 degrees. Small knee flexion contractures can sometimes be improved following prosthetic limb fitting.. Viability of remaining tissue in the dysvascular patient is determined by preoperative vascular testing and intraoperatively by muscle color and consistency. which require intimate prosthetic socket fit. Transtibial amputation should be performed when the following structures can be retained: (1) a serviceable joint with no more than a 25degree loss of full extension. If these problems cannot be overcome by plastic revision of the residual limb or by use of a weight-bearing thigh corset." and the patient will stumble or fall unless he can accomodate by forceful quadriceps contraction. every effort should be made to retain the forward propulsive capacity of the knee joint and proximal end of the tibia.oandplibrary. It is unusual to see a patient with the vascular capacity to heal a surgical wound at the knee disarticulation level not be able to heal at the high transtibial level. In patients with nonsalvageable lower limbs secondary to trauma or infection. (2) the proximal end of the tibia including the patellar tendon attachment. A transtibial amputation without an adequate soft-tissue envelope in an active post-traumatic patient will often lead to continued skin breakdown and residual-limb discomfort. When this happens. as in renal failure) are also better tolerated than in surgical levels. Surgical correction is rarely indicated. skin and muscle bleeding. (3) an adequate soft-tissue envelope of mobile muscle to cover the end of the tibia and. Increased hip flexion at initial floor contact (heel strike) causes the dynamic weight-bearing line (hip-knee-ankle axis) to fall posterior to the knee center. knee joint excursion and hence forward propulsion following transtibial amputation will not be adequate to make functional use of the quadriceps-tibia lever arm due to the greatly increased energy cost of flexed-knee gait. (4) full-thickness skin in areas of load transfer. The metabolic cost of walking with knee disarticulation is less than with transfemoral amputation but somewhat greater than with transtibial amputation due to the walking propulsion provided by the quadriceps-tibia lever arm. Residual-limb volume fluctuations (e.org/alp/chap19-01.). SURGICAL PROCEDURES Soft-Tissue Envelope http://www. Wagner's technique allows retention of the entire expanded surface area of the distal portion While this provides an excellent method of of the femur to efficiently dissipate pressure. the knee will "buckle.19A: Surgical Procedures | O&P Virtual Library unphysiologic unloading of the terminal part of the residual limb and indirect load transfer of transfemoral and transtibial amputations. USE IN THE DYSVASCULAR PATIENT Viable tissue to provide an adequate soft-tissue envelope is the first consideration. the patient may be better served with knee disarticulation.g. B). allows the patient to be operated upon in the supine position under regional anesthesia. The knee joint capsule is incised circumferentially at the level of the joint. The an-teromedial portion of the retinaculum is sutured to the posterior part of the capsule and semimembranosus.. The cruciate ligaments are severed from their attachment on the tibia. The patellar tendon and biceps femoris are sutured to the stumps of the cruciate ligaments. A soft compression or rigid plaster or fiberglass dressing is applied. the operation must be performed with the patient in the prone position. The capsule and ligaments are incised circumferentially at the joint level. Sagittal Flaps Knee disarticulation. and an appropriate dressing is applied ( Fig 19A-9.). The skived patellar ligament is sutured to the stumps of the cruciate ligaments. http://www.3 cm (½ in. Most late breakdowns in residual limbs. and biceps femoris muscles are divided at a level leaving adequate length for suturing to the patellar tendon without undue tension. To minimize late tissue breakdown. and the knee joint capsule is incised circumferentially. with the patellar tendon and pes anserinus elevated before the knee joint is entered. Anterior and Posterior Skin Flaps The incision for the anterior flap begins posteromedially just proximal to the joint line and extends convexly. This technique is well suited to the dysvascular patient since the skin flaps. and distally to a point approximately 2. The gastrocnemius is removed from its origin on the femur. anteriorly. The skin is reapproximated and an appropriate dressing applied ( Fig 19A-8. The menisci can be removed because their shock-absorbing function will be replaced by the gastrocnemius muscle flap.A).). The suture line assumes a midline posterior position between the femoral condyles.asp[21/03/2013 21:55:54] .). In this case. the origins of the gastrocnemius from the femur. and the skin is reapproximated ( Fig 19A-7. are due to tissue shear. the incision is carried down to bone. as advocated by Wagner and others. being equal. the surgical scar lies posteriorly. The posterior flap is also convex but somewhat shorter than the anterior flap. The vascular bundle components are ligated at this level..A). The patellar ligament is incised at its insertion. semitendinosus.. The gastrocnemius is retained to provide a cushioned soft-tissue envelope that will allow comfortable direct load transfer.) distal to the tibial tuberosity. and a circumferential skin incision is performed approximately 1. between the femoral condyles ( Fig 19A6. On closure. the posterior junction is placed more distally to achieve equal sagittal flaps.19A: Surgical Procedures | O&P Virtual Library The soft-tissue envelope is the interface between the hard prosthetic socket and the hard bone of the residual limb. The vascular bundle is ligated at the joint level. nonadherent muscle mass and full-thickness skin in the areas of load transfer ( Fig 19A-5.5 cm distal to the tibial tuberosity. and the cruciate ligaments are skived from their attachments on the tibia. The knee is flexed to 90 degrees. The gastrocnemius is divided distally to form a flap long enough to allow gastrocnemius myofascia to be sutured to the remaining knee joint capsule. not direct pressure. Circumferential Incision The main value of this technique is that no flaps are produced.org/alp/chap19-01. The ili-otibial band and pes anserinus are sutured to the remaining anterior retinaculum.. The posterior fascia of the gastrocnemius is then sutured to the remaining knee joint capsule. the soft-tissue envelope should be formed with a mobile.B). Anteriorly and medially. and the sciatic nerve is severed proximally. and the tibial and peroneal nerves are transected proximally and allowed to retract. each have minimal length ( Fig 19A6. with care taken to ensure that the distal pole of the patella does not extend distally into the weight-bearing plane of the knee joint ( Fig 19A-7. and the biceps femoris from the fibular head. however. It then curves proximally and posterolaterally to end just proximal to the joint line. however. Each flap is mobilized proximal to the knee joint.oandplibrary. The semimembranosus. The skin is closed longitudinally. The cruciate ligaments are skived from the tibia. The patellar ligament is isolated and skived off the tibial tubercle. Sagittal skin flaps equal in length to half of the transverse diameter of the limb at the midpatellar tendon level are created with their anterior junction midway between the distal pole of the patella and the tibial tuberosity and the posterior junction directly opposite unless the knee has a major flexion contracture. Greene MP: Four bar linkage knee analysis. Any of the described surgical approaches can be modified to incorporate these options. Clin Orthop 1985. knee disarticulation has the added advantages of preservation of distal femoral growth potential and the elimination of appositional bony overgrowth. References: 1. This restores useful proprioception as well as the ability to take advantage of the intrinsically stable. Burgess advocates shortening the femur by removing the distal portion of the condyles in order to keep the knee centers level ( Fig 19A-10. 69:1155-1160. in press. Burgess EM: Disarticulation of the knee. Williams & Wilkins. nonadherent cushion fashioned from the gastrocnemius muscle belly. Wagner FW: A classification and treatment program for diabetic. A new technique and a new knee-joint mechanism. 2. By maintaining the expanded metaphyseal region of the distal end of the femur. Pinzur MS. 00:000. Chapter 19A . Epps CH Jr. simply by trimming the medial. neuropathic. so auxiliary suspension might be required. Weight bearing and shear stress dissipation are enhanced when the distal end of the femur is covered with a mobile. Rogers SP: Amputation of the knee joint.Atlas of Limb Prosthetics: Surgical. 12. Schopler S. This is accomplished at the cost of decreased suspension from the expanded femoral condyles. J Bone Joint Surg [Am] 1989. SUMMARY Knee disarticulation allows the direct transfer of body weight from the end of the residual femur to the prosthesis. 194:87-92. lateral.org/alp/chap19-01. should generally be reserved for traumatic and tumor patients with normal vasculature in whom the extra surgical dissection will not compromise wound healing. J Bone Joint Surg [Am] 1988. Orthopedics 1992. knee disarticulation rather than transfemoral amputation is recommended for the reasons mentioned above. 10. 112:1250-1255. ). et al: The knee in arthrogryposis.19A: Surgical Procedures | O&P Virtual Library Reduction Osteoplasty Reduction osteoplasty decreases the bulk of the distal end of the residual limb to permit fabrication of a more cosmetic prosthetic socket. McCollough NC III: The dysvascular amputee: Surgery and rehabilitation. Daluga DJ. 71:273-277. In these cases. Inman VT. 1981. 9. J Bone Joint Surg 1940. J Bone Joint Surg [Am] 1987. In addition.oandplibrary. Loder RT. 5. Long-term results. 6. Ralston HJ. Smith DG. In children. The distal articular surface can be retained. 4. direct load transfer can still be accomplished. 48:126-139. Schneider PL: Treatment of hemimelias of the lower extremity. 28:143-165. poly-centric four-bar-linkage prosthetic knee joint. Arch Surg 1977. Gold J. In-str Course Lect 1979. Mazet R. 11. A functional assessment. and dysvascular foot problems. Prosthetic. In adults. Thomas B. Orthot Pros-thet 1983. Another relative indication for knee disarticulation is in patients with large residuallimb volume fluctuations as seen in severe renal failure or congestive heart failure. 8. Todd F: In Human Walking. however.asp[21/03/2013 21:55:54] . Herring JA: Disarticulation of the knee in children. Schwartz D. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 19A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Baltimore. Wood W. Contact Us | Contribute http://www. 37:15-24. as advocated by Mazet and Hennessy. et al: Selection of patients for through-the-knee amputation. it is primarily used for patients with peripheral vascular disease who have the biological capacity for healing an amputation wound at the transtibial level but will be unable to functionally utilize a prosthesis. 22:973-979. 3. et al: Energy demands for walking in dysvascular amputees as related to the level of amputation. 70:746-750. Pinzur MS. Reduction osteoplasty. traumatic transtibial amputees left with an inadequate soft-tissue envelope or with a nonfunctional tibial segment due to severe loss of knee mobility or knee motor strength will not be able to utilize the transtibial level. 7. Curr Probl Surg 1971. and posterior protruberances. A modified technique. J Bone Joint Surg [Am] 1966. Hennessy CA: Knee disarticulation. These include the use of an inflated air splint (with or without a walking Unna's paste semirigid dressing. Prosthetic. such as those in and Toronto. during ambulation the femur will remain stationary while the proximal socket borders will press against the soft tissues of the upper part of the thigh ( Fig 19B-2. ©American Academy or Orthopedic Surgeons. Prosthetic.oandplibrary. and because of lack of experience with the procedure. edition 2. which has apparently changed very little over the intervening 38 years: "Disarticulation at the knee joint has been periodically extolled as the procedure of choice over amputation through the thigh.P. and Rehabilitation Principles Knee Disarticulation: Prosthetic Management John W.asp[21/03/2013 21:55:59] . Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. the center of rotation for the transfemoral socket is located near the ischium." Reproduced with permission from Bowker HK. Rosemont. Prosthetic.A).Atlas of Limb Prosthetics: Surgical. however. This may have more to do with the unfa-miliarity of this level of amputation to both prosthetist and surgeon than any other factor. As is the case in all end weight-bearing amputation stumps (e. but the procedure has not been generally accepted because of the belief that the stump is unsightly and that the prosthesis is difficult to fit. and a novel polyurethane foam apparatus over it). Click for more information about this text. knee disarticulation can be managed by the same range of techniques as more familiar amputations. 1992. the principles of knee disarticulation biomechanics are less commonly understood.19B: Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 19B Chapter 19B . BIOMECHANICS Although the biomechanics of the transfemoral (above-knee) amputation are well known. This latter technique (Neofract) incorporates a full-length zipper for easy dressing removal. there is no need for any proximal weight bearing.). POSTOPERATIVE MANAGEMENT Although immediate postoperative fitting with a prosthesis is technically feasible. C. In contrast. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. American Academy of Orthopedic Surgeons.. However.. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. While immediate ambulation on a plaster of paris socket is seldom advocated for the dys-vascular individual today.Ed.. gradually increases to about 20% in centers that advocate this level. dressing that is formed directly over the residual limb between layers of stockinette. Successful knee disarticulation surgery is predicated on the ability to comfortably tolerate full end weight bearing on the residual limb. Once this is accomplished. The basic problem at midstance is similar: to stabilize the superincumbent body mass during single-limb support on the prosthesis ( Fig 19B-1. the Syme level). Those who advocate such a rigid dressing believe that it enhances wound healing and facilitates rehabilitation. preferably applied by the surgeon in the operating theater.O. it is rarely provided today. the effective center of rotation in the socket is at the distal-most aspect. so http://www. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Knee disarticulation is an uncommon level for amputation in North America and hence is seldom encountered by the physician or prosthetist. Michael. reprinted 2002. Convincing arguments and statistics have been presented to support this view. IL. M. and ischial contact is superfluous. Thus.g. are significantly different from those at the transfemoral level. The resultant socket stresses. some opt to use the postoperative plaster cast alone. Copenhagen Batch and colleagues began their 1954 paper with a statement that aptly summarizes the contemporary situation. Soft gauze dressings followed by elastic bandaging once the wound has healed is probably the most common approach.org/alp/chap19-02. Most demographic surveys suggest that the frequency of knee disarticulation in the United States is between 1% and 2% of all major The incidence appears to be similar in many other countries but lower-limb amputations. and Rehabilitation Principles. they are only rarely encountered. it can be easily adapted to modern developed for molded leather sockets flexible plastics.19B: Prosthetic Management | O&P Virtual Library ambulation causes rotary forces at the distal part of the socket ( Fig 19B-2. such differential growth is not inevitable.. In the knee disarticulation socket with end weight bearing. There are two primary approaches to taking the plaster of paris cast impression for knee http://www.). SOCKET VARIATIONS A number of socket variations are possible and differ primarily in their adjustability and cosmetic appearance. This is especially true for the initial fitting when postoperative edema may be present. ). One approach is to fashion a removable plate that permits the bony condyles to pass during donning but locks them securely in place when fastened with a Velcro closure Fig 19B-3. This would obviate the prosthetic problems of limited cosmesis and restricted choice of knee mechanisms that are inherent in knee disarticulation. In many respects the knee disarticulation socket is the inverse of the transfemoral type: the distal portion supplies precise weight bearing. while the proximal aspect provides prosthetic stability. the prosthetist will encounter a significant percentage of pediatric cases. When combined with a socket that is rigid distally but gradually changes to flexible at the proximal edges. The biomechanics of prosthetic knee function are directly analogous to transfemoral principles: the amputee must use hip musculature to compensate for the loss of active knee control.). marked This ultimately improves cosmesis for fleshy individuals distal atrophy occurs over time. This socket where flexible inner walls barely allow the condyles to pass approach may also be feasible when the condyles have been surgically trimmed. it may be extremely difficult to secure adequate supracondylar suspension. Because the polyethylene success even with geriatric and bilateral amputees foam inner liner can be readily adjusted to maintain snug pressure over the condyles.). Botta of Switzerland is With two decades of one of the leading prosthetic advocates of knee disarticulation fittings.). any socket materials. Since the transfemoral socket is primarily pelvic bearing. this version is termed the The majority of the thigh is not covered by Icelandic Push-on Suction Socket (ICEPOSS). Weiner has reported three cases where the femurs remained identical in length (even though amputation occurred as early as 1 year of age) and suggested epiphysiodesis just prior to the end of growth.). Although originally ( Fig 19B-7.B). it is easier for the knee disarticulate to control the prosthetic knee mechanism than if he were a transfemoral amputee. he reports good ( Fig 19B-9. Because such sockets are extremely difficult to fit and allow no adjustments. Since knee disarticulation in children preserves the distal femoral growth plate and eliminates the risk of bony overgrowth. It is generally assumed that the affected femur will not grow as rapidly as the uninvolved one and therefore by adulthood the residual limb will retain all the positive aspects such as full end bearing and self-suspension but will terminate far enough above the anatomic knee center to present as a very long transfemoral amputation.oandplibrary. the femur is effectively stabilized by body weight. Zettl has described a segmental socket design with independently adjustable proximal and distal portions to accommodate linear growth in ( Fig 19B-5.asp[21/03/2013 21:55:59] . It should be noted that particularly for obese or muscular individuals. Because the center of rotation is just above the knee mechanism and because the bony lever arm is full length with undisturbed musculature. In such cases. an adjustable circumferential band is attached to a medial strut to provide stability ( Fig 19B-11. ). experience involving several hundred cases. Despite being somewhat cumbersome to don and doff. since the residual limb dimensions become smaller than the uninvolved thigh ( Fig 19B-10. he advocates a carefully molded distal liner to protect the condyles and provide suspension ( Fig 19B-8. Suspension is achieved by adjustable supracondylar straps immature condyles are not very bulky. Since the patient pushes his condyles into the suspension cup to don the prosthesis. it is sometimes possible to create a self-suspending ( Fig 19B-6. However. Because children.). Another socket option for this level is the traditional anterior lacing design.org/alp/chap19-02.). Kristinsson of Iceland has reported success with a variation using a flexible rubber cup that terminates just above the condyles to provide suction suspension. it has the advantage of accommodating moderate volume fluctuations in the residual limb. the femur is relatively unconstrained and tends to displace within the soft tissue distally. ( Fig it may be necessary to augment suspension with suction or a Silesian belt variant 19B-4. Suspension in the knee disarticulation socket is ideally provided by intimate fitting just proximal to the condyles. ).oandplibrary. Some are available in lightweight versions of carbon fiber or titanium. In addition. particularly for geriatric individuals. ). With the widespread availability of polycentric mechanisms. Because these hinges transmit weight-bearing forces in the knee disarticulation socket (in contrast to their orthotic application). such mechanisms are very stable ( Fig 19B-15. nor could they meet the functional demands of the young active amputee. As a recent text notes. this is a significant disadvantage. it results in a decidedly bizarre appearance that most find objectionable. they protrude as much as 2 in. beyond the anatomic knee center. Modifications for both approaches are similar and consist primarily of establishing the supracondylar contours necessary for suspension and altering the proximal thigh region to provide stability during stance phase. a somewhat wider mediolateral dimension is the inevitable result ( Fig 19B-13. One manufacturer provides a yoke attachment permitting use of a fluid( Fig 19B-12. function of four-bar polycentric knees through geometric analysis. ). ). thus minimizing the ( Fig 19B-17. It is available with either mechanical swing-phase protrusion of the knee friction control or hydraulic swing-phase control to allow a varying cadence for more active individuals ( Fig 19B-18. the four-bar knee point of rotation of the knee mechanism behaves as if it were a single-axis knee articulated at the instantaneous center of rotation. ). the only available knee alternative was external hinges similar to those used on knee-ankle-foot orthoses. Although this causes no significant gait deviations. The only other available alternative for knee disarticulation is the polycentric knee. ). the locus of rotation of the four-bar polycentric knee changes with the flexion angle ( Fig 19B-16. The intersection of the anterior and posterior knee links define the instantaneous center of rotation: the effective ( Fig 19B-14. The first polycentric knee designed for knee disarticulation applications was developed at the Orthopedic Hospital Copenhagan (OHC) in 1969. Like the human knee. This technique is difficult for some geriatric or bilateral amputees to manage. manual locking is only rarely necessary. COMPONENTRY Despite its functional advantages. ). As he notes. Relief is usually provided for the lateral posterior femoral condyle. At heel strike. Lyquist suggests a weight-bearing procedure by placing a foam pad beneath the cast while the plaster is wet to form the transcondylar contours. when used for knee disarticulation. Since disarticulation retains full femoral leverage and thigh musculature. Because the instantaneous center is both proximal and posterior to the anatomic knee center. "Until about fifteen years ago none of the prosthetic knee mechanisms available could meet even reasonable cosmetic requirements.asp[21/03/2013 21:55:59] . It also makes sitting in confined spaces such as automobile and theater seats difficult since the thigh segment juts out so far. Several European and Asian manufacturers have developed similar polycentric designs during the past decade. but durability remains a concern Although external hinges result in the least possible protrusion of the thigh segment when sitting. Botta and Baumgartner advocate a non-weight-bearing method with the amputee supine and stress meticulous hand molding of the femoral condyles. Greene has published an excellent paper discussing the four-bar class of poly-centric mechanisms. it is possible to analyze the including those designed for knee disarticulation. The second is that the shin automatically decelerates late in stance phase as the instantaneous center of rotation moves proximally back to its original location. Most knee disarticulation sockets are laminated of reinforced plastic resins." Most available knee units are designed for transfemoral amputation. Locking modules are also available for those who unable to manage a free knee ( Fig 19B19.org/alp/chap19-02.19B: Prosthetic Management | O&P Virtual Library disarticulation sockets. lack of durability has been a chronic problem. Many find the bulky appearance objectionable despite specialized finishing techniques to minimize the discrepancy. external hinges offer no swing-phase control. From the time knee disarticulation was first reported by Fabricius Hildanus in 1581 until the early 1970s. but thermoplastic materials are also being used successfully. Due to the inherent stability of polycentric knees. controlled cylinder with these hinges. Careful design of the linkage arms results in a mechanism that appears to fold back under the thigh when sitting. ). This has two major effects on amputee gait. Their technique is applicable to geriatric as well as other knee disarticulation amputees. the cosmetic liability of knee http://www. knee disarticulation significantly restricts amputees' options in prosthetic knee mechanisms and results in cosmetic compromises in addition to reduced durability when compared with transfemoral levels. One is that the effective length of the shin shortens with increasing knee flexion. Batch JW. Prosthet Orthot Int 1983. Eaton WR: Knee disarticulation treated as above-knee amputation. J Bone Joint Surg [Am] 1954. 7:96-99. Prosthet Orthot Int 1983. it has strong proponents in many quarters. Glattly HW: A statistical study of 12. Cummings GS. Baumgartner RF: Knee disarticulation versus above-knee amputation. Ann Arbor. 10. American Academy of Orthopedic Surgeons. Goel MK. Donaldson WF: Knee disarticulation in childhood. 29:3-16. Ghiulamila RI: Semi-rigid dressing for postoperative fitting of below-knee prosthesis.asp[21/03/2013 21:55:59] . Kay HW.S. Greene MP: Four bar linkage knee analysis. 21. LeBlanc MA: Patient population and other estimates of prosthetics and orthotics in the U. Bar A. Zettl JH: Amputation management utilizing immediate postsurgical fitting. Inter-Clin Info Bull 1962. 22. Newman JD: Relative incidences of new amputations. 18. Orthot Prosthet 1975. J Prosthet Orthot 1990. et al: A clinical study of amputations of the lower limb. Baumgartner RF: Through-knee socket design and manufacture. and Chapter 21B). 3. http://www. Prosthet Orthot Int 1969. Prosthet Orthot Int 1983. Girling J: A clinical assessment of immediate postoperative fitting of prosthesis for amputee rehabilitation. 7:116-118.53:186-190. 20. 1988. 7:100-103. 7. SUMMARY Although knee disarticulation remains uncommon in most of North America. Foot and ankle mechanisms are selected for knee disarticulation prostheses by using the same criteria that apply to transfemoral and higher levels (see Chapter 18B. but specialized knee disarticulation joints are not as rugged as conventional transfemoral mechanisms. 51:1007-1011. Mich. 13. 19. 8. Clin Prosthet Orthot 1988. Donovan RG (eds): Amputation Surgery & Lower Limb Prosthetics. 11. Orthot Prosthet 1977.org/alp/chap19-02. 6. 17. Phys Ther 1971. Prosthet Orthot Int 1983. Susack A: Pneumatic supracondylar suspension for kneedisarticulation prostheses. 3:15-19. Orthot Prosthet 1983. Prosthet Orthot Int 1979. 1:5-9. 9. Edwards JW (ed): Orthopedic Appliance Atlas. Baumgartner RF: The knee disarticulation prosthesis. 3:38-40. Hughes J: Biomechanics of the through-knee prosthesis. Srivastava RK. 37:15-24. Chapter 20B. but prosthetic options. South Med J 1964. Orthot Prosthet 1973. Arch Phys Med Rehabil 1972. It is undoubtedly the transfemoral level of choice for children since it preserves the distal epiphysis and avoids bony overgrowth. 40:235-237. Gilley R: Technical note: Cosmesis and the knee disarticulation prosthesis. 3:28-37. 5. Baumgartner RF: Failures in through-knee-amputation. Romano RL. Seliktar R. Ebskov B: Choice of level in lower extremity amputation-nationwide survey. Ann R Coll Surg Engl 1967. in Murdoch G. 1960.19B: Prosthetic Management | O&P Virtual Library disarticulation has been reduced.oandplibrary. Inter-Clin Info Bull 1962. 14. There is general consensus that it is functionally superior to higher-level amputation provided that full end weight bearing is achieved. McFaddin JG: Advantages of the knee disarticulation over amputation through the thigh. The cosmetic liabilities and knee mechanism shortcomings have been significantly reduced through the development of specialized four-bar polycentric designs. Spittler AW. 7:58-60.000 new amputees. 31:3-7. vol 2. Burgess EM. 36:921-930. 12. 57:13731378. Blackwell Scientific Publications. 12:123-127. Agarwal AK. 27:38-44. Botta P. 2. England. and durability are still somewhat compromised when compared with the transfemoral levels. 16. Harding HE: Knee disarticulation and Syme's amputation. Some advocate consideration of feet with elastic keels and/or tranverse rotation units to absorb some of the stress of ambulation since this is believed to reduce stress on the somewhat fragile knee mechanisms. Oxford. 15. Botta P. References: 1. Durability has also improved over that of external hinges. appearance. Kempfer JJ: Technical note: Thermoplastic use in the geriatric knee-disarticulation prosthesis. 4.A. Prosthet Orthot Int 1980. although not completely eliminated ( Fig 19B-20. 1:11-14. ). 4:162-164. J Bone Joint Surg [Am] 1978. 32. Radcliffe CW: The Knud Jansen lecture: Above knee prosthetics. 27.oandplibrary. Zettl JH. Woods JM: Lower extremity amputation: A five-year review and comparative study. 7:104-106. 37. Inter-Clin Info Bull 1976. 2:870-872. 30:27-28. 7:107-112. Michael JW: Component selection criteria: Lower limb disarticulation. 16:11-15. Inter-Clin Info Bull 1977. 24. Richards JF. Prosthet Orthot Int 1983. Inter-Clin Info Bull 1972. 11:1-5. 7:75-78. 34. 28. Prosthet Orthot Int 1977. 16:7-10. England. 1:146-160. Wells GG. Oberg K: Knee mechanisms for through-knee prostheses. Brunner H. Prosthet Orthot Int 1983. Contact Us | Contribute http://www. Fillauer CE. Med J Aust 1970. Chupurdia R: Disarticulation of the knee: A follow-up report. 12:5-9. Jensen JS: Incidence of major amputations following gangrene of the lower limb. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. 31. J Assoc Child Prosthet Orthot Clin 1986. Can J Surg 1987. Messner DG: Knee disarticulation following snakebite in a young child. Lexier RR. 41. 1:92-103. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 19B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Oxford. Prosthet Orthot Int 1982. Harrington IJ. 30. 6:35-37. Clin Prosthet Orthot 1988. Little JM: The use of air splints as immediate prostheses after below-knee amputation for vascular insufficiency. Orthot Prosthet 1976. in Murdoch G. Inter-Clin Info Bull 1973. 29. Schmitter ED. 60:675-678. 43. Weiner DS: Prosthetic stimulation of femoral growth following knee disarticulation. Prosthet Orthot Int 1983. 26. Murdoch G: The postoperative environment of the amputation stump. Fillauer KD: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. 25.org/alp/chap19-02. Mazet R. 15:15-16. Chapter 19B . Lyquist E: The OHC knee-disarticulation prosthesis. Pritham CH. Bigelow E. Shaw IB: Choice of prosthetic knee for bilateral knee disarticulation (abstract). Steen Jensen J: Success rate of prosthetic fitting after major amputations of the lower limb. 1988. 35. Romano RL: Knee disarticulation socket design for juvenile amputees. Lyquist E: Casting the through-knee stump.asp[21/03/2013 21:55:59] . Sweitzer RR: A Silastic-lined knee-disarticulation prosthesis. Steen Jensen J: Life expectancy and social consequences of through-knee amputations. 7:113-115.Atlas of Limb Prosthetics: Surgical. 36. Pierce JN: Knee disarticulation successfully fitted with a PTS socket. 40.19B: Prosthetic Management | O&P Virtual Library 23. 30:374-376. Inter-Clin Info Bull 1977. 12:99-108. J Prosthet Orthot 1989. Blackwell Scientific Publications. Mandrup-Poulsen T. Prosthetic. 42. 51:144-151. Lyquist E: The knee unit dilemma with respect to the knee disarticulation procedure.7:119-121. 39. 21:55. Prosthet Orthot Int 1983. Prosthet Orthot Int 1983. 38. Donovan RG (eds): Amputation Surgery & Lower Limb Prosthetics. Phys Ther 1971. 33. In these cases a small portion of the femur at the trochanteric level should be left where possible.asp[21/03/2013 21:56:04] . This allows for enhanced prosthetic fitting by providing additional contouring. M.oandplibrary. It is well accepted that transfemoral (above-knee) amputees have an increased energy expenditure for walking.D. http://www. The normal anatomic alignment of the femur is thus in adduction. leaving the femoral shaft axis in abduction as compared with the sound limb. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. the energy expenditure will be 65% or more It is important to maintain as above normal for level walking at a regular walking speed. the major portion of the adductor insertion is lost in conventional transfemoral amputations.)Orth. The abducted femur of the transfemoral amputee leads to an increase in side lurch and higher energy consumption. the easier it is to suspend a prosthesis as well as to align it.C. Although one of the major goals of surgery is primary wound healing. as long a stump as possible should be left.20A: Transfemoral Amputation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 20A Chapter 20A . Thus a smaller mass of adductor muscle would have to generate a larger force to You can help expand the O&P Virtual Library with a tax-deductible contribution. Only the adductor magnus has an insertion on the mediodistal third of the femur. IL.A.S. this can be achieved while maintaining biomechanical principles of lower-limb function. The functional ability of the patient is also improved with a longer residuum.. Click for more information about this text. In the usual procedure the surgeon then sutures the residual adductors and the other muscles around the femur with the residual femur in an abducted and flexed position. In the majority of transfemoral amputees who have had a conventional surgical procedure. the femur swings into abduction because of the relatively unopposed action of the abductor system. much length as possible when doing a transfemoral amputation.Atlas of Limb Prosthetics: Surgical.). and Rehabilitation Principles. their effective moment arm becomes shorter. F. Even those with no concomitant medical problems are unable to achieve normal gait in terms of velocity. Once this attachment is lost at the time of surgery. In those patients where prosthetic use is not considered. Prosthetic.(S. The femoral shaft axis measures 9 degrees from the vertical. Too often the procedure is performed without thought for biomechanical principles or preservation of muscle function. ©American Academy or Orthopedic Surgeons.C. American Academy of Orthopedic Surgeons. mechanical and anatomic alignment is disrupted since the residual femur no longer has its natural anatomic alignment with the tibia. Despite improvements in prosthetic design and fabrication. The longer the residual limb. and Rehabilitation Principles Transfemoral Amputation: Surgical Procedures Frank Gottschalk. Rosemont.org/alp/chap20-01. artificial limbs are unable to provide a reasonable replacement for the lost limb when poor surgery has been done and an inadequate residual limb has been created.S. In two-legged stance the mechanical axis of the lower limb runs from the center of the femoral head through the center of the knee to the midpoint of the ankle and measures 3 degrees from the vertical. In addition. reprinted 2002. edition 2. In most transfemoral amputees. Older dysvascular amputees do not have the physical reserve required and oftentimes will be limited household walkers or be totally unable to use a transfemoral prosthesis. Prosthetic. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. 1992. which allows the hip stabilizers (gluteus medius and minimus) and abductors (gluteus medius and tensor fasciae latae) to function normally and reduce the lateral motion of the center of mass of the body.R.Ed. F. or walking economy. cadence. In some circumstances a higher level of amputation may be dictated by the prevailing local pathology. Reproduced with permission from Bowker HK. Prosthetic. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists BIOMECHANICS The normal anatomic and mechanical alignment of the lower limb has been well defined ( Fig 20A-1. This provides a longer lever arm and may help with transfers as well as reduce the potential for bone erosion through the soft tissues. As the insertions of the adductor muscles are lost. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).. thus producing a smoother and more energy-efficient gait. split-skin grafts may be used with a view to secondary skin expansion.). which correlated with inadequate muscle stabilization.org/alp/chap20-01. In addition. and an abducted position is then maintained. A radiologic study of transfemoral amputees revealed that the position of the residual femur could not be controlled by the prosthetic socket shape or alignment. Prosthetists have recognized that residual femoral abduction compromised patient function and that prosthetic fitting of the transfemoral amputee was not satisfactory.20A: Transfemoral Amputation | O&P Virtual Library hold the femur in its normal position. a reduction in the effective moment arm. It is then difficult to re-establish the normal muscle tension as recommended in the A muscle-preserving technique is preferred whereby the distal insertions of standard texts. Their physical reserve is often insufficient for them to become prosthetic users. A residual limb with dynamically balanced function should allow the amputee to function at a more normal level and use a prosthesis with greater ease. Transection of the adductor magnus at the time of amputation leads to a major loss of muscle cross-sectional area. the remaining tissue can be excised. in actuality this is infrequently achieved since the remaining muscle mass will have retracted at the time of transection ( Fig 20A-3. combined with inadequate mechanical fixation of muscles as well as atrophy of the remaining musculature. They are unable to generate this force to hold the femur. The adductor magnus has a moment arm with the best mechanical advantage as compared with the adductor longus and brevis ( Fig 20A-2. INDICATIONS FOR TRANSFEMORAL AMPUTATION Vascular Disease This is probably the most common cause for transfemoral amputation. loss of the extensor portion of the adductor magnus leads to a decrease in hip extension power and a greater likelihood of a flexion contracture. vascular. Most times the indication for amputation will be severe soft-tissue. Patients with combined diabetic/vascular disease tend to be an average of 10 years younger than those (refer to Chapter 2C). Several authors recommend transecting the muscles through the muscle belly at a length equivalent to half the diameter of the thigh at the level of amputation. it is often necessary in those patients with very severe vascular and diabetic disease who are deemed to have poor potential to heal a lower-level amputation. and a loss of up to 70% of the adductor pull.oandplibrary. Patients with purely vascular patients with purely vascular problems disease tend to have a higher incidence of transfemoral amputation. extensor. Newer prosthetic socket designs have tried to hold the residual femur in a more adducted position by using the Another method using prosthetic alignment with adjustment of socket ischium as a fulcrum. It is mandatory to do at least a two-stage procedure and leave the wounds open at the initial stage to avoid wound infection and allow for additional debridement if necessary. This combination results in overall weakness of the adductor force of the thigh and subsequent abduction of the residual femur. the muscles are resected from the bony attachment. Most noticeable was a decrease in strength of the flexor. shape is also claimed to better control abduction of the residual femur. Preservation of the adductor magnus muscle is possible and helps maintain the muscle balance between the adductors and abductors. On occasion. abductor. It has been noted that a reduction in muscle mass at amputation. http://www. was the major factor for the decrease in muscle strength detected in transfemoral amputees.asp[21/03/2013 21:56:04] . but it is important to have a good soft-tissue envelope and avoid a split-thickness skin graft to bone (refer to Chapter 2B). and bone injury. The retained muscle bulk allows the adductor magnus to maintain close-tonormal muscle power and a better advantage for holding the femur in the normal anatomic position. neurologic. The goal of surgery in a transfemoral amputation should be the creation of a dynamically balanced residual limb with good motor control and sensation. Trauma The majority of patients who require a transfemoral amputation for trauma are generally in the younger age group. The majority of these patients have widespread systemic manifestations of the disease which may often compromise their postoperative rehabilitation. Although muscle stabilization is advocated as a means of controlling the femur. and adductor muscles of the hip. Although this procedure is done less frequently than in the past. Once the myodesis has been done. Maximum length should be retained.). The adductor magnus tendon is sutured with nonabsorbable or long-lasting absorbable suture material to the lateral aspect of the residual femur via the drill holes ( Fig 20A-5. The femur is exposed just above the condylar level and is cut with a power saw using an oscillating blade so that the femur is transected approximately 7. The quadriceps should be detached just proximal to the patella to retain some of its tendinous portion. they should be ligated and cut at the proposed level of bone section. The orientation of skin flaps is not critical. Skin flaps should be marked out prior to the skin incision ( Fig 20A4. while the adductor magnus is brought across the cut end of the femur while maintaining its tension.5 cm from the cut end. Infection Amputation for severe infection or osteomyelitis should be done as a two-stage procedure with antibiotic coverage. The major nerves should be dissected 2 to 4 cm proximal to the bone cut and sectioned with a new. especially in dysvascular cases. as long a stump as possible is preserved.). Additional anterior and posterior sutures are placed to prevent the muscle from sliding forward or backward on the end of the bone.org/alp/chap20-01.asp[21/03/2013 21:56:04] . Muscles should not be sectioned until they have been identified. It may be necessary to detach 2 to 3 cm of the magnus from the linea aspera. The central vessel can be lightly cauterized or secured by a stitch tie around the nerve.oandplibrary. a tourniquet is not used for the majority of transfemoral amputations.0) are used to close the skin and are placed no closer than 1 cm apart. while at the same time. but closure should be without tension. Fig 20A-7. Anterior flaps are fashioned longer than posterior flaps so that the suture line will be posterior.5 to 10 cm above the knee joint line. the quadriceps is sutured to the posterior aspect of the fe>mur via the posterior drill holes ( Fig 20A-6. Prior to securing the stitches. Once the adductor magnus has been anchored.). and fine nylon sutures (3. The placement of a small catheter in the nerve for local anesthetic infiltration is said to decrease the severity of postoperative pain and phantom sensation.). longer than the proposed bone cut to facilitate their inclusion and anchorage. Additional holes are made anteriorly and posteriorly. TECHNIQUE In general. The adductor magnus is detached from the adductor tubercle by sharp dissection and reflected medially to expose the femoral shaft. sharp blade. Subcutaneous stitches may be used to approximate the skin edges. the placement of antibiotic-impregnated methacrylate beads is useful for controlling local infection. a sterile tourniquet can be placed as high on the thigh as possible and released prior to setting muscle tension. Preservation and restoration of function are important factors (refer to Chapter 2E). The hip should be in extension when this is done to prevent creating a hip flexion contracture. If necessary.0 or 4. The investing fascia of the thigh is then sutured as dictated by the skin flaps. the femur is held in maximum adduction. http://www. In some situations. The principles of tumor eradication need to be considered. shows a postoperative roentgenogram with the femur held in adduction by the adductor myodesis. All infected tissue must be excised (refer to Chapter 2D). One should make the skin flaps longer than may be initially thought necessary to avoid having to shorten the bone too much. The blade should be cooled with saline. Once the major vessels have been isolated. Tumors Often the level of amputation is determined by the type and location of the tumors. and any flap configuration that will enhance feasible preservation of length is acceptable in trauma or tumor. The smaller muscles should be transected approximately 1 to 2 in.20A: Transfemoral Amputation | O&P Virtual Library Fractures of the femur should be stabilized by appropriate means rather than amputating through a proximal fracture site. The remaining hamstring muscles are then anchored to the posterior area of the adductor magnus. Two or three small drill holes are made on the lateral cortex of the distal end of the femur 1 to 1. A long medial flap in the sagittal plane is also acceptable. In addition. 6. 4. et al: Does socket configuration influence the position of the femur in above-knee amputation? J Prosthet Orthot 1989. The waist belt helps prevent the shrinker from slipping off. 2. conditioning of the well leg should take place. Stills M. Gottschalk F. By using aggressive rehabilitation techniques in a motivated patient. the sutures can be removed at around 2 weeks for traumatic amputations and at 3 weeks in the dysvascular amputee. pp 32-33. WB Saunders Co. This does not provide a stable situation. in Moore W. Gonzalez EG. they are cumbersome to apply and do not offer any great advantage in the long term in transfemoral amputations. Another method of controlling the swelling and reducing discomfort is to apply an elastic shrinker with a waist belt. 55:111-119. 1980. Malone J (eds): Lower Extremity Amputation. A controlled study has confirmed the effectiveness of this method and showed that the amount of postoperative narcotic analgesic could be considerably reduced. During this time the patient will have been wrapping the residual limb or using a shrinker. 5. J Bone Joint Surg [Am] 1988. A relatively new method is to place a small catheter in the nerve so that local anesthetic can be intermittently administered directly to the nerve. 1987. New York. pp 86-90. Flexion contractures should be prevented from occurring by correct positioning of the patient in bed as well as muscle-strengthening exercises.org/alp/chap20-01. The shrinkers are made of a oneor two-way stretch material that applies even pressure distally to proximally. The loss of muscle tension and the inability to restore it leads to some loss of control and reduced muscle strength in the residual limb.oandplibrary. Springer-Verlag NY Inc. Freeman MAR: The surgical anatomy and pathology of the arthritic knee. GENERAL POSTOPERATIVE CARE While the wound is healing. 1989. 3. early return to walking can be accomplished in a short time.asp[21/03/2013 21:56:04] . References: 1. Thieme Medical Publishers. The shrinker may be applied at the first dressing change at 48 hours. The patient needs to have sufficient upper-body strength to use crutches or a walker. Falstie-Jensen N. http://www. The decision to provide the patient with a wheelchair should be made early in the postoperative period.20A: Transfemoral Amputation | O&P Virtual Library Although some authors advocate the use of myoplasty alone to anchor the muscles. in Atlas of Amputation Surgery. This is only done for 3 to 4 days and then discontinued. Christensen E. Philadelphia. Christensen K. et al: Results of amputation for gangrene in diabetic and non-diabetic patients. Transfer training is important in this regard. Burgess E: Knee disarticulation and above-knee amputation. 70:15141519. Arch Phys Med Rehabil 1974. Although rigid dressings control the edema and stump position better than soft dressings do. Bohne WHO: Above the knee amputation. Postoperative phantom pain is not uncommon and can be reduced by infiltrating the sectioned nerve with bupivacaine (Marcaine) at the time of surgery. At the time of myoplasty the agonist and antagonist groups of muscles are sutured to each other over the bone end. The appropriate surgery allows for easier prosthetic fitting as well as enhancing physical therapy to allow the patient to achieve the goals set by the treating team. Corcoran PJ. The overall rehabilitation of the patient with a trans-femoral amputation begins at the time of surgery and continues until the patient has achieved maximum functional independence for that individual. A temporary plastic adjustable prosthesis can now be fitted and gait training started. Those patients who do not have the physical or mental ability to participate in a rehabilitation program designed to teach prosthetic use will be better off using a wheelchair. A well-applied elastic bandage will not slip off the residual limb. Reyes RL: Energy expenditure in below-knee amputees: Correlation with stump length. The soft-tissue envelope around the distal end of the residuum is unstable and may compromise prosthetic fitting. POSTOPERATIVE CARE The residual limb should be wrapped with an elastic bandage applied as a hip spica with the hip extended. nor does it allow for adequate muscle control of the femur. and the residual femur moves in the muscle envelope and produces pain. Most often. Kourosh S. 2:94-102. the patient should be mobilized in a wheelchair and in the parallel bars and upper-body exercises started. in Freeman MAR (ed): Arthritis of the Knee. New York. this technique does not restore normal muscle tension. Hungerford DS. 65:599-604. New York. 5:5566. Clin Orthop 1991. Contact Us | Contribute http://www. 9:15-26. Malawer M. 58:42-46. J Bone Joint Surg [Am] 1976. et al: Postoperative in-fusional continuous regional analgesia.Atlas of Limb Prosthetics: Surgical. Krackow KA. Maquet P: Biomechanics of the Knee. NY Inc. 12. Buch R.oandplibrary. Chapter 20A . Scand J Rehabil Med 1973. 1980. 9:9-14. Springer-Verlag.asp[21/03/2013 21:56:04] . et al: Energy cost of walking of amputees: Influence of level of amputation. Mandrup-Poulsen T. 14. New York. 13. Kenna RV: Total Knee Arthroplasty. 1984. Prosthet Orthot Int 1982. Steen JJ. Waters RL. Perry J. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. Thiele B. 11. 8. 10. Clin Prosthet Orthot 1985. St. Baltimore. Wagner FW: Ambulation levels of bilateral lower-extremity amputees. 9. p 22. 6:105-107. in Kostuik JP (ed): Amputation Surgery and Rehabilitation. Khurana J. Alberg E: Neurophysiological studies on muscle function in the stump of above-knee amputees. Prosthetic. Scand J Rehabil Med 1973. Harris WR: Principles of amputation surgery. 16. Chambers RB. 17. Volpicelli LJ. Williams & Wilkins. Krasnik M: Wound healing complications following major amputations of the lower limb. J Bone Joint Surg [Am] 1983.The Toronto Experience. James U: Maximal isometric muscle strength in healthy active male unilateral aboveknee amputees with special regard to the hip joint.20A: Transfemoral Amputation | O&P Virtual Library 7. James U. Antonelli D.org/alp/chap20-01. Churchill Livingstone Inc. 1981. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 20A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 15. 5:67-70. Clin Prosthet Orthot 1985. 266:227-237. pp 34-39. O. Prosthetic. Reproduced with permission from Bowker HK. This will be demonstrated in the next sections on the biomechanics of transfemoral prosthetics. 1992. Rosemont. Especially important is the amputee's ability to extend the residual femur fully. Prosthetic. reprinted 2002. and Rehabilitation Principles Transfemoral Amputation: Prosthetic Management C.asp[21/03/2013 21:56:09] . are not uncommon and are more prevalent in shorter residual limbs. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. (2) function. thus a hip flexion contracture is not uncommon and is more prevalent in shorter residual limbs.Atlas of Limb Prosthetics: Surgical. Normal femoral adduction angles average about 6 degrees. Range of motion in the sagittal plane consists of flexion and extension of the residual femur. Range of motion in the coronal plane consists of abduction and adduction of the residual femur. Perhaps more important and less understood is the need for accurate measurement and evaluation of the range of motion of the residual limb in both the sagittal and coronal planes. medical history. residual and intact anatomy and kinesiology. Obviously. The normal hip is capable of a maximum of 5 degrees of extension posterior to the vertical without anterior The inability to fully extend the residual femur usually indicates a pelvic rotation or lordosis. The analysis and measurement of the ranges of motion of the femur in the sagittal and coronal planes are important in establishing the initial angular alignment of the socket for a transfemoral prosthesis. Click for more information about this text. Analysis and Relevance of Residual-Limb Range of Motion Careful measurement and evaluation of residual and intact anatomy and kinesiology are essential for correct socket design and initial socket alignment. REVIEW OF TRANSFEMORAL BIOMECHANICS The basic goals for fitting and aligning prostheses for transfemoral amputees seem simple enough: (1) comfort. instability can be quite dangerous by causing unexpected falls. The inability to fully adduct the residual femur usually indicates an abduction contracture. American Academy of Orthopedic Surgeons. Especially important is the amputee's ability to adduct the residual femur fully. and Rehabilitation Principles. This range of motion in the coronal plane should also be documented. This range of motion in the sagittal plane should be documented along with other necessary measurements. like hip flexion contractures. Knee instability is the buckling or unintended flexing of the prosthetic knee during the stance phase of walking.20B: Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 20B Chapter 20B . however. and diameters is obvious enough. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. edition 2. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Biomechanics of Knee Stability-Stance Phase of Gait Knee stability in a transfemoral prosthesis refers to the ability of the prosthetic knee to remain extended and fully supportive of the amputee during the stance phase of walking. and (3) cosmesis. hip flexion contracture. C. and available prosthetic technology. IL. Owing to the location of muscle insertion points. The adductors of the femur are at a mechanical disadvantage when compared with the abductors due to their location and the fact that the most effective adductors have been severed at amputation. Prosthetic. http://www.oandplibrary. prognosis.P. Proper planning and incorporation of these angular measurements into the socket and overall prosthesis design allow for certain biomechanical and alignment principles that are advantageous to the amputee during the various phases of gait. This is because of the many and varied interrelationships between patient diagnosis. equivalent to the adduction of the femur on the sound side. circumferences.org/alp/chap20-02. Abduction contractures. obtaining these goals is significantly more challenging than might be expected. ©American Academy or Orthopedic Surgeons. Michael Schuch. the flexors of the hip have a better mechanical advantage than the hip extensors do. The necessity for measurement of lengths. the need for analysis of the range of hip flexion and extension of the residual limb was discussed. a moment or torque is created that tends to rotate the shin forward and thus flex the knee. the more stable the knee. the gluteus maximus. knee stability is achieved in the stance phase of gait. all common to the more elderly and otherwise debilitated amputee. It is also known that the only intact hip extensor. In biomechanical terms. The goal is to align the prosthesis so that the amputee uses the minimum amount of "alignment stability" or involuntary knee control necessary." The amount of initial flexion increases as the amputees ability to extend his hip decreases. One form of involuntary knee control is alignment stability in which the prosthesis viewed laterally is aligned so that the knee axis is posterior to the biomechanical weight line. The hip extensor muscles contribute to knee stability by pulling the prosthetic knee into extension or by maintaining existing knee extension. as described earlier. involuntary knee control and voluntary knee control Involuntary knee control implies that control is not subject to the will of the amputee but is automatic. Ankle-foot dynamics refers to the shock-absorbing and stabilizing abilities of this combined component system of the prosthesis. Additional factors that contribute to control of knee stability are initial socket flexion.) In this ideal situation. The TKA relationship is best understood as the socket-knee-ankle relationship. are present.). the prosthetic socket is designed and aligned in a position of "initial flexion. there are two descriptions of knee stability or knee control: ( Fig 20B-1. In normal human locomotion. When these muscles can exert enough force and are consciously fired at the proper time by the amputee. In addition to enhancing voluntary control of knee stability. Excessive knee stability. The only limiting factor is the length of the residual limb. increased weight bearing tends to force the knee into extension and locks it against the extension stop. Excessive energy expenditure and an unnatural swing phase of the gait cycle are the results. Better muscle tone and coordination are achieved as well. The key to avoiding these two undesirable characteristics and achieving optimum knee stability is an understanding of the biomechanics of prosthetic knee function. (Such an alignment device may later be transferred out of the finished prosthesis. and certain hydraulic knee systems. hip flexion contractures. thereby creating an instant of potential knee instability ( Fig 20B-2. With the weight line anterior to the prosthetic knee axis. yet efficient gait. and fear. At heel strike. There is a very fine distinction between knee instability and excessive knee stability. However. Other forms of involuntary knee control are mechanical and include locking knees. is not capable of exerting any significant force until the hip is flexed at least 15 degrees. For the stronger and more physically fit amputee. the more anterior the socket is placed to the knee joint and ankle. In most cases. occurs when the prosthetic knee joint is located too far posterior to the biomechanical weight line.oandplibrary. The hamstring muscles. are believed to function best when stretched just beyond their rest length. A critical balance between these two biomechanical conditions is required to achieve a safe.). some cosmesis has to be sacrificed as initial flexion is increased. smooth and uninterrupted plantar flexion http://www. which generally extends from the midpoint of the socket proximally to the midpoint of foot contact with the ground. voluntary control is not always possible. voluntary control provides for a smoother and more energy-efficient gait because it takes less effort to initiate swing-phase flexion than with an involuntary knee alignment. thereby optimizing voluntary knee control for each individual patient. weight-activated stance-control knees. For longer residual limbs. transfemoral prostheses are set up so that the socket is mounted on an adjustable alignment device that permits multidimensional freedom of movement of the socket with respect to the knee-shank and ankle-foot components.asp[21/03/2013 21:56:09] . initial socket flexion decreases the tendency of the amputee to use increased pelvic lordosis to compensate for weak hip extensors. Voluntary knee control implies that control is directly subject to the will of the amputee and is achieved and maintained through active participation of the hip extensor muscles. The most unstable phase of gait for a transfemoral amputee is at heel strike.20B: Prosthetic Management | O&P Virtual Library Excessive knee stability is a condition in which the knee of the prosthesis is so stable and resistant to flexing that it is difficult for the amputee to initiate the knee flexion required to achieve toe-off and swing of the shank. These muscles include the gluteal muscles (primarily the gluteus maximus) and the hamstring muscle group. To review. the anteroposterior (AP) setting of the socket is determined under dynamic conditions as the amputee's gait is analyzed carefully. To achieve some degree of stretching of the gluteus maximus.org/alp/chap20-02. Earlier. especially when muscle weakness. The degree of involuntary control varies in complexity. which are transected by transfemoral amputation. and ankle-foot dynamics. the trochanter-knee-ankle (TKA) relationship. In these situations. in length. only 60 lb of force need be exerted to equalize the moment or torque of 600 in. When coupled with the normal and desirable gait determinant of lateral pelvic shift over the support limb. can be distributed. with particular attention to the medial and lateral walls of the socket ( Fig 20B-3. restriction of adduction.-lb and thus stabilize the pelvis and trunk.org/alp/chap20-02. or skin breakdown. Effective pelvis-trunk stabilization and the resultant narrow-based gait can only be achieved in a transfemo-ral prosthesis by providing adequate lateral support to the femur. If the force is distributed over a smaller area. with such motion occurring around the hip joint of the weight-bearing limb.-lb of torque. 120 lb of force is required to equalize the 600 in. and more http://www. floats in a mass of muscle. tissue. the moment or torque around this lever system will be 600 in. the femur does not terminate in a foot planted firmly on the ground. Shown in Fig 20B-4. the more tolerable they become.. as when an abduction contracture is present. The amputee will typically compensate by widening the base of his gait and using trunk sway over the wide-based point of support (compensatory Trendelenburg) rather than gluteus medius activity. The femur must be maintained in a position as near as possible to normal adduction. In the case of the transfemoral amputee. and contraction of the gluteus medius is effective in controlling pelvic tilt at the hip joint of the stance leg. However. primarily the gluteus medius.. occurs through the bones of the leg. hip abductors. and the force or weight is 150 lb. "F" (fulcrum). the ideal gait is compromised for the first and foremost goal of comfort ( Fig 20B-5. The residual femur tends to displace laterally in the mass of residual muscle and tissue rather than maintain horizontal stability of the pelvis and trunk. Additional factors that affect the ability to maximize mediolateral pelvis and trunk stability are the length of the residual limb. and fluid. the medial wall is flat and vertical to help distribute stance-phase counterpressure forces. This phenomenon is one of several "gait determinants" inherently designed to In normal locomotion. In the transfemoral prosthesis.asp[21/03/2013 21:56:09] . The goal is inherent stability throughout mid-stance followed by smooth. will significantly limit the ability to control pelvis and trunk stability. "P" (proximal part of the femur). pressure concentration may cause discomfort. lb. prevent any additional drop through eccentric contraction. The biomechanical reaction to the contraction of the hip abductors and resultant femoral force against the lateral wall of the transfemoral socket is a laterally directed force or moment concentrated at the proximo-medial aspect of the transfemoral socket during mid-stance. and proper alignment of the prosthetic components below the socket. Obviously. is a lever system: "W" (weight). the shorter the residual limb.). the forces generated at the perineum are significant. These two goals are very much interrelated and are perhaps the most difficult and challenging of goals facing the prosthetist as well as the amputee. A longer residual limb provides a longer lever and larger surface area over which to distribute the inherent forces." and resulting forces or moments depend on weight and lever length. the lateral wall of the socket should be designed and aligned in a position of adduction that matches the "adduction angle" measurement obtained early in the residual-limb range-ofmotion evaluation. Firmer. denser. if the femur length as simulated by lever "P-D" is only 5 in. The residual femur. uninterrupted. the pelvis drops about 5 degrees toward the unsupported side during The midstance. if the lever "W-F" has an effective length of 4 in. gradually increasing flexion throughout the initial swing phase of gait. These factors are discussed below. the more difficult the task of establishing and maintaining mediolateral pelvis and trunk stability. The effective lever arms are "W-F" and "P-D. For this reason.20B: Prosthetic Management | O&P Virtual Library serves to dampen the significant moment initiated at heel strike. In normal locomotion.A and B). with concurrent perineal or pubic ramus pressure and discomfort. and "D" (distal part of the femur). two specific goals are mediolateral pelvis-trunk stability and a narrow-based gait. thus subjecting The more evenly that pressures our hypothetical femur to much greater levels of pressure. For example.oandplibrary. ankle-foot components that more closely replicate normal ankle-foot function contribute to knee stability. Biomechanics of Pelvis and Trunk Stability-Stance Phase of Gait In any discussion of gait of the transfemoral amputee. This lack of support and ineffective pelvic stabilization results initially in excessive pelvic tilt from the prosthetic support leg (positive Trendelenburg sign). proximomedial tissue density. pain. now a lever only 40% or less of the normal length of the lower limb. thereby putting the gluteus medius and other abductor muscles in a position of stretch that allows them to function most effectively. This objective is accomplished through socket design and alignment. weight bearing provide energy efficiency in normal locomotion. Generally. If the lever "P-D" is 10 in. Deviations in the sagittal plane include "whips" during the swing phase caused by improper socket shape or improper knee axis alignment. In such cases. as well as circumduction. which is usually thought of as a deviation in response to a prosthesis that is too long. was the socket of choice from the 1960s until recently and remains the most commonly prescribed socket system even today. can also serve to subtly compensate for a delayed advancement of the prosthetic shank in midswing. fleshy (often shorter) residual limbs lacking muscle tone in the adductor region are very susceptible to tissue trauma and bruising and offer a less stable reaction point for support. http://www. The origin is attributed to Ivan Long. and Techniques of molding and fabricating the socket remain similar in Christopher Hoyt. from the standpoint of energy consumption. Stabilizing pressure should be applied on the skeletal structures as much as possible and areas avoided where functioning muscles exist. The relatively recent advent of the ischial-ramal containment transfemoral socket design provides one solution to this problem. Problems with vertical displacement are due to poor suspension and resulting piston action and/or inappropriate length of the prosthesis.asp[21/03/2013 21:56:09] . This socket design and philosophy has become known generically as the "ischial containment" socket. Changes center around the position of the ischium with respect to the socket proper and related biomechanical and socket comfort enhancements. innovative designs for transfemo-ral sockets began to emerge and were published under various acronyms. Daniel Shamp. Vaulting. Prosthetic alignment is a significant variable that contributes to trunk and pelvis stability. 2. There has been considerable controversy over socket and foot relationships in the coronal plane as Foot placement in the coronal plane is best determined viewed from the sagittal plane. Soft. Overcoming such "alignment stability" takes effort and delays the initiation of swing phase. should be stretched to slightly greater than rest length for maximum power." excess energy and effort are required to initiate knee flexion. The socket must be properly contoured and relieved for functioning muscles. content and approach to those of the quadrilateral socket. with credit for furthering its development due John Sa-bolich. significant deviations result in greater demand. Specific Transfemoral Socket Designs and Rationale Hall described five important principles of socket design that were intended as objectives of the quadrilateral socket but apply equally well to any modern trans-femoral socket : 1. When the prosthesis is aligned with too much "alignment stability. despite new designs and techniques.org/alp/chap20-02. Biomechanics of Knee and Shank Control-Swing Phase of Gait The requirements and goals of the swing phase of gait for the transfemoral amputee are normally easier to attain and are less demanding than those of the stance phase of gait. which has both American and European variations.). By the early 1980s. TRANSFEMORAL SOCKET DESIGNS: VARIATIONS AND INDICATIONS Overview of Transfemoral Variants The total-contact quadrilateral socket. Swing-phase tracking refers to the smoothness of the pathways of the prosthetic limb during the swing phase of the gait cycle. Thomas Guth. where possible. dynamically by using adjustable alignment devices within the prosthesis ( Fig 20B-6.oandplibrary. Our discussion will focus on two aspects of the transfemoral prosthesis swing phase: swing-phase timing control and swing-phase tracking.20B: Prosthetic Management | O&P Virtual Library muscular residual limbs (which are often longer in length) are better able to tolerate this reaction force. usually caused by excessive prosthesis length or poor alignment. 3. Goals are to minimize vertical displacement of the prosthesis on the residual limb and to minimize deviations in the sagittal plane as the prosthetic limb advances during swing phase. Functioning muscles. mediolateral pelvis-trunk stability will be compromised unless these reaction forces are directed against more stable anatomic features such as the skeletal anatomy in this area. However. As the concepts of total contact and total surface bearing became better understood. According to Radcliffe. as well as femoral anteversion. including comfortable weight bearing. Careful attention to this proximomedial socket contour is absolutely essential for stance-phase comfort in the perineum. "the socket is truly more than just a cross-section shape at the ischial level.A and B).org/alp/chap20-02.20B: Prosthetic Management | O&P Virtual Library 4. The orientation of the four walls will vary according to the amputee's specific anatomy and the biomechanical requirements of the socket. soft tissue. The quadrilateral socket accomplishes this by contouring the lateral wall in the desired degree of adduction. it is a three-dimensional receptacle for the stump with contours at every level which are justifiable on a sound biomechanical basis." http://www. The goal is to re-establish the normal adduction angle of the femur with respect to a level pelvis. Properly applied pressure is well tolerated by neurovascular structures. anterior counterpressure was de-emphasized." Weight bearing in the quadrilateral socket is achieved primarily through the ischium and the gluteal musculature. As previously discussed. a narrow-based gait. which is formed into a wide seat that is parallel to the ground. 5. intended to maintain the position of the ischium and gluteals on this posterior seat. midstance firing of the hip abductor muscles leads to reaction forces occurring in the proximomedial aspect of the residual limb and socket. As a means of providing counterpressure and distributing these reaction forces. If the AP dimension of the lateral half of the quadrilateral socket is too tight. Proper socket contours for actively functioning muscles (primarily the rectus femoris and gluteus maximus) also affect swing-phase tracking in the sagittal plane. provide the format for a description of transfemoral sockets. This suggests that tissue and muscle loading occurs as a supplementary weight-bearing mechanism. will vary depending on proximal circumference and muscular firmness of the residual limb.oandplibrary. with the forces and loads being evenly shared by skeletal anatomy. The concept of total surface bearing suggests that weight bearing be as evenly distributed over the entire surface area as possible. The posteromedial wall angle varies from 5 to 11 degrees. the socket for any amputee must provide the same overall functional characteristics. The depth of the rectus femoris channel. the lateral wall is contoured into and over the hip abductor muscle group to discourage abduction. of the socket before reversing into a smooth flare directed away from the residual limb and toward the perineum. The quadrilateral socket should be designed with "initial flexion" to improve the ability of the amputee to control knee stability at heel contact and to help in minimizing the development of lumbar lordosis at toe-off ( Fig 20B-8. Countersupport. in the transverse view. Obviously. The AP dimension of these respective walls is based on anatomic measurements. muscle. then muscle activity in the swing phase of gait can lead to undesirable socket rotations about the residual limb that appear clinically as swing-phase "whips..) because there are four distinguishable sides or walls of the socket. the contour of the medial wall of the socket is flat in the sagittal plane along the proximal 4 in. proper suspension enhanced by careful matching of residual-limb and socket contours aids in achieving a normal swing phase. stability in the stance phase of gait. which is carefully fitted against Scarpa's triangle. exaggerated Scarpa's triangle contours. Proximal to the greater trochanter. The entire lateral wall is flattened along the shaft of the adducted femur with the exception of a laterally projected relief for the terminal aspect of the femur. Regardless of the fitting method employed.). generally a function of the length of the residual limb. as viewed transversely.asp[21/03/2013 21:56:09] . A common error is to create deep. and as normal a swing phase as possible These characteristics will consistent with the residual function available to the amputee. The achievement of normal swing phase is dependent upon several factors. and hydrostatic compression of residual limb fluids. Force is best tolerated if it is distributed over the largest available area. Quadrilateral Socket The term quadrilateral refers to the appearance of the socket when viewed in the transverse plane ( Fig 20B-7. is provided by the medial third of the anterior wall of the socket. This combination of skeletal and muscular anatomy rests on the top of the posterior wall of the socket. Clinical experience with other socket designs has shown that enlarging this dimension of the socket often allows for additional comfort in the perineum with no loss of comfortable weight bearing. Incorporation of adduction into the quadrilateral socket depends on the range of motion available. depending on the muscular density of the proximoposterior aspect of the residual limb ( Fig 20B-9. identical residual limbs have greater force distribution and hence lower pressures with an ischial containment design. intended to keep the ischium and ramus solidly against the medio-posterior aspect of the socket. Of particular importance are the variations in the position of the ischium with respect to the trochanter. quadrilateral techniques at about the time that the "ischial containment" socket initiated new concepts in transfemoral socket theory.S. femoral abduction http://www. soft tissue. The third form of counterpressure. or else edema and other skin problems will develop. quadrilateral shapes. and normal swing phase. The posterior brim of the socket is proximal to and tightly childbearing posterior to the ischium. The physical and functional characteristics of this socket will be described within the perspectives of comfortable weight bearing.20B: Prosthetic Management | O&P Virtual Library The distal end of the socket must match the contour of the distal end of the residual limb and provide adequate distal contact. Utilization of suction socket suspension whenever possible. countersupport occurs through the "distal mediolateral" dimension. The concept of the "U. 5.S. the "skeletal mediolateral" dimension.oandplibrary. Therefore. must be carefully designed into the socket. to allow for ( Fig 20B-10. proximal contours are affected primarily by muscular variation. quadrilateral brims. the is-chia are positioned more laterally. ). 6. It has been hypothesized that the quadrilateral socket is displaced laterally during midstance and thus results in a shearing force on the perineal tissues. First. Maintenance of normal femoral adduction and narrow-based gait during ambulation. Countersupport. several European-style quadrilateral socket casting brims became available in the United States. The socket encompasses both the ischial tuberosity and the ramus. is anterolateral counterpressure from the trochanter anteriorly to the tensor fasciae latae. these subtle changes began to influence U.S. the transitions from the four socket walls were smoother and less abrupt. as well as from It pressures distributed as evenly as possible over the entire surface of the residual limb. should be noted that significantly more residual limb surface and volume is contained within the ischial containment socket as compared with the quadrilateral socket. the distance between the medial aspect of the ischium and the inferolateral edge of the trochanter. Pritham has described objectives that would ideally be achieved in the ischial containment socket : 1. Although the biomechanical principles remained the same. It describes several similar concepts in socket design in which the ischium (and in some cases the ischial ramus) are enclosed inside the socket. these European brims featured a larger AP dimension balanced by a smaller mediolat-eral dimension as compared with typical U. In the transverse view. 2. distal to the skeletal mediolateral dimension. stance-phase stability. most important in females because of their pelvic anatomy. creation of a "bony lock. in the socket medially and posteriorly so that forces involved in maintenance of mediolateral stability are borne by the bones of the pelvis medially and not just by the soft tissues distal to the pelvis. A decreased emphasis on a narrow AP diameter between the adductor longusScarpa's triangle and ischium for the maintenance of ischial-gluteal weight bearing. Second. During the decade of the 1980s. in which the skeletal structure of the amputee. and As opposed to the quadrilateral socket. Maximal effort to distribute forces along the shaft of the femur. a soft-tissue measurement that reflects the diameter of the residual limb 1 to 2 in. Secondarily. the specific contour depends on the musculature. 4. proximal contours of the ischial containment socket are affected by differences in pelvic skeletal anatomy. Additional weight-bearing support is thought to be provided by the gluteal musculature and the lateral aspect of the femur distal to the trochanter. in females. to varying extents.asp[21/03/2013 21:56:09] . The medioproximal wall was slightly lower and increased comfort in the perineum. is produced in three ways. The original concept also continued to develop independently in Europe. Total contact. When compared with the U. quadrilateral socket" was borrowed from Europe and refined through significant biomechanical analysis and research conducted in the United States. Enclosure of the ischial tuberosity and ramus. that is to say." 3. Weight bearing in the ischial containment socket is focused primarily through the medial aspect of the ischium and the ischial ramus. or closer to the trochanter. Ischial Containment Socket The term "ischial containment" is rather self-descriptive.org/alp/chap20-02.S. asp[21/03/2013 21:56:09] . In the process considerable confusion has caused many of the issues involved to be obscured. . . Socket Indications-Current Trends The question has been previously put forth: how is the clinician to choose among these Some of the new socket designs have been associated with competing philosophies? strident claims coupled with concurrent rebuttal of the quadrilateral design. Swing-phase suspension is critical and is usually achieved by suction. and the material should not be elastic enough to stretch under the loads it will be subjected to. 6. the shape and channels of the anterior wall. The solution provided by the ischial containment socket is to extend the medial brim of the socket upward until pressure is brought to bear against the ramus. and the post-trochanteric contour of the lateral wall seen in transverse view ( Fig 20B-12. and laterodistal aspect of the femur provides a much more stable mechanism for acceptance of perineal biomechanical forces. this allows more effective transmission of the movements of the femur to the prosthesis. Socket rotation control for very fleshy residual limbs with poor muscle tone is best achieved with an ischial containment socket. Rotational control is provided by the proxiomedial brim and its bony lock against the ischium.A-D). . and the socket-frame combination has to be structurally strong and stable enough to counteract the reaction forces. 5. The resulting "bony lock" between the ischium.org/alp/chap20-02. these techniques have gained considerable favor during The concept uses flexible thermoplastic vacuum-formed sockets the past decade." Kristinsson additionally states: When designing a flexible socket system the most critical aspect for the comfort of the wearer is how the frame is designed. As with the quadrilateral socket. 3. Flexible Transfemoral Sockets In 1983 Kristinsson of Iceland introduced the concept of a flexible socket design. Taught in the United States under various acronyms such as ISNY (Icelandic-Swedish-New York) and SFS (Scandinavian Flexible Socket). the perception that the new style sockets are different from quadrilateral style sockets and unaffected by the principles of above-knee prosthetics as explained by Radcliffe (1955. Two clinical results are increased comfort in the groin and better control of the pelvis and trunk ( Fig 20B-11.A and B). 1970. Medium to long residual limb (where a significant portion of the wall will be left exposed and flexible) 3. supported in a rigid (or semirigid) fenestrated frame or socket retainer ( Fig 20B-13. The socket retainer may be either vacuum-formed or laminated plastic ( Fig 20B-14. The advantages of flexible wall sockets as put forth by Pritham are as follows 1. Suspension not a factor The most recent form of flexible socket used in trans-femoral prostheses is in the form of a silicone roll-on socket (used to enhance suction suspension) coupled with a socket retainer. trochanter. and somehow or another. 4. http://www.oandplibrary. preventing permanent deformation.20B: Prosthetic Management | O&P Virtual Library may occur and decrease the effectiveness of the gluteus medius. Stance stability may be enhanced by extensive contouring posterior to the femoral shaft. Kristinsson describes a flexible socket as follows: "To label a socket as flexible I would say that you should be able to deform it by your hands.A and B). It has to be capable of supporting the flexible socket. 2. ). Mature residual limb (frequent socket changes not anticipated) 2. proper contours allow for smooth swing-phase tracking. To quote Pritham. Flexible walls Improved proprioception Conventional fitting techniques Minor volume changes readily accommodated Temperature reduction Enhanced suspension : : Pritham proposes the following indications for use of a flexible socket 1. thereby compromising socket fit.oandplibrary. As experience gained in both thermoplastics techniques and ischial containment fitting techniques is further disseminated." In reality. however. A variety of designs for each of these components is available which can be combined to meet the individual needs of the amputee. Two construction alternatives are available for trans-femoral prostheses ( Fig 20B-15. In a similar vein. Further. One concern regarding the ischial containment technique is the difficulty some prosthetists have reported in efficiently obtaining a successful fit. It is the author's [Pritham's] contention that most if not all of the major factors influencing the shape of the newer sockets can be explained in terms of the principle of ischial containment. Total flexible brims are essential to the success of "maximal" ischial-ramal containment sockets. the knee system. 1988) and attention has come to be focused on the role of the ischium. The traditional form of construction is the exoskeletal or "crustacean" design fabricated http://www. Lack of agreement existed on the best recommendation for the bilateral transfemoral amputee.A and B). Two reported factors creating concern about flexible-socket techniques have been the tendency for the thin flexible thermoplastic to tear and the tendency of the thermoplastic to shrink when removed from the patient cast model and continue shrinking over time. these concerns should cease to be a consideration. TRANSFEMORAL PROSTHETIC COMPONENTS: VARIATIONS. Recently. Quadrilateral sockets are most successful on long. There are several additional factors to be considered to a lesser degree.20B: Prosthetic Management | O&P Virtual Library 1977) has crept into popular consciousness. Both of these concerns are being reduced with experience and new materials. the shank (or shin). Schuch. CONTRAINDICATIONS Systems Overview As noted by Wilson. and engineers who participated in an international workshop on transfemoral fitting and alignment techniques follows: No specific contraindications were noted for any socket design. more than one initial test socket is rarely necessary with the quadrilateral technique. it is the author's [Pritham's] belief that this principle is fully compatible with Radcliffe's biomechanical analysis of the function of the quadrilateral socket and that the varying socket configurations are not at odds but rather are separate but related entities in a continuum labeled above-knee sockets. The above-knee prosthesis consists of a minimum of four major parts: the socket. Thermoplastics are now being extruded for use in prosthetic socket construction that are specially designed to resist both tearing and shrinkage. Flexible wall sockets are not linked to any one philosophy of transfemoral socket design. it seems that the use of thermoplastics in prosthetic socket design is on the rise and offers some significant advantages over conventional laminated plastic socket techniques. Ischial containment sockets are more successful than quadrilateral sockets on short.asp[21/03/2013 21:56:09] . . in contrast.org/alp/chap20-02. socket design indications can only be offered from because there are no impartial field tests or shared clinical experience and workshops objective scientific studies produced to date to provide substantial answers to this question. a suspension system is needed. Michael contends "that these new designs represent evolutionary rather than revolutionary advances. The conclusions of a panel of physicians. 1988. INDICATIONS. and the foot-ankle system. Indeed. Repeated test or trial sockets are the norm in this technique. firm residual limbs with firm adductor musculature. fleshy residual limbs. Ischial containment sockets are the better recommendation for high-activity sports participation. Some advocated not changing successful quadrilateral socket wearers. some semblance of order has begun to emerge (Pritham. If suction is not used to retain the leg in place. prosthetists. The increasing compatibility of components from all manufacturers greatly enhances prosthetic prescription options. The cosmetic covering may be additionally covered with skin-colored hosiery or custom-sprayed with one of the "skinlike" finishes available. ). Prosthetic Feet This topic has been previously discussed in detail in the transtibial chapter of this Atlas. which enhances sitting cosmesis for very long ( Fig 20B-19. Polycentric-axis Knee This knee mechanism usually consists of a four-bar linkage that provides more than one point of rotation. there is one special consideration for the transfemoral amputee. (2) smooth and controlled swing phase. Prosthetic Knee Components Prosthetic knees provide three functions: (1) support during stance phase. an ankle-foot combination that dampens the knee flexion torque moment generated at heel strike can be an important consideration. a mix of endoskeletal and exoskeletal components may be beneficial. plastic-laminated outer skin. Additional advantages of the poly-centric design are the inherent shortening of the shank during flexion. Ankle-foot combinations with actual moving joints achieve foot flat more rapidly than do the solid-ankle feet that lack a moving joint and are therefore often preferred for the transfemoral amputee. In this design. . residual limbs http://www. thereby decreasing potential knee instability. This results in the advantage of varying mechanical stability throughout the gait cycle. and the ability to rotate the shank under the knee during sitting.A and B). Since heel strike though midstance on the transfemoral prosthesis is the most difficult period for knee control. at least within the manufacturer's system. which improves foot clearance in swing phase. with enhanced stability during heel strike and decreased stability at toe-off. The more quickly the foot achieves foot flat. shank. The knee units are usually interchangeable. titanium. ).org/alp/chap20-02. considered by most to be superior to exoskeletal prostheses. The primary disadvantage of this knee design is its lack of mechanical stability ( Fig 20B-16. as opposed to simulated plantar flexion (solid-ankle feet). Single-axis Knee This knee consists of a simple hinge mechanism. and/or carbon fiber epoxy) through which the weight load is transmitted. kneeling. and (3) unrestricted flexion for sitting. thus allowing for easier initiation of swing phase ( Fig 20B-18. depending on the relative amount of flexion or extension of these components ( Fig 20B-17. The cosmesis. the strength is obtained by the outer plastic lamination through which the weight load is transmitted. The simplicity of design and low maintenance of this knee mechanism leads to its popularity and frequent use. and ankle are custom-shaped to the individual amputee's contours and measurements before being covered with an outer plastic-laminated skin that is pigmented for appropriate color. The cosmesis or leg shape is integral to the system because the thigh. Use of an ankle-foot combination that allows true plantar flexion within the ankle mechanism (single-axis foot. stooping. other ankle components). It is mechanically simple. provides better absorption of shock and torque generated at heel strike. the knee component systems described are available in both exoskeletal and endoskeletal formats. and related activities. is provided by an external soft foam cover shaped to the individual amputee's anatomy and measurements.oandplibrary. Hybrid endoskeletal prostheses utilizing several different manufacturers' components are quite common. This is particularly true for the elderly or otherwise debilitated amputee. The endoskeletal form of prosthesis is constructed of an inner tube or pylon (of aluminum.asp[21/03/2013 21:56:09] .20B: Prosthetic Management | O&P Virtual Library from wood or polyurethane foam covered with a reinforcing. However. The design is mechanically complex and provides a changing instantaneous center of rotation between the prosthetic thigh and shank. and in some cases. In most cases. ). the greater the knee stability. multiaxis foot. and stance stability is dependent on alignment stability (involuntary control) and amputee muscle contraction (voluntary control). Friction Control Knee swing is dampened by some form of mechanical friction. Polycentric knees are generally used on three categories of amputees.asp[21/03/2013 21:56:09] . and aircraft aluminum. Amputees with short above-knee amputations (femur length less than 50%) will benefit from this unit because they also can take advantage of the higher instant center of rotation and the increased zone of stability provided by the polycentric unit. An additional disadvantage is delayed initiation of swing phase if the stancecontrol "brake" is set for a high degree of stance stability. The historical disadvantage of polycentric knees is the increased weight and bulk due to the numerous linkage mechanisms and greater amount of moving parts.20B: Prosthetic Management | O&P Virtual Library As noted by Mooney and Quigley. This disadvantage has been reduced with the advent of newer materials such as carbon fiber. but may also be used by amputees in unstable situations such as uneven terrain when hiking or hunting or activities such as fishing while standing in a boat. an extension assist is a spring that is compressed during knee flexion in initial swing. a braking mechanism mechanically prevents the knee from flexing or buckling. unstable. The amount of weight required to effectively engage the "brake" and prevent flexion can be adjusted depending on the amputee's weight. Extension Assist In the simplest form. Manual Locking Knee This knee unit automatically locks in extension but can be unlocked by voluntary action. Pneumatic Control http://www. titanium. allowing the appearance of equal thigh and shank lengths compared to the sound limb. due to the lack of knee flexion during swing phase. Extension assistance also prepares the prosthetic limb for initial stance support by ensuring full knee extension at terminal swing. This is the most commonly used system for control of swing phase. usually applied to the axis of rotation.A and B). The third group of amputees benefitting from the polycentric knee mechanism is those individuals with weak hip extensors. This knee design is generally used for weak or debilitated amputees who cannot rely on more complicated and demanding means of stance control. in whom the high instant center of rotation is advantageous.org/alp/chap20-02. activity level. this knee is by far the most stable during stance. The first is the knee disarticulation amputee.oandplibrary. thereby reducing the effort expended by the amputee. Ambulation with the locking mechanism disengaged is also possible. The one disadvantage is that the friction can be set for only one cadence and any variation in cadence by the amputee results in a prosthetic knee and shank that will not flex and extend with the same timing as the natural leg. Currently there are lightweight polycentric knee components available in both children's and adult sizes ( Fig 20B-20. primarily due to its simplicity and dependability. When locked. Weight-activated Stance-control Knee In this knee mechanism. . . when weight is applied. The "braking" mechanism is usually only effective to a maximum range of 15 to 20 degrees of flexion ( Fig 20B-21. The friction is adjusted to the patient's normal cadence so that the pendulum action of the shank will correspond to that of the opposite limb. before initial stance. uncoils during late swing. The primary disadvantage is increased maintenance. However. increased energy expenditure and gait deviations often occur during ambulation with a locked knee. and propels the shank into full extension.A and B). and stance-control needs. A positive locking knee is generally indicated for weak. debilitated amputees. so that the polycentric knee will swing under the thigh when the amputee sits. The air travels upward within and around the sides of the cylinder. The "Mauch Swing-N-Stance" (S-N-S) is the most advanced system of hydraulic control and the only system that includes hydraulic stance-phase control. and needle valves to meet normal walking requirements. It allows free plantar flexion of the foot at heel strike and provides dorsiflexion of the foot after 20 degrees of knee flexion in swing for improved ground clearance during swing phase. The design provides normal heel rise and extension in the swing phase independent of walking speed. Hydraulic control achieves nearly normal knee action over a wide cadence range. it acts as an extension assist within the pneumatic unit. Although quite advanced in design and function. ankle. As described by Mooney and Quigley. Knee flexion forces the piston down into the cylinder. therefore.oandplibrary. however. and increased expense. Silicone oil is used in most prosthetic hydraulic units because it minimizes viscosity changes with temperature. The heel height of the foot is adjustable through the hydraulic mechanism of the ankle and allows for patient changes and adjustments. Teen and adult males are commonly hydraulic users. Some pneumatic units also have coil spring-type extension assists built into them. and foot system that is hydraulically linked at the knee and ankle. Because air is compressible. there are separate adjustments for http://www. the difference being the medium: liquid is used rather than air.20B: Prosthetic Management | O&P Virtual Library Pneumatic control of the swing of the prosthetic shank is provided by a pneumatic cylinder attached to the knee and housed within the upper shank. The knee and shank swing control is hydraulic. shank. this Mechanism consists of a piston rod that is attached to the thigh section of the prosthesis behind the knee bolt. An adjustment knob is turned clockwise or counterclockwise to either decrease or increase this port opening. but to a greater degree: need for increased maintenance. Resistance to knee swing velocity can be adjusted for the individual amputee by adjusting the opening size of the port at the top of the cylinder. possibly preventing adequate knee flexion and speed during swing phase. Two hydraulic systems that provide more than simply swing-phase control are worthy of special mention. increased weight. The varying control is caused by the characteristics of hydraulic flow through ports or orifices where the resistance to flow increases with increasing cadence. The "Hydra-Cadence" hydraulic system is an entire knee. check valves. and increased expense. The hydraulic knee mechanism is indicated for amputees who can take advantage of the cadence response function. Pneumatic control is more responsive to varying walking speeds and is a more advanced form of swing control than friction is. the Hydra-Cadence is quite heavy and expensive and has been associated with decreasing durability and reliability during recent years. in some instances. Disadvantages are the same as those of pneumatic units. which in turn forces air through a bypass channel at the bottom of the cylinder. through a port at the top of the cylinder. Disadvantages of pneumatic units include increased necessity for maintenance. However. Hydraulic Control The principles of hydraulic control are similar to those of pneumatic control. thus avoiding stiffness in cold weather and looseness in hot weather. they are simpler. increased weight. there are active females who enjoy the benefits as well. Hydraulic units also utilize a cylinder and piston rod arrangement as described earlier. Decreasing the opening provides greater restriction of the amount of air passing through the port and. greater swing-phase control. and less expensive than hydraulic units. and back into the central cylinder above the piston.org/alp/chap20-02.asp[21/03/2013 21:56:09] . lighter. The liquid provides resistance to motion depending on its viscosity and temperature. Setting this opening too small would make the swing too stiff. The programmed flow is obtained by a special pattern of internal ports. the amputee. Independent adjustments of flexion and extension control are available on most hydraulic units and are easily adjusted by the prosthetist and. The hydraulic control of swing phase is fundamentally the same as that described earlier. The unit may also be set to function without stance control for activities such as bicycling. ). An additional functional mode available is a setting that provides a lock against knee flexion. This fact coupled with its significant variety of functional options makes it the most widely used hydraulic system. Torque Absorbers A torque-absorber component is designed to allow transverse rotations about the long axis of the prosthesis. tennis.asp[21/03/2013 21:56:09] .org/alp/chap20-02. Thus. if during extension of the shank the toe is stubbed. Secure and dependable suspension enhances proprioception and provides the feeling that the prosthesis is more a part of the wearer. Without such a component. The hyperextension moment. Suction Suspension Suction suspension is usually accomplished by the use of an air expulsion valve at the distal http://www. The S-N-S unit is the most reliable and durable of the hydraulic systems. which can only occur when the knee is safely extended.oandplibrary. The yielding speed in weight bearing is easily adjustable to accommodate the amputee's weight and needs. Provision of stance-control options is what makes this system uniquely functional. the knee and shank are free to rotate. decreased safety. Release of the high flexion resistance can also be accomplished voluntarily by an amputee who is standing and wishes to sit down quickly. the higher level of resistance is reinstated. endoskeletal components that provide multiple degrees of motion within the ankle independent of the foot. This component is particularly useful for bilateral amputees and is especially indicated for any amputee participating in golf. and the range of adjustments is greater than in other hydraulic units. Suspension Variants Improper suspension results in poor gait. thus generating the hyperextension moment necessary to release the high flexion resistance. Although primarily intended for endoskeletal prostheses. As the knee nears maximum flexion and the speed of bending decreases to zero. Function-Enhancement Components There are three additional components available that provide additional and useful functions. the high resistance to flexion is available to aid in stumble recovery. and increased skin problems. This type of ankle system smooths out the gait pattern and enhances knee stability in transfemoral prostheses. these forces are transmitted as shear forces between the residual limb and the socket. and other sports and activities demanding rotational movements.20B: Prosthetic Management | O&P Virtual Library flexion (initial swing) and extension (terminal swing). unless the amputee generates a hyperextension moment about the knee that occurs naturally when rolling over the ball of the prosthetic foot after midstance. This can also facilitate entry/ exit to or from confined spaces such as an automobile. Knee-shank Rotation Components Such components were initiated in the Orient where sitting cross-legged on the floor is a cultural requirement. The design provides a high resistance to knee flexion. results in disengagement of the high flexion resistance and permits the knee to flex easily to begin the swing phase. It too has the disadvantages of extra weight and additional expense ( Fig 20B-22. He simply extends his residual limb while maintaining the foot in contact with the floor. Multiaxis Ankle Modules These are modular. This is useful for situations requiring maximum knee stability such as rough terrain or standing and fishing from a pitching boat. The amputee may also walk downstairs and downhill step over step in a weight-bearing manner by stepping on the prosthesis without hyperextending the knee. The multiaxis ankle modules are adaptable to a variety of feet. they can also be incorporated into an exoskeletal prosthesis by creating a hybrid system. Conventional multiaxial feet require the use of a specific ankle-foot combination. By releasing a locking mechanism. The hip joint with pelvic band and waist belt also provides rotational stability plus a significant degree of mediolateral pelvic stability. . Most commonly. Because most amputees object to the weight and bulk of this suspension. and the requirement of weight and volume stability. suction suspension is indicated for amputees with smooth residual limb contours. This is usually necessary in obese amputees or those with significant redundant tissue that is difficult to stabilize. Disadvantages include difficulty in obtaining such a precise fit with some amputees and occasional loss of suction in sitting or other positions. Soft Belts There are two types of soft suspension belts available. After the limb is completely into the socket.A). Suction suspension of transfemoral prostheses provides the best proprioception. and the amputee pushes into the socket. Other disadvantages include no medium for absorbing perspiration. The suspension is applied directly to the residual limb. there are simpler and less cumbersome alternatives if suspension alone is the goal. and other such conditions preclude this method of donning and have traditionally been considered contraindications for suction suspension. Lotion is spread either on the residual limb or inside the socket. it attaches at either a single point or. soft belt usually made of leather. As the category implies. upper-limb deficiencies. Additional auxiliary belt suspension is generally prudent. Within a short period of time the lotion is absorbed into the skin. the skin is in direct contact with the socket. Anteriorly. Suction suspension can be used along with any of the other forms of suspension. This donning procedure requires some skill and effort. putting the end of the stockinette through the valve hole at the distal end of the socket. This method of donning a suction socket has allowed its use by amputees who traditionally would have been excluded from consideration for this suspension. of the prosthesis and then around the waist and fastens anteriorly with Velcro ( Fig 20B-24. Disadvantages include body heat retention and limited durability. heart problems. This suspension belt fits around the proximal 8 in.org/alp/chap20-02. the stockinette is gradually removed from the socket. For the patient with weak hip abductors. and the discomfort associated with constrictive waist belts. even very short amputation limbs can often be successfully fitted with suction as a primary suspension. especially if it is not removable for washing. An alternative and easier method of donning a suction socket is with the use of hand creams or lotions. It is quite comfortable and forgiving due to its elasticity.oandplibrary. It provides very positive suspension and enhances rotational control of the prosthesis. either as primary or auxiliary suspension. Negative air pressure suspends the prosthesis during swing phase. It is attached to a pivot point on the socket in the area of the greater trochanter and passes as a belt around the back and opposite iliac crest. Partial suction suspension in which the above principles are utilized with a thin prosthetic sock or nylon sheath sometimes eliminates or reduces the disadvantages. The prosthesis is donned by one of two methods. the amputee pulls his residual limb into the socket by applying a length of open-ended stockinette around his residual limb. or Dacron materials. it is http://www. . A new and quite simple alternative soft belt is the TES (total elastic suspension) belt made of elastic neo-prene material lined with a smooth nylon material. strength deficiencies. and the movements of the limb are transmitted to the prosthesis without lost motion. Hip Joint With Pelvic Band and Belt Although this form of belt does provide suspension. Generally. With the advent of ischial containment sockets. Balance problems. The socket is sealed around the residual limb directly against the skin. in some cases. it is a flexible. The disadvantages of the Silesian belt are hygiene. skin shear. ). In the process of pulling the residual limb completely into the socket. this suspension is particularly useful ( Fig 20B-23. where it achieves most of its suspension. and pulling the residual limb down into the socket.20B: Prosthetic Management | O&P Virtual Library end of the socket combined with a precisely fitted socket. the valve is applied and suction achieved. cotton webbing. Volume fluctuations such as weight gain or loss or fluid retention problems are contraindications for suction sockets.B). as opposed to belts around the waist. This belt provides a comfortable and positive form of suspension of the prosthesis and is simple to use. double attachment points ( Fig 20B-23. The traditional form of soft belt is the Silesian belt or bandage.asp[21/03/2013 21:56:09] . without the use of prosthetic socks. PRESCRIPTION CRITERIA: RELEVANT CASE PRESENTATIONS General Considerations When recommending transfemoral prosthetic components. Secondary considerations include the level of amputation. Rationale. He is very healthy http://www. Case 2. a four-bar polycentric knee with either pneumatic or hydraulic control. A lightweight endoskeletal component system of titanium or carbon graphite epoxy with a manual locking knee and either a lightweight solid-ankle. Case 3. Case 1. -Stability is a primary concern due to the combination of weakness and poor vision. two levels of criteria may be utilized. a torque absorber. cushion-heel (SACH) foot or multiaxis foot and ankle is also advised. Case Presentations Following are five case presentations. weight of components. She has no other health problems.-A 78-year-old man presents with a right transfemoral amputation and a history of peripheral vascular disease secondary to diabetes mellitus. He is plagued with failing eyesight as well. The intent is to exemplify several typical amputee cases as encountered in everyday prosthetic practice. is smooth in swing. However. Clearly. His left lower limb has vascular disease involvement and is weak and insensate.asp[21/03/2013 21:56:09] . and is athletically and socially active.org/alp/chap20-02. Either pneumatic or hydraulic knee control is essential for active athletes with varying cadences. Minimization of weight reduces effort involved in ambulation. Rationale. design. Recommendation. the less the likelihood of success in change. muscular residual limb. Recommendation. cosmesis..20B: Prosthetic Management | O&P Virtual Library generally reserved for cases where rotational control or mediolateral stability is needed. He is retired and interested in household ambulation. component. and is compatible with long amputations that might not have room beneath for other knee components.-A 29-year-old woman presents with a long left transfemoral amputation at the supracondylar region of the femur. durability of components. The cosmesis afforded by an endoskeletal prosthesis with soft cover meets the social and vocational needs of this amputee. Suction suspension is ideal for active amputees and is enhanced by a long. Prosthetic components that previously have been satisfactory should not be changed without significant discussion with the amputee. The four-bar polycentric knee provides inherent stability during the critical stance phases of activity. has normal range of motion and strength. The longer the amputee's experience with a specific system. provides better propulsion and response during all activities. and functional requirements.-A 15-year-old boy presents with a right transfemoral amputation at the proximal third of the femur secondary to cancer 6 years ago.-A semiflexible thermoplastic quadrilateral socket fit with thin prosthetic socks and the use of a soft suspension belt such as a neoprene TES belt is suggested. Her preferred sports are tennis and racquetball.-A quadrilateral suction socket is recommended with either a rigid laminated plastic socket or a thermoplastic flexible socket with semiflexi-ble socket retainer. safety requirements. other good recommendations are also possible. The first and most important level includes previous experience of the amputee.oandplibrary. and a dynamic-response foot are also suggested. and cost. A flexible socket system is more forgiving for the active athlete and thus more comfortable. quadrilateral sockets are usually quite successful in the young and muscular amputee with a long residual limb. vocational and avocational needs. and the dynamic-response foot. including one prosthetic recommendation. An endoskeletal component system with soft-cover cosmesis. He has decreased strength and range of motion of the residual limb. She is employed as an attorney's assistant. plus the rationale for each case. designed for the active amputee. -There are no contraindications for an ischial containment socket. etc. It has a single-axis friction knee.-A 24-year-old woman presents with a very short left transfemoral amputation caused by a motor vehicle accident 2 years ago. along with a weight-activated stance-control knee and a multiaxis ankle foot. both difficult to achieve given her femur length and poor muscle tone. She is currently finishing college and is interested in dating and dancing. Case 5. The Mauch S-N-S hydraulic knee provides stability and safety options meeting vocational needs. left transfemoral amputation. Clinical improvements and new materials and http://www. She also complains about the heavy feeling of the prosthesis.g. Rationale. clumsy prosthesis.-An ischial containment. Flex-Foot) for maximum dynamic response. thin cotton sock fit with a valve for partial suction is advised. -An ischial containment. Rationale.asp[21/03/2013 21:56:09] . An endoskeletal-type torque absorber in the shank above the graphite shank-ankle-foot should be considered. midthigh residual limb. The foot and knee mechanisms enhance stability while allowing active function.oandplibrary.-A 38-year-old male presents with a muscular. pelvic band.g.-A quadrilateral socket.-An ischial containment. preferably swing and stance control. The partial suction socket with a cotton sock provides a medium for absorption of perspiration and excellent and safe suspension when coupled with the Silesian belt.org/alp/chap20-02. Her short residual limb is significantly scarred. Heat and perspiration are a problem. flexible thermoplastic suction socket with a semiflexible thermoplastic socket retainer is advised. SUMMARY AND CONCLUSION During the decade of the 1980s. An exoskeletal design. An ischial containment socket will provide better mediolat-eral and rotational stability. and the swing-and-stance (e. The foot is simple and durable and conforms well to varying terrain. is quite adequate for a muscular. conforming foot such as a solid-ankle flexible-endoskeleton (SAFE) foot should be considered. midthigh. along with a carbon graphite epoxy strut shank-ankle-foot (e. The endoskeletal construction readily accommodates linear growth. and the torque absorber reduces shear stresses to the residual limb.20B: Prosthetic Management | O&P Virtual Library and active now and participates in junior varsity basketball and baseball. Silesian belt suspension is preferred. has poor muscle tone. Mauch swing-andstance hydraulic-control knee. Rationale. The exoskeletal construction is durable for vocational needs. The flexible socket enhances comfort and suspension. which is a quadrilateral socket with a hip joint.. An endoskeletal system of ultralight components and soft-cover cosmesis is recommended. suction socket is indicated by both the short residual femur and high activity level. An endoskeletal system with hydraulic knee control. is advised. The cause of the amputation was a mine explosion in the Viet Nam War." Recommendation. -The quadrilateral socket is familiar to this amputee and. and a simple. as well as being an avid hunter and fisherman. He is very strong and agile and needs to depend on his prosthesis for his work. as well as auxiliary suspension provided by a soft TES or Silesian belt. when properly fitted. He is reportedly "growing like a weed. maintenance-free. She complains of inability to control the prosthesis and the knee.. and lacks rotational stability. -Although perhaps difficult to fit in this case. Case 4. He has worn several prostheses. the suction suspension should be attempted to reduce the sensation of a heavy. Recommendation. She has not been able to consider a more demanding activity level. flexible socket with a rigid socket retainer and suction suspension is recommended with the option of auxiliary suspension in the form of a soft TES belt that is removable when desired. all quadrilateral socket designs. She is currently wearing her first prosthesis. He works as a framing carpenter and climbs ladders and scaffolding. Recommendation. The graphite epoxy shank-ankle-foot provides maximum possible dynamic response for demanding sports activities in addition to dependable durability. significant and controversial progress and change have taken place in transfemoral prosthetics. and waist belt. Mauch SN-S) hydraulic knee control offers many options. therefore he requests a socket fit with prosthetic socks. including a knee-locking option when hunting and ambulating in rough terrain. The optional auxiliary suspension provides confidence for high-demand activities. 6. in Donovan R. Berger N. 1989. pp 31-37. Kristinsson O: Flexible above-knee socket made from low density polyethylene suspended by a weight-transmitting frame. 15. International Workshop on Above-Knee Fitting and Alignment (Appendix C) Copenhagen. Radcliffe CW: Functional considerations in the fitting of above-knee prostheses. function. Kristinsson O: Flexible sockets and more. 11. Pritham C. pp 86-104. Pritham C. in Atlas of Limb Prosthetics. Quigley MJ: Above-knee amputations. International Workshop on Above-Knee Fitting and Alignment. International Society for Prosthetics and Orthotics. Wilson AB Jr (eds): Report of ISPO Workshops. 1989. and designs. International Society for Prosthetics and Orthotics.20B: Prosthetic Management | O&P Virtual Library components will continue to be developed. International Society for Prosthetics and Orthotics: In Donovan R. Pritham CH: Above-knee flexible sockets. International Society for Prosthetics and Orthotics. 9:9-14. 1987. Long I: Allowing normal adduction of femur in above-knee amputations. 12. Orthot Pros-thet 1983. Lundt J. 16. components. 20. Wilson AB Jr (eds): Report of ISPO Workshops. Through the use of new materials. Fishman S. UCLA School of Medicine.Above-Knee Amputations. 65:742. 1989. Ohio. 1970. Mooney V. Hall CB: Prosthetic socket shape as related to anatomy in lower extremity amputees. 1989. 14. 39:373-378. Green MP: Four bar linkage knee analysis. 14:9-21. Wilson AB Jr (eds): Report of ISPO Workshops. Prosthetics Education Program.oandplibrary. Copenhagen. section II. Fillauer K: Experience with the Scandinavian flexible socket. Los Angeles. Clin Prosthet Orthot 1985. and cosmesis are unchanged. Mauch Laboratories Inc: Manual for the Henschke-Mauch Hydraulic Swing-N-Stance Control System. International Workshop on Above-Knee Fitting and Alignment. 13. Springfield. Bassett LW. Copenhagen. International Workshop on Above-Knee Fitting and Alignment.asp[21/03/2013 21:56:09] . 3. Pritham C. pp 191-198. J Bone Joint Surg [Am] 1987. Mosby-Year Book. Los Angeles. in Murdoch G (ed): Prosthetic and Orthotic Practice. Anderson M. Ill. 1957. Edward Arnold. in Donovan R. Anderson M. Orthot Prosthet 1985. pp 24-29. International Workshop on Above-Knee Fitting and Alignment. Sollars RE: Manual of Above-Knee Prosthetics for Prosthetists. 4. Berger N: The ISNY (Icelandic-Swedish-New York) flexible above-knee socket. Radcliff CW: A short history of the quadrilateral above-knee socket. 1960. 23. 69:745-749. prosthetic management. Sollars RE: Manual of Above-Knee Prosthetics for Physicians and Therapists. 29:53-54. Michael JW: Current concepts in above-knee socket design. UCLA Prosthetics Education and Research Program. International Society for Prosthetics and Orthotics. pp 95-111. Wilson AB Jr (eds): Report of ISPO Workshops. in Donovan R. Instr Course Led 1990. 7. Hennessey C: Prosthetic Principles . 1989. Wilson AB Jr (eds): Report of ISPO Workshops. Phys Ther 1985. 22. Orthot Prosthet 1983. Long I: Normal shape-normal alignment (NSNA) above-knee prosthesis. Pritham CH. Hanker GJ: Radiographic analysis of the axial alignment of the lower extremity. Moreland JR. Littig D. pp 129-146. Wilson AB Jr (eds): Report of ISPO Workshops. Hoyt C. in Donovan RG. ed 3. London. 1981. 18. in Donovan R. 2. Pritham C. Copenhagen. 19. 9. Pritham C. 21. 37:15-24. International Society for Prosthetics and Orthotics. pp 20-23. International Society for Prosthetics and Orthotics. UCLA School of Medicine. 1989. Pritham C.org/alp/chap20-02. February 1976. the perspective from Durr-Fillauer. 24. Fillauer C. Dayton. 10. Radcliffe CW: Comments on new concepts for above-knee sockets. Pritham CH: Biomechanics and shape of the above-knee socket considered in light of the ischial containment concept. Prosthetics Education Program. Charles C Thomas Publishers. 8. Anderson M. Radcliff CW: Biomechanics of above-knee prostheses. Artif http://www. Los Angeles. References: 1. St Louis. 37:32-46. the transfemoral amputee can now achieve a higher activity level than was possible before. International Workshop on Above-Knee Fitting and Alignment. Krebs D: The ISNY (Icelandic-Swedish-New York University) flexible above-knee socket. 1957. Orthot Prosthet 1975. et al: The UCLA CAT-CAM Above-Knee Socket. 37:25-27. Clin Orthop 1964. Copenhagen. 5. Prosthet Orthot Int 1990. pp 15-19. Copenhagen. technical note. The fundamental goals of comfort. Bray J. 17. 39:17-32. pp 4-12. Schuch CM: Thermoplastic applications in lower extremity prosthetics. Wilson AB Jr: Brief history of recent development in above-knee socket design. Los Angeles. University of California. 27. Prosthetic. International Society for Prosthetics and Orthotics. 33. Clin Prosthet Orthot 1988. Copenhagen. Department of Surgery. 28. Sabolich J: Contoured adducted trochanteric-controlled alignment method: Introduction and basic principles. Orthopedics. in Donovan R. Pritham C. 12:77-90. Prosthet Orthot Int 1979. 26. 32. 1:146-160. 29. Saunders JBM.asp[21/03/2013 21:56:09] . September 1976. ProstheticsOrthotics Education Program: Total Contact Socket for the Above-Knee Amputation. pp 2-3. 1964. 1989.Atlas of Limb Prosthetics: Surgical. Prosthet Orthot Int 1988. 2:35-60. Inman VT. J Prosthet Orthot 1990. 35:543-558. New York. Continuing Education in Medicine and Health Sciences. 34. 35. Wilson AB Jr (eds): Report of ISPO Workshops. 9:15-26. J Bone Joint Surg [Am] 1953.oandplibrary. Wilson AB Jr: Limb Prosthetics. ed 5. above-knee prosthetics.20B: Prosthetic Management | O&P Virtual Library Limbs 1955. 31. 12:81-98. 3:1-8. ed 6. Clin Prosthet Orthot 1985. Design News December 9. Demos Publications.org/alp/chap20-02. 30. Prosthet Orthot Int 1977. School of Medicine. Schuch CM: Modern above-knee fitting practice. 3:126-136. Chapter 20B . and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 20B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Schuch CM: Report from international workshop on above-knee fitting and alignment techniques. Redhead RG: Total surface bearing self suspending above-knee sockets. Contact Us | Contribute http://www. Eberhart HD: The major determinants in normal and pathological gait. 1989. Radcliffe CW: The Knud Jansen Lecture. International Workshop on Above-Knee Fitting and Alignment. Schrader EW: Hydraulic damping programs knee action over cadence range. 25. inferior to the antero superior iliac spine and curves medially about the upper portion of the thigh just inferior to the inguinal ligament ( Fig 21A-1. The iliopsoas and the short external rotator muscles are divided at their insertions on the femur.B). Prosthetic. Numerous methods have been described. edition 2. C. the superficial muscles about the anteromedial aspect of the hip are transected at their origin on the pelvis. these areas being relatively avascular. Ablative surgery of this magnitude is indicated most often to eradicate a malignant tumor of the bone or soft tissues about the thigh. Transpelvic amputation is the surgical removal of the entire lower limb plus all or a major portion of the ilium. Reproduced with permission from Bowker HK. especially gas gangrene. Tooms. In developing his technique. the incision passes distal to the ischial tuberosity and then curves laterally to pass about 8 cm distal to the base of the greater trochanter. and Rehabilitation Principles Hip Disarticulation and Transpelvic Amputation: Surgical Procedures Robert E. In most instances. which begins just malignancies.21A: Surgical Procedures | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 21A Chapter 21A . draining sinus tracts. Boyd attempted to minimize blood loss by transecting muscles at either their origin or insertion. The hip joint capsule is then circumferentially incised and the liga-mentum teres divided to complete the disarticulation ( Fig 21A-1. Prosthetic. ©American Academy or Orthopedic Surgeons. Hip disarticulation is the surgical removal of the entire lower limb by transection through the hip joint. After ligation and division of the femoral vessels and transection of the femoral nerve. however.B). The hip abductors are then divided at their insertion on the greater trochanter. and the gluteus maximus is detached from its insertion on the femur. Frederick L.P. and Rehabilitation Principles. For purposes of http://www. Transpelvic Amputation This formidable procedure is performed almost exclusively for treatment of malignant tumors about the hip and pelvis. From this point.Atlas of Limb Prosthetics: Surgical. and the sciatic nerve is ligated and divided. The obturator artery is carefully ligated and divided. but the operative technique follows the same general pattern in each of the various methods. hip. Less frequent indications are extensive trauma or uncontrolled infections. Michael JW (eds): Atlas of Limb Prosthetics: Surgical..A).D. The hamstring muscles are detached from their origin on the ischial tuberosity. or pelvic region. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.. American Academy of Orthopedic Surgeons. The resultant stump is well padded and provides an excellent weight-bearing surface for prosthetic use. Placement of the incision may be varied to avoid large areas of scarring or to provide access to the retroperitoneal lymph nodes when excision of this tissue is indicated in certain The standard incision is an anterior racquet incision. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.oandplibrary.. IL. the techniques are followed as presented. 1992.asp[21/03/2013 21:56:15] . Rosemont. the function and prosthetic fit of a congenital limb anomaly may be improved by surgical conversion to a hip disarticulation. M. reprinted 2002. Hip Disarticulation The technique of hip disarticulation as described by Boyd is the basic procedure in general use. Hampton. On rare occasions. Prosthetic. and the obturator nerve is transected ( Fig 21A-1. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). The wound is closed by suturing the gluteus maximus to the remnants of the adductor muscles and approximating the skin edges ( Fig 21A-1. Posteriorly.. Click for more information about this text. SURGICAL TECHNIQUES The basic surgical techniques outlined here may require selective modification because of limb scarring. or the location of a tumor. the incision swings anteriorly and proximally to join the beginning of the incision.org/alp/chap21-01.A). D). Lazarri JH.asp[21/03/2013 21:56:15] . These problems. After ligating and dividing the obturator vessels and nerves.oandplibrary. perineal.. and this muscle is elevated with the overlying fat and skin as a large flap. Ehrlich HE: Exarticulation of the lower extremities for malignant tumors. 4.A). This can be accomplished by using a soft compression dressing in the conventional manner or by applying a rigid dressing of plaster of paris according to the immediate postsurgical prosthetic fitting technique. Munro RS: Technique and management of "hindquarter" amputation. King D. Chapter 21A . 84:346-349. The aponeurosis of the gluteus maximus is divided in line with the skin incision. many surgeons discovered that the available prosthetic components of this system do not permit comfortable sitting. Ann Orthop Traumatol 1948. In this position the abdominal contents fall away from the part of the pelvis to be removed. 133:267-269. and Rehabilitation Principles http://www. The operation is divided into three parts: anterior. the psoas and the levator ani muscles are transected. and the fossa between the iliacus muscle and the peritoneum is dissected. the initial anterior incision is continued posteriorly along the iliac crest to the posterosuperior iliac spine. The inguinal ligament and rectus abdominis muscle are severed from the pubis and retracted medially along with the spermatic cord and the bladder. From this point the incision swings laterally to the greater trochanter and then follows the gluteal crease into the perineum to join the perineal part of the incision. Br J Surg 1952..C). 6. Ann Surg 1946. In younger individuals. have led most surgeons to discontinue using the immediate postsurgical prosthetic fitting technique for amputations at the hip disarticulation and transpelvic levels. and the femoral nerve. Stump wrapping is continued until a definitive prosthesis is fit. 123:965-985.B). Boyd HB: Anatomic disarticulation of the hip.usually on the third or fourth postoperative day.. often at 6 to 8 weeks after surgery. The patient is positioned on the operating table in the lateral position with the sound side down.. 25:351-367. Furthermore. Sarondo JP. Ann Surg 1951. The wound is closed by suturing the gluteal flap to the abdominal muscles and approximating the skin edges ( Fig 21A-2. standing in parallel bars can be instituted at this time and rapidly followed by crutch ambulation.Atlas of Limb Prosthetics: Surgical.E). and divided.org/alp/chap21-01. 5. hip joint disarticulation (with and without deep iliac dissection) and sacroiliac disarticulation (hemipelvectomy). Gordon-Taylor G.. 39:536-541. ligated. Surg Gynecol Obstet 1947. Ferre RL: Amputacion interilio-abdominal. This provides exposure of the external iliac artery and vein. J Bone Joint Surg 1943. suspension of the temporary prosthesis is rather cumbersome. After stripping the perineal muscles from the rami. The initial incision begins at the pubic tubercle and is extended laterally along the inguinal ligament and then posteriorly along the iliac crest ( Fig 21A-2. After the anterior and perineal portions of the procedure are completed. Pack GT. 3. which is divided ( Fig 21A-2. plus rapid maturation of these amputation stumps when treated in the conventional manner. The sciatic nerve is then identified. Prosthetic. 1:143. After an initial enthusiastic application of an immediate postsurgical prosthetic fitting to hip disarticulations and transpelvic amputations.21A: Surgical Procedures | O&P Virtual Library this chapter. the ligaments and fibrocartilage of the pubic symphysis are completely divided ( Fig 21A-2. the technique as described by King and Steelquist will be outlined. The limb is then widely abducted and the skin incision extended from the pubic tubercle along the pubic and ischial rami to the ischial tuberosity. References: 1. thus eliminating the need for excessive retraction of the abdominal viscera. The ilium is then divided adjacent to the sacroiliac joint and rotated laterally to expose the intrapelvic structures ( Fig 21A-2. Steelquist J: Transiliac amputation. which are ligated and divided. nor do they provide a satisfactory gait. Resolution of edema from the surgical site is quite rapid after treatment by either of these postoperative management techniques. Postoperative Treatment After surgery the soft tissues of the amputation site should be firmly supported.F). completely freeing the ilium and entire lower limb ( Fig 21A-2. The abdominal muscles and the inguinal ligament are detached from the iliac crest. the patient is mobilized from bed as soon as comfort allows. and posterior. When a soft compression dressing is used. Rack FJ: Method of hemipelvectomy with abdominal exploration and temporary ligation of common iliac artery. 2.. performed in that order. org/alp/chap21-01.asp[21/03/2013 21:56:15] .21A: Surgical Procedures | O&P Virtual Library O&P Library > Atlas of Limb Prosthetics > Chapter 21A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .oandplibrary. Contact Us | Contribute http://www. 21B: Prosthetic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 21B Chapter 21B . reprinted 2002. This information.C. 1992. Often shoulder straps were required for suspension.). and a vaulting gait was common. C. American Academy of Orthopedic Surgeons.org/alp/chap21-02. Click for more information about this text. Prosthetic. and ankle joints that relied on biomechanics to achieve stance-phase stability while permitting http://www. knee.W) studied a group of 20 male and female hip disarticulation and transpelvic amputees who were representative of the age and diagnoses typically encountered. Prosthetic. knee. This unique approach demonstrated the feasibility of using unlocked hip. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. The energy requirements to use such prostheses has been reported At the same time.). was introduced by McLaurin in 1954 ( Fig 21B-2.asp[21/03/2013 21:56:19] .oandplibrary. HISTORICAL PERSPECTIVE The traditional device prior to 1954 consisted of a molded leather socket with a laterally placed locking hip joint called a tilting-table prosthesis.. only those who develop sufficient balance to ambulate with a single cane (or without any external aids at all) are likely to wear such a prosthesis long-term.d.C. still. and Rehabilitation Principles Hip Disarticulation and Transpelvic Amputation: Prosthetic Management Tony van der Waarde. A radical departure.Atlas of Limb Prosthetics: Surgical.(c). the senior author (T. Michael. Ninety percent of those polled reported that increased comfort was the main reason for using the prosthesis more often. Interestingly. a significant number do not become long-term wearers.v. Only 15% had been full-time users of their initial prostheses. The majority increased their wearing time. the lack of muscle power to be as much as 200% of normal ambulation. and Rehabilitation Principles. Although the anatomic differences between hip disarticulation and transpelvic prosthetic component selection and (hemipelvectomy) amputations are considerable. Gross pelvic thrust was required to propel the prosthesis. ©American Academy or Orthopedic Surgeons. the actual weight of the prosthesis had increased in several cases due to incorporation of more sophisticated componentry such as units to absorb torque while walking. John W. many complained of how cumbersome or uncomfortable their rigid sockets seemed. particularly if any portions of the pelvis have been excised. A full surgical report identifying muscle reattachments along with postoperative radiographs can be extremely valuable during the initial examination of the amputation site. and ankle/foot results in a fixed. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). later termed the "Canadian" design. C. Those who remain dependent on dual canes or crutches for balance eventually realize that mobility with crutches and the remaining leg. As a practical matter. edition 2. M.B. Prosthetic. and alignment for both levels are quite similar.O. in fact. at the hip. will influence the ultimate fit and function of the prosthesis. slow cadence. Other significant reasons were less effort when walking and improved appearance of the prosthesis. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.P. F. IL. a significant improvement in prosthesis utilization was noted.Ed. Prosthetic fitting is typically limited to motivated and physiologically vigorous individuals. Rosemont. After a 3-year follow-up during which these patients were fitted with a totally new prosthesis that included a novel silicone rubber socket ( Fig 21B-1. is much faster and requires no more energy expenditure than using a prosthesis does. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. To investigate this further.P. combined with a thorough physical examination and a precise plaster impression. The major differences are in socket design will therefore be discussed in some detail. without a prosthesis. Reproduced with permission from Bowker HK. Many authors have noted that the rejection rates for lower-limb prostheses are the highest at these proximal levels. the fulltime users' group increased from 15% to 65%. and the prosthetic thigh is thrust forward. A strong knee extension bias enhances this goal and offers the patient the most stable biomechanics possible with this mechanism. the hip flexion bias system was developed for the young. A more significant concern is that as the spring compresses between heel strike and midstance. it also improves ground clearance. Because there is very little increase in cost or weight and reliability has been good.org/alp/chap21-02. kinetic energy from the coil spring is released. from Michael J: Clin Prosthet Orthot 1988. As a result. active amputee who wished to walk rapidly. Missteps causing up to 15 degrees of knee flexion will not result in knee buckle. it creates a strong knee flexion moment. Another hip joint option is the Otto Bock four-bar knee disarticulation joint mounted in reverse ( Fig 21B-6. At toe-off. It should be noted that use of such knee http://www. the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. and locking joints are very rarely necessary.asp[21/03/2013 21:56:19] . KNEE JOINT MECHANISMS Other than the exception discussed above. Not only does this provide the amputee with a more normal-appearing gait. The prosthetic hip joint is attached to the socket anteriorly. Only then does the thigh segment rotate anteriorly and cause the hip joint to flex. two potential problems have been noted with this approach. the prosthetist is forced to shorten the limb for ground clearance. Friction resistance is often eliminated to ensure that the knee reaches full extension as quickly as possible. knee mechanisms are selected by the same criteria as for transfemoral (above-knee) amputees. The friction-brake stance control (safety) knee is probably the second most frequently utilized component. and excellent durability. One of the inherent limitations of the Canadian design is that the prosthesis must be significantly short (1 cm+) to avoid forcing the amputee to vault for toe clearance.). extends over the crest of the ilium to provide suspension during swing phase. some patients have difficulty in mastering the weight shift necessary for sitting. with minor modifications. Although this generally presents no problem during swing phase. which sometimes tend to recur inexorably. A molded plastic socket encloses the ischial tuberosity for weight bearing. At toe-off. the patient may fall. and Fig 21B-4. Fig 21B-3. and this results in excellent stance-phase stability plus good swing-phase flexion. many clinicians feel that the enhanced knee stability justifies this approach. However. Unless this is resisted by a stance control knee with a friction brake or a polycentric knee with inherent stability.21B: Prosthetic Management | O&P Virtual Library flexion at the hip and knee during swing phase. The single-axis (constant-friction) knee remains the most widely utilized due to its light weight.). In an effort to overcome this limitation. In essence. 12:99-108. Benefits claimed are parallel to as proposed by Peter Tuil of The Netherlands those expected from a polycentric knee unit: increased ground clearance during swing phase due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike amputees comment favorably on the smooth deceleration and good appearance while sitting that this joint offers.oandplibrary. One is the development of annoying squeaks in the spring mechanisms after a few months of use. low cost. Since the patient has no voluntary control over any of the passive mechanical joints. and affords excellent mediolateral trunk stability by fully encasing the contralateral pelvis. more sophisticated mechanisms have proved their value and are gradually becoming more common. The major drawback to this knee is that the limb must be non-weight bearing for knee flexion to occur. which makes gait training less difficult for the patient and therapist. the prosthesis can be lengthened to a nearly level configuration in most cases ( Fig 21B-5. the prosthesis is at its full length during midswing. particularly for the novice amputee. This is now the standard for prosthetic fitting worldwide. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. the polycentric knee is the preferred component with this hip mechanism. illustrate why this is so. Although the single-axis type was proposed as the knee of choice for the Canadian hip disarticulation design. Since the friction-brake mechanisms lose their effectiveness as the surface wears. HIP JOINT MECHANISMS The sections dealing with joint and foot mechanisms are reprinted. Furthermore. the use of fluid-controlled knee mechanisms for high-level amputees was considered unwarranted since these individuals obviously walked at only one (slow) cadence.). Unlocking the knee joint in order to sit requires the use of one hand in the unilateral case. they are particularly well suited for the bilateral Patients with all levels of amputation. this component offers maximum stance-phase stability. In addition. the fluid-controlled knee results in a hip flexion bias ( Fig 21B-7. experience has shown that this is rarely required and should be reserved as a prescription of last resort. the fluid resistance at the knee transmits the momentum up to the thigh segment and pushes the hip joint forward into flexion. In effect. The preferred mechanism has separate knee flexion and extension resistance adjustments. a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage of fluid control for the hip-level amputee. In addition. knee stability with this foot has generally been quite acceptable. (hemicorporectomy). In essence. Richard Lehneis et al. Added weight. and excellent durability. FOOT MECHANISMS Traditionally. In those cases where slightly more knee stability is desired. http://www. A third type that has proved advantageous for this level of amputation is the polycentric (fourbar) knee.21B: Prosthetic Management | O&P Virtual Library mechanisms bilaterally must be avoided. Gait analysis has demonstrated that utilization of a hydraulic knee in a hip disarticulation prosthesis results in a significantly more normal range of motion at the hip joint during the walking cycle than is possible with conventional knees. However. The development of hip flexion bias mechanisms and more propulsive foot designs have challenged this assumption. Finally. This adaptation provides a hip extension bias and has resulted in a smoother gait ( Fig 21B-8. up to and including translumbar amputee. Since it is impossible for the amputee to simultaneously unload both artificial limbs. For many years. Only additional medical disabilities such as blindness will require this mechanism. have reported on a coordinated hip-knee hydraulic linkage using a modified Hy-drapneumatic unit. expecting a bilateral amputee to cope with dual locking knees and dual locking hips is unrealistic. good durability. even in the definitive limb. Although slightly heavier than the previous two types. the solid-ankle cushion-heel (SACH) foot has been recommended for the Canadian hip disarticulation design due to its moderate weight. a single-axis foot with a very soft plantar flexion bumper is preferred. Motion studies conducted at Northwestern University have confirmed that a more normal gait for the hip dis-articulation/transpelvic amputee is also produced.oandplibrary. For example. and realignment capabilities of the endoskeletal polycentric mechanisms. Because the stability is inherent in the multilinkage design. have successfully ambulated with these components. Furthermore. sitting with two stance control knees becomes nearly impossible. fully locked joints may prevent the amputee from bending his trunk to protect his head from impact. a manual locking knee seems a logical choice. a number of new components have been developed recently that combine the characteristics of some of the above classes of knee mechanisms. So long as the heel durometer is very soft. Such "hybrid" designs are expected to increase over the next few years. This permits significant changes to the biomechanical stability of the prosthesis. maintenance. low cost.). and cost plus reduced cosmesis are the liabilities of this component. all polycentric mechanisms tend to "shorten" during swing phase. a more rapid cadence was also possible. As the shank moves into extension. Teh Lin manufactures a "Graphlite" knee consisting of a polycentric unit with pneumatic swing-phase control in a carbon fiber receptacle. It is well accepted that any fluid-control mechanism (hydraulic or pneumatic) results in a smoother gait. thus adding slightly to the toe clearance at that time.org/alp/chap21-02.asp[21/03/2013 21:56:19] . At first glance. Many of the endoskeletal designs feature a readily adjustable knee extension stop. it does not erode as the knee mechanism wears during use. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. the limb steps forward more rapidly. Because of the powerful stability. in the event of a fall backwards. these devices permit the amputee to press a button and passively rotate the shank 90 degrees or more for sitting comfort ( Fig 21B-10. The Carbon Copy II. This increases durability by placing the torque unit away from the sagittal stresses of the ankle while avoiding the risk of introducing swing-phase whips (which can occur if it is placed proximal to the knee axis). Finally. The SAFE version offers some transverse rotation as well. SOCKET DESIGNS AND CASTING TECHNIQUES The most important part of any prosthesis is the socket. more flexible forefoot that results in a smoother rollover for the patient. Many clinicians prefer fluid-controlled knees. Examples include the SwePro ankle from Sweden. In the last 5 years." Once again. the reverse occurs: the prosthesis actually becomes more stable during late stance phase. Otherwise. hence. who stated after receiving a Seattle foot. In general. and protecting the patient's skin from shear stresses. transverse-rotation units or positional rotators originally developed for the Oriental world have become available worldwide. The solid-ankle flexible-endoskeleton (SAFE) foot inaugurated a class that could be termed "flexible-keel" Other members of this class include the STEN foot and the Otto Bock Dynamic designs. They seem to provide a more rapid cadence. and the Seattle ankle. which leads to its powerful stability at heel strike. several ankle components have recently reached the American market. can also be used to advantage for the hip-level amputee. This component is particularly advantageous for entering and exiting automobiles. and Flex-Foot have all been successfully utilized for this type of patient. they may sometimes be utilized http://www. the more responsive the foot mechanism. Presumed reductions in energy consumption with the newer feet have not yet been documented by scientific studies for this level of amputation but have been demonstrated under certain circumstances for transtibial amputees. the interaction between the foot and knee must be carefully monitored. Ideally. sacrum. It flexes during swing phase only if the forefoot remains This creates a firmly planted on the floor as the body "rides" the prosthesis over it. and all have been demonstrated to function successfully for the high-level amputee. The polycentric knee mechanism strongly resists a bending moment.asp[21/03/2013 21:56:19] . more sophisticated foot mechanisms have reached the market. Seattle foot. In general. which provide a subjective sense of active push-off. the more important the knee unit resistances become. examination of postoperative radiographs and careful palpation of the pelvis are recommended. much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. or ischium remains. The major justification for such a component is that the high-level amputee has lost all physiologic joints and. or at least one with powerful friction cells. Springlite. the polycentric knee is actually more stable in late stance than with a more rigid foot. ). Installed above the knee mechanism. they are located just beneath the knee mechanism ( Fig 21B-9.21B: Prosthetic Management | O&P Virtual Library Multiaxis feet (such as the Greissinger) have liabilities similar to the single-axis versions but add extra degrees of freedom in hindfoot inversion/eversion and transverse rotation. has no way to compensate for the normal rotation of ambulation. shearing force that disrupts the linkage and permits easy flexion of the knee. "For the first time in my life I can pass someone in a crowd. In addition to foot mechanisms. Some amputees present as "hip disarticulation" when they have a short femoral segment remaining or as "transpelvic" when part of the ilium. as noted by one long-term hip disarticulation wearer. Dynamic-response feet. However. On the other hand. These can be paired with most of the feet mentioned above to add additional degrees of motion as desired. They not only facilitate sitting cross-legged upon the floor but also permit much easier entry into restaurant booths and other confined areas. In addition to accommodating uneven ground. when used in concert with a polycentric knee. Because the softer flexible keel delays this shearing moment. Torque-absorbing devices are often added to hip dis-articulation/transpelvic prostheses to reduce the shear forces transmitted to the patient and components. All are characterized by a softer. Unanticipated bony remnants can become a puzzling source of discomfort. a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. foot. During the initial assessment of the amputee. absorbing some of the torque of walking. The Blatchford (Endolite) Multi-Flex ankle from England.).oandplibrary. which provides the man-machine interface. multiaxis feet seem to decrease the wear on the other prosthetic mechanisms as well.org/alp/chap21-02. we believe that careful attention to shaping the medial wall in the ischial region is important to improve control of the prosthesis for both walking and sitting. The recent advent of laminating silicone rubbers allows even more flexibility than do available thermoplastics. and patient acceptance ( Fig 21B-14. The goal of casting is to create an exact replica of the pelvis including the often neglected areas inferior to the lateral. more than two dozen polypropylene/polyethylene copolymer sockets for hip-level amputation over the past decade with good long-term results in durability.org/alp/chap21-02. The male genitalia should be placed to the side prior to casting to permit the smallest practical anterodistal opening for the transpelvic socket. Although firm oblique counter-pressure toward the midline does reduce perineal shearing forces. a racing-style bicycle seat makes a useful adjunct when casting ( Fig 21B-13. Due to the success of ischial containment transfemoral sockets.oandplibrary. anterior. Although the fabrication is complex and difficult and the finished result slightly heavier than thermoplastic designs. the most commonly utilized socket material is a rigid thermosetting resin: An increasing trend toward more flexible thermoplastic materials is polyester or acrylic. As was noted earlier.) Soft rubber tubing or a similar shaping device can be pulled snugly about the waist just proximal to the iliac crests to ensure good definition of this critical suspension area and simultaneously define the contours of the thoracolumbar region ( Fig 21B-12.21B: Prosthetic Management | O&P Virtual Library to assist suspension or rotary control or to provide partial weight-bearing surfaces. As is the case with other levels of lowerlimb amputation.) has fitted 35 silicone rubber sockets over the past 2 years. This contour may add a measure of gluteal bearing on the contralateral side. However. it should not be overdone. in addition. We prefer to have the amputee simulate weight bearing during the plaster impression technique to create as precise a mold as possible. ). ). A sling suspension system should be utilized.W. and posterior aspects of the iliac crest. ).) has fitted evident. as noted by Lyquist. Many materials are suitable for socket fabrication. especially those of slight build. Prior to the removal of the plaster mold. Good distal contours often provide sufficient weight-bearing stability to allow the proximal border of the socket to be trimmed far below the second rib margin. More importantly. combined with the sling suspension provides sufficient compression.d. ).W. If the distance from the iliac crest to the ischial tuberosity is too large in the mold. The transpelvic socket requires careful attention to the distal contours for proper weight bearing. Hutter reported a single case of successful fitting of a transfemoral http://www. One of the authors (J. In like manner. comfort.M. as in other aspects of prosthetic practice. Although this can be done by hand. the socket will piston up and down with every step. Gentle contouring with the palm of the hand.asp[21/03/2013 21:56:19] .v. to firm up redundant soft tissue for obese individuals or transpelvic amputees. the importance of precise contours at the The same principles can ischium and ascending ramus is now more widely recognized. it prevents the hemipelvis from slipping through the inferior border of the socket and adds significant weight-bearing stability. it is useful to contour the area of the contralateral gluteal fold precisely. (A casting platform alone will suffice for many hip disarticulates. the anterodistal trim line should be as close to the midline as tolerable lest the panniculus protrude hernia-like during weight bearing. the resulting comfort and range of motion has been associated with significantly higher rates of prosthetic usage. ( Fig readily be applied to hip disarticulation sockets to increase both comfort and control 21B-11. Suction Suspension Nearly 40 years ago. favorable patient response and good durability recommend further development and more widespread application of this technique. During model rectification. ). Amputees who have previously worn more rigid designs typically describe the rubberized sockets as feeling "more natural" or "more like a part of me" ( Fig 21B-15. the ischial tuberosity area may be highlighted by adding more plaster splints while cupping the ischium firmly in the palm of the hand. in contrast to the technique advocated by Otto Bock. which was considered the proper trim line 30 years ago It is rarely necessary to extend the socket onto the thorax if the distal contours are correct. The senior author (T. In addition to using the sling casting technique to firm the tissues. relief must be provided for the inferior pubic ramus and pubic tubercle as well as the proximal edge of the iliac crests. Giaccone V. Foort J: Some experience with the Canadian-type hip-disarticulation prosthesis. 7. J Bone Joint Surg 1949. Higinbotham NL.21B: Prosthetic Management | O&P Virtual Library suction socket to a hip disarticulate with a mass of redundant tissue distal to the ischium. and carefully aligned. References: 1.asp[21/03/2013 21:56:19] .) has personally fitted three such cases recently ( Fig 21B-16.oandplibrary. 21. Huang CT: Energy cost of ambulation with Canadian hip disarticulation prosthesis. p 32. J Assoc Child Prosthet Orthot Clin 1988. 35:230-232. Orthot Prosthet 1980. Leonard JA: Above-knee prosthesis for hip disarticulation (abstract). 82:27-43. Orthot Prosthet 1967. Davis BP. Artif Limbs 1964. 52:47-48. J Bone Joint Surg 1968. Foort J: Construction and fitting of the Canadian-type hip-disarticulation prosthesis. 20. 8:3-27. Hampton F: A Hemipelvectomy Prosthesis. 5. Prosthetic Devices Research Project. components. and alignment ultimately determines the effectiveness of the prosthesis. Imler C. Prosthet Orthot Int 1979. Daniel R. Chicago. 2. foot. 23. J Bone Joint Surg [Am] 1953. Phys Ther 1977. Dankmeyer CH Jr: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees.A. Childs C: The S. Glattly HW: A preliminary report on the amputee census. sophisticated joint and foot mechanisms is often helpful. et al: Locomotion of the hemipelvectomy amputee. Hutter CG: Improved type of hip-disarticulation on prosthesis. 31:404-409. 15. elastic Silesian belt despite the total absence of any femur. J Prosthet Orthot 1990.E. 11. Stack D: Temporary prosthesis for the hip-disarticulation amputee. Iwakura H. Desio MA. 23:37.W. Artif Limbs 1957. Orthot Prosthet 1983. Warner R. Immediate postoperative fitting is technically feasible but rarely performed today. 50:389391. 4. Greene M: Four bar knee linkage analysis. Am J Surg 1951. Northwestern University Prosthetic Research Center. 22. 21:271-273. 4:52-70. careful attention to socket design. Orthot Prosthet 1981. 13. Friedmann LW: Comments and observations regarding hemipelvectomy and hemipelvectomy prosthetics. 4:39-51. Hampton F: A hemipelvectomy prosthesis. CONCLUSIONS Although wearing a transpelvic or hip disarticulation prosthesis may be cumbersome. Artif Limbs 1963. 1964. Arch Phys Med Rehabil 1986. Fujinaga H. 9. J Med Assoc State Ala 1983. Gillis L: A new prosthesis for disarticulation at the hip. Radcliffe CW: The Canadian-Type Hip-Disartic-ulation Prosthesis. 57:1394-1396. the initial acceptance rate appears to be similar to that for transfemoral amputation. 7:5-10. 24.d. Inter-Clin Info Bull 1964. 1980. Each was able to ambulate successfully and to retain full suction suspension with only the assistance of a thin. 67:667-668. 3:34-37. Banzinger E: Hip disarticulation prosthesis for infants (abstract). Medical Center Prosthetics. 12. Quigley M: A technique for thermoforming hip disarticulation prosthetic sockets.org/alp/chap21-02. 1956. 3. The major difference in socket configuration is the creation of a trough like channel to contain both the medial and lateral aspects of the ischiopubic ramus since no femur remains. ). 35:745-748. The senior author (T. 14. 18. 10. application of newer. This approach warrants further follow-up and evaluation to determine its practicality. et al: The problem of fitting a satisfactory prosthesis following hemipelvectomy. Artif Limbs 1957. Haslam T. University of California. Project Berkeley. In view of the magnitude of loss at this level. Concept 80. 8. Coley BL. 19. 16. J Bone Joint Surg [Am] 1953. Hutter CG: Suction-socket prosthesis for a hip-disarticulation amputee. 37:15-24. 6. 3:111-114. 3:5-9. 35:11-18. when fitted within a few weeks of amputation. Every case requires review on its own merits.F. Foort J. Brittain HA: Hindquarter amputation. 17. Such fittings have been done on an experimental basis where there is sufficient residual muscle tissue to create both suction suspension and biomechanical "locking" to stabilize the socket on the patient. Houston. http://www. Romieu C: Hemipelvec-tomy for tumors of bone: Report of fourteen cases. Long-term wearing rates increase significantly when sockets are comfortable. Campbell J. 34: 3-17. flexible.v. Wilson M: Hip Flexion Bias. Abe M. 43. Otto Bock Industries.A. 55. Alt LP: Hemipelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity. 45. Lundt JE: The UCLA anatomical hip disarticulation prosthesis. Chicago. 33. Technical Information Bulletin No. 1961. Northwestern University Prosthetic Research Center. 00:259-270. 1985. Prosthetic Services Centre. Institute of Rehabilitation Medicine. 30. Hubbard S. Beauregard M: An endoskeletal hip disarticulation prosthesis for the toddler. O'Riain M: Clinical Data on Floor Reaction Forces. Instr Course Lect 1990. Clin Prosthet Orthot 1987. J Bone Joint Surg [Br] 1989. Marx HW: Some experience in hemipelvectomy prosthetics. 49:987990. Nader M. Publication V. et al: Polycentric. 29. Michael J: Component selection criteria: Lower limb disarticulations. Artif Limbs 1958. J Trauma 1975. McLaurin CA. 56:917. 46. 9:307-312. Orthot Prosthet 1986. 37. Artif Limbs 1957. 40:58-60. Acta Orthop Scand 1968. Toronto. Oppenheim WL. Phys Ther 1969. Lyquist E: Canadian-type socket for a hemipelvectomy. Michael J: Energy storing feet: A clinical comparison. 53:170-172. Radcliffe CW: The biomechanics of the Canadian-type hip-disarticulation prosthesis.org/alp/chap21-02. 1980. Lee CM. et al: Prosthetics Management for High Level Lower Limb Amputees. 32. Canada. Smith RB: Traumatic hemipelvectomy-The tenth survivor: A case report and a review of the literature. 48. Orthot Prosthet 1968. Artif Limbs 1958. Prosthet Orthot Int 1983. Artif Limbs 1958. 26. De Bari A. Ann Surg 1953. p 3. Littig DH. Mandrup-Poulsen T: Success rate of prosthetic fitting after major amputations of the lower limb. Artif Limbs 1957. Murphy EF: Danish experience with Canadian HD (technical note). Krajbich I. et al: Surgical and prosthetic-orthotic treatment of patients with unilateral congenital or early childhood hip disarticulation or hemipelvectomy (abstract). 5:130-132. Hakelus A. Klasen HJ. Duders-tadt. Tricker J. et al: Prosthesis management of the cancer patient with high level amputation. 1954. 39:367-372. Hampton F: Diagonal Type Socket for Hip Disarticulation Amputees. 41. Nilsonne U. 39:44-47. McLaurin CA: Hip Disarticulation Prosthesis. Ten Duis HJ: Traumatic hemipelvectomy. Ann Surg 1946. 44. Injury 1978. 54. 5:132-133. 50. West Germany.-V1005 M 1079. Surgical problems in hemipelvectomy. 11:9-12. 137:704-717. Ann Chir Gynaecol 1967. Olerud S: Traumatic hemipelvectomy in a ten-year-old boy. Clin Prosthet Orthot 1988. J Bone Joint Surg [Am] 1971. J Prosthet Orthot 1991. 35:10-28. 31. Pinzur MS.asp[21/03/2013 21:56:19] . Jay GR. 56. 42. 52. New York. Meester GL.oandplibrary.21B: Prosthetic Management | O&P Virtual Library 25. Pack GT. Orthot Prosthet 1981. 16:541-545. Michael J: Overview of prosthetic feet. 49. 12:99-108. Department of Veterans Affairs. 4:22-28. Royal Ottawa Rehabilitation Center. Myerley WH: Traumatic hemipelvectomy: Case report and literature review. 53. Ockenfels PA: Management and construction procedure of bilateral split-bucket type hip disarticulation prosthesis. 51. Lehneis HR. Gauthier-Gagnon C. 40. Hjelmstedt A. Orthot Prosthet 1967. Levesque CM. Leppanen RE: A temporary prosthesis for hip disarticulation. McLaurin CA: The evolution of the Canadian-type hip disarticulation prosthesis. Sabolich L: A bilateral above-knee/hip disarticulation fitting. 4:29-38. 7:119-122. Orthot Prosthet 1985. Four Bar Linkage Knee Joint. 22:29-36. Inter-Clin Info Bull 1972. 27. Madden M: The flexible socket system as applied to the hip disarticulation amputee. 35. 123:965-985. Koskinen EVS: Hemipelvectomy for malignant tumours of bone: A study with preoperative arteriographic examination of the growth. J Assoc Child Prosthet Orthot Clin 1988. 5:129-130. 12:114-118. Report No. 38.Shear (report). 15. http://www. 1986. 11:154-168. Lehneis HR. 45. Jensen JS. et al: An easy-to-fabricate modified hip disarticulation temporary prosthesis (technical note). 39:161-170. Ehrlick H: Hip joint exarticulation and sacroiliac disarticulation. 23:37. 47. 3:120-124. 34. 71:291-295. 28. Johansson H. Lyquist E: New hip joint for Canadian-type hip-disarticulation prosthesis (technical note). 36. Clin Prosthet Orthot 1988. 39. 69. Vitali M. Bull Prosthet Res 1970. 59.asp[21/03/2013 21:56:19] . 74. Werne S: Two cases of hindquarter amputation. Wagner C. 62. 15:9-13. 1:13-18. 11:1-8. Wilson LA.21B: Prosthetic Management | O&P Virtual Library 57. 23:90-99. Ann R Coll Surg Engl 1967. 64. Taylor J. Machsood WA: Traumatic hemipelvectomy: A report of two cases with rectal involvement. Guth T: The CAT-CAM-HD. Phys Ther 1971. Contact Us | Contribute http://www. 40:260-266. 10:64-69. 58. Inter-Clin Info Bull 1971. J Bone Joint Surg [Am] 1976. 1988. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 21B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . J Trauma 1965. 72. Svetz WR. 12:109-113. Cook TM.M. et al: Biomechanics of the hip disarticulation prosthesis. Prosthet Orthot 1nt 1977. Acta Or-thop Scand 1954. Buckwalter JA. Solomonidis SE. Clin Prosthet Orthot 1988.oandplibrary.I. Gardner J: The immediate postsurgical adjustable pylon prosthesis for the hip-disarticulation and short-above-knee amputee. Inter-Clin Info Bull 1972.Atlas of Limb Prosthetics: Surgical. Van Zandt ML. Waters RL. Harris EE. 60. England. Inter-Clin Info Bull 1976. 12:119-122. Van Zandt ML. Noord Nederland. Orthot Prosthet 1984. 22:63-68. Clin Prosthet Orthot 1985. 65. 70.org/alp/chap21-02. et al: Hip disarticulation: A prosthetic follow-up. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. Prosthetic. Clark MW: A young hemipelvectomy patient. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. 31:426-430. 37:50-57. 51:144-151. 10:7-10. Taylor H. et al: Prosthetic management of hemicorporectomy. 16. Simons BC. Van Vorhis RL. 73. Zettl JH. Redhead RG: Amputees and their prostheses in action. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. 68. 63. Lehman JF. Orthot Prosthet 1983. Zettl JH. Tuil P: The hip disarticulation prosthesis as developed by the O. et al: Energy costs of walking of amputees: The influence of level of amputation. Orthot Prosthet 1968. J Bone Joint Surg [Am] 1949. Blackwell Scientific Publications. Shurr DG. 5:554-562. 9:15-26. 38:29-33. 66. 61. Gardner J: The hip-disarticulation and short above-knee immediate postsurgical adjustable pylon prosthesis. Chapter 21B . Childress DS: Kinematic aspects of the Canadian hip disarticulation prosthesis: Preliminary results in Murdock G (ed): Amputation Surgery and Lower Limb Prosthetics. Shepherd WG: Clinical trial of the diagonal socket prosthesis for hip disarticulation amputation. 17. Oxford. 67. 71. Wade FV. 58:46. A new design for hip disarticulation patients. Clin Prosthet Orthot 1988. Sabolich J. Loughran AJ. Seaton DG. Wise RA: A successful prosthesis for sacro-illiac disarticulation (hemipelvectomy). MRI is sensitive to changes induced by radiation therapy and can differentiate between tumor and radiation changes. Patients must be slowly advised of the individual losses they will face and the relative benefit of the operation in relation to the disease process and their symptoms. The need for intactness of the body becomes one of the major driving forces in the patient's rehabilitation. chronic urinary tract disease due to a neurogenic bladder. and Rehabilitation Principles Translumbar Amputation (Hemicorporectomy): Surgical Procedures Lawrence D.D. Regardless of the nomenclature. nonmetastatic tumors in whom there is an excellent chance for long-term cure. Patients must be given latitude in deciding on the operation. M. physical and social rehabilitation. preoperative patient and family education. TLA involves the loss of structures used in functions other than mobility and manipulation. These might include low-grade chondrosarcoma. Jose J. reprinted 2002. IL. giant-cell tumors. Patients with significant spinal cord injury resulting in paraplegia. and functional aids to the handicapped. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). the ravages of the operative procedure can be ameliorated. 1992. Prosthetic. The rehabilitation must be structural and functional. Coercion.22A: Surgical Procedures | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 22A Chapter 22A . and severe pressure ulcers may rarely be candidates for TLA. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. intimidation. insensate anal sphincter. PATIENT SELECTION Ablation of the caudal 50% of the human body has been named by the level of amputation. and guaranteed postoperative problems charge the surgeon and the support team with the task of careful patient selection. and incomplete discussion of the extent of the operation will foil any attempts at providing optimal patient care and the requisite strong patient-physician relationship. hemicorporectomy. TLA cannot be planned and executed in a short period of time. loss of potency. Unlike all other amputations. M. and it may be anticipated that a patient will cancel or delay the planned TLA. as well as soft-tissue masses encroaching on the nerve roots and dural sac. and Rehabilitation Principles. Despite the functional losses and significant structural distortion. translumbar amputation (TLA). Wagman. patients who become eligible for TLA have a disease process that is recurrent or chronic. Reproduced with permission from Bowker HK. Rosemont.Atlas of Limb Prosthetics: Surgical. The infiltration of the paraspinal muscles by tumor can be identified. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. sacral chordomas. Prosthetic. edition 2. ©American Academy or Orthopedic Surgeons. and by the extent of amputation. The importance of "looking whole" even when the whole is defective is primary. anticipated. Sexuality is severely diminished due to loss of both internal and external endocrine and reproductive organs. The surgeon and rehabilitation team must be sensitive to this reluctance and respond with further supportive and educational input. As a group. due to advances in surgical reconstruction. http://www. The recurrent group is made up of patients with low-grade. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. The sphincteric and storage functions of the anus and rectum and urogenital diaphragm and bladder are lost.org/alp/chap22-01. Current diagnosis of the intrathecal extension of sacral tumors includes a magnetic resonance imaging (MRI) study. or vascular neoplasms (massive hemangiomas or arteriovenous malformations). Prosthetic. An evaluation of the extent of the primary disease should include an exhaustive search for metastases or proximal local growth. this operative procedure is extensive in its loss of structure and function. The extensive known. few patients would consider loss of these cumbersome limbs and dysfunctional structures. prosthetic materials and fitting. Click for more information about this text. American Academy of Orthopedic Surgeons. Terz.asp[21/03/2013 21:56:24] .D. and absolute clarity in description of the risks and benefits. Fortunately.oandplibrary. Patients in whom the disease cannot be encompassed are not candidates for translumbar amputation. An exploration can be performed to assess the intra-abdominal extent of the tumor and potential sites of metastases. on the left.org/alp/chap22-01. reconstructive surgeon. cecum. The proximal portion of the aorta is closed with a running 3-0 monofilament vascular suture. psoas muscle. Rarely. The abdomen is then opened. Care must be taken in dividing the sigmoid colon at its most distal. the aorta is cross-clamped by placing a vascular clamp approximated 2 cm cephalad to the planned division site. The latter two are definitive commitments. orthopaedic surgeon. Because of the level of amputation the majority of the blood supply to the ureters will descend in a caudad direction from the renal pelvis. If any suspicious findings are noted.22A: Surgical Procedures | O&P Virtual Library SURGICAL TECHNIQUE The strategy for the surgical portion of the operation can be divided into three sections: soft tissue. In the male. Hemodynamic monitoring with arterial and central venous catheters is secured. urine output. sutures and pledgets may be required due to atherosclerotic changes or injury from previous radiation therapy. With the completion of mobilization and division of the aorta and vena cava. On the right. and central venous or left ventricular end diastolic pressure (pulmonary capillary wedge pressure). Consideration of tumor location. and in a mirror image pattern on the contralateral side. After the resectability of the tumor is confirmed. including the periaortic nodes above the planned level of transection (L3-4). This is especially important if the inferior mesenteric artery has been ligated at its takeoff from the aorta. and the liver parenchyma. whereas the former can be undertaken as the preliminary portion of the operation and be used as a diagnostic as well as a therapeutic maneuver. large ligaclips or a tie is placed on the proximal portion of the ureter to allow dilatation prior to reconstruction. biopsies can be performed before any irreversible steps are taken. An incision is outlined and extends anteriorly from the most posterior aspect of the iliac crest. Acute hypertensive changes may require stepwise clamping with the addition of peripheral vasodilators (nitroglycerine) and mild volume reduction (diuresis). and the inferior epigastric artery and vein are divided. previous radiation therapy. Communication between anesthesiologist and surgeon is required at this point to ensure precise evaluation of changes in arterial blood pressure. urologist. neurosurgeon. a thinner suture material (4-0 monofilament) can be used for the closure. and vascular. the gonadal artery and vein are the primary remaining retroperitoneal vascular structures to be ligated and divided at the level of the planned muscular transection. viable extent. attention is turned to the right and left sides of the retroperitoneum. along the inferior edge of the anterior abdominal wall at the level of the inguinal crease along the pubic bone to the pubic symphysis. The use of the right colon and terminal ileum to construct a continent reservoir for the urinary diversion (with loss of the ileocecal valve and the majority of the right colon) makes preservation of maximum colonic length important. Communication with the anesthesiologist is critical in anticipating and monitoring the sudden loss of venous return. the gonadal vein and. The integrated operative team includes an anesthesiologist. the anterior flap is reflected superiorly by dividing the balance of the anterior abdominal muscles. Positioning of the patient after intubation will depend on the plans for the individual patient as described in the text. The paired structures of the retroperitoneum. Mobilization of the great vessels will invariably require division of one or two of the lumbar vessels and the right gonadal artery. the spermatic cords are left with the specimen. The muscles of the anterolateral abdominal wall are divided from their bony insertions. The aorta is trans-sected sharply and the distal end oversewn. At the time of ureteral division. Adequate amounts of blood and blood products or alternatively a system for intraoperative blood loss collection and reinfusion should be prepared. Care is taken to preserve the entire length of the ureter with its enveloping blood supply. paraspinal soft tissues.asp[21/03/2013 21:56:24] . After complete mobilization. The vena cava is clamped and divided in a similar manner. The intraoperative findings will dictate the degree of involvement of each of these specialists.oandplibrary. The aorta and vena cava are mobilized above their bifurcation and below the renal artery and veins. The vascular clamp is released one or two clicks and any additional hemostasis secured with interrupted sutures. and genitofemoral and http://www. and surgical oncologist. The ureters are identified at or above the level of the common iliac vessels. Often. The base of the small-bowel mesentery with the right and ileocolic vessels. and right colon are mobilized cephalad in a fashion similar to a right retroperitoneal lymph node dissection. including the sympathetic trunk. and attention can be directed toward division of the intra-abdominal vascular structures and soft tissues. and planned urologic reconstruction will dictate the level of ureteral division. bony and neural. If necessary the inferior mesenteric artery can be divided. the closure of the flaps may be performed under tension because of the reduction in the volume of the intra-abdominal space (loss of the false and true pelvis.. tissue can be preserved from one of the lower limbs. the division of the bony and neural elements is the final step in the TLA. After adequate mobilization of the distal portion of the colon and re-examination of vascular integrity. One such flap utilizes the skin.org/alp/chap22-01. transverse processes.asp[21/03/2013 21:56:24] . ( Fig 22A-2. In addition. ( Table 22A-1. If any doubt exists regarding the level of tumor infiltration. Occasionally. and the extensive surgical procedure. The colostomy and urinary pouch stoma can then be matured and all wounds covered with appropriate dressings or drainage bags. and spinous process) and the du-ral sac with the spinal cord can be approached in one of two ways. in the paravertebral muscles. Care should be taken to resect any posterior elements (spinous or transverse processes) or residual vertebral bodies that may cause compression on the posterior flap. COMPLICATIONS The complications of TLA are primarily related to flap formation. Significant bleeding can occur at this point from the spinal artery and veins. If not easily controlled. division of the cauda equina (at the Ll-2 level). The patient can be turned to begin the anterior and intra-abdominal portions of the procedure. In patients whose disease is best approached with a primary anterior approach (those who require abdominal exploration or biopsy of retroperitoneal or anterior paraspinal musculature). The disk is removed or divided sharply with a knife and the dural sac identified anteriorly. no ostomy bag is required. In patients with neoplastic disease that may extend proximally along the dura or meninges or in cases where preoperative evaluation has suggested possible tumor extension intrathecally above a resectable level.. The division of http://www.).). Fig 22A-3. This initial exploration can be extended to include opening of the dura. A net-type dressing covering the TLA stump helps in securing the dressings in place without placing tape on the skin of the tenuous flaps ( Fig 22A-1. The result is a 350. a biopsy should be performed to ensure that the soft-tissue margin is pathologically negative. and along the skin edge. are divided.22A: Surgical Procedures | O&P Virtual Library femoral nerves. The division of the bony structures (vertebral bodies.to 700-mL continent reservoir that requires catheter drainage approximately every 5 to 6 hours. and Fig and muscle perfused by the femoral artery 22A-5. the disk space is identified at the planned level of the TLA. the surgical procedure should begin with a posterior-element laminectomy from approximately T1l to L3. The use of free flaps has not been attempted but may provide an additional alternative for coverage of the soft-tissue defect and closure of the wound. and the difficulty in fitting the patient in the bucket prosthesis is reduced. permanent suture material. The flap closure is performed in layers approximating the well-defined fascia of the anterior abdominal wall to the lumbodorsal fascia with interrupted. Continent urinary diversion has been used more recently with creation of an Indiana pouch formation of a detubularized reservoir from the right colon combined with plication of the terminal ileum and submu-cosally tunneled ureters. When this approach is used. The posterior flap is relatively ischemic due to the division of the aorta and associated lumbar vessels above the level of the aortic and caval transection. The musculature of the posterior abdominal and lumbar areas is divided at a level selected to preserve the maximum amount of vascularized soft tissue for closure. The specimen is removed from the operative field and meticulous hemostasis secured along the dura. The stoma is created by using the plicated terminal ileum and is placed through the anterior body wall flap in the mid to upper right quadrant. and repair of the cephalad dural division. Meticulous hemostasis is essential to prevent an epidural hematoma. Care must be exercised in planning a stoma that will be not compressed by the upper edge of the prosthetic bucket.). The subcutaneous tissues are closed with interrupted absorbable suture and the skin with metal staples or monofilament suture. The sac is opened and the neural elements ligated and divided. packing with cottonoid sponges can tamponade the vessels and allow for better exposure of these vessels by completing the softtissue division.. In cases where large amounts of skin are to be removed.oandplibrary. or approximately 25% to 30% of the volume). flap reconstruction with myocutaneous or fascial cutaneous flaps can be considered. The posterior skin and remaining musculature is rapidly divided. urinary reconstruction. Fig 22A-4. After initial healing. This will usually be in the central or left upper portion of the anterior abdominal wall flap. The anterior flap suffers from distal ischemia due to the division of the inferior epigastric artery and vein. an end colostomy is formed in a comfortable position. The final division of the transverse process and spinous process is performed with an osteotome. subcutaneous tissue. and ß-blockers and angiotensin I-converting enzyme inhibitors. sequentially increasing positions. These exercises all begin in the bed with range of motion. In the chronic phase.asp[21/03/2013 21:56:24] .e. This increases the shear and compressive pressure on the posterior and lateral aspects of the flap. the need for respiratory support on the ventilator. The blood loss may range from 3. urinary diversion or colostomy formation). even after a return to correct preoperative volume status (adjusted for new body size). the patients begin to use the wheelchair (standard or electric) as their primary source of mobility (see Fig 22A-6. Following ex-tubation. the patient's positions are limited to supine and lateral ones due to new stoma formation.000 to 8.. The sense of being able to move from side to side and arising from the supine position has psychological benefits. light weights. and fresh frozen plasma is required. the wheelchair is difficult to maneuver early in the postoperative period. Sitting upright is accomplished by graduating through a series of semirecumbent. The use of centrally administered high glucose and amino acid mixtures with http://www. gain of self-confidence. which they can operate in a prone position. problems are related to urinary tract infections. peripheral a. The initial problems are related to urinary leaks from the conduit and site of ureteral implantation. and friction. In the postoperative period. They must overcome significant deficits in balance and transfer. This is normally their first method for self-mobilization and travel outside their room.. The beds are structured as a (1) series of air cells that inflate in a cephalad-caudal and right-to-left sequence or (2) fluidized ceramic microspheres within a monofilament polyester filter sheet.500 mL. The patients utilize the gurney. Upper-limb strength-training exercises are required to provide adequate power for transfer and locomotion.22A: Surgical Procedures | O&P Virtual Library the posterior musculature and prior treatments (particularly radiation for sacral malignancies and embolization for arteriovenous malformations) also contribute to the tenous vascular supply to this myocutaneous or fascio-cutaneous flap. Although this was thought to be due to volume expansion during surgery. With additional education in transferring. chronic reflux and metabolic (prevented by the nonrefluxing ureteral implantation in the Indiana pouch). and hemodynamic monitoring. Those patients with severe pain or chronic infections may be malnourished when first evaluated. Patients are generally able to carry out this activity 1 to 2 months postoperatively. A variety of specialized beds have been designed to reduce pressure areas and shear effect. the hypertension persists indefinitely. and fitting in the bucket prosthesis. Nutritional maintenance in the preoperative and early postoperative period can be a difficult problem. This occurs during the first postoperative week and often requires a combination of diuretics. It is important to remove all posterior bony elements to minimize pressure points on the flap. i. Care is taken to prevent pulmonary overload and renal dysfunction by utilizing volume assessment with central venous or pulmonary artery catheters. These beds serve primarily to automatically shift the patient's position and prevent pressure. They are progressed to self-mobilization in the wheelchair and a self-propelled gurney stretcher. An unusual postoperative problem has been hypertension.org/alp/chap22-01. The bed is initially equipped with a trapeze device to encourage the patients to look around and strengthen the upper part of their body. Because of pain and positioning. Although the rare patient may begin to take an adequate protein and calorie diet at 7 days postoperatively (those patients who have already had a portion of the procedure performed. and replacement with packed red cells. whole blood. and use of the trapeze. and usually do not require formal revision. These are treated with diversion and drainage. Problems with the urinary diversion system occur both in the acute and chronic postoperative period. Hypertension can be a problem for unknown reasons but is hypothesized to be due to changes in the distribution of the intravascular volume.oandplibrary. the majority of patients are not achieving this nutritional goal until about 3 to 4 weeks postoperatively. Intravenous alimentation (either total or supplemental) may be started preoperatively and carried through to the postoperative period. central a-adrenergic stimulators. shear.A-D). Care must be taken not to put excessive pressure or shear on the stump suture line. patients begin a slow re-education to the upright position. This is due to decreased intake and increased metabolic demands. POSTOPERATIVE MANAGEMENT The early postoperative period is marked by redistribution of the large volumes used in the intraoperative replacement of blood and fluid losses. problems related to pouch bicarbonate wasting that result in hyperchlore-mic metabolic acidosis. including those for acceleration. incisional pain. physical and occupational therapists. 2. possibility for further education. The sequential use of intravenous narcotics (morphine). and anticipated difficulties in social interactions. which includes mobilization. Education has been provided regarding the care of the colostomy and may include the use of stomal supplies and techniques of irrigation as well as education regarding the care of the urinary diversion system (either use of the appliances or catheterization of the pouch). and long-term results. SUMMARY TLA is a structurally and functionally feasible ablative procedure. and physicians. Unfortunately. Razor B: A comparative study of the ileal conduit. Ahlering TE. For younger patients. is critical. The preoperative preparation must include an extensive search for metastatic disease and discussion with the patient and family of the risks. the patient has had the ablative surgery and care for any initial postoperative problems. Patients in whom the operation was performed for malignant disease must be evaluated for recurrence according to standard methods. Ahlering TE. The initial bucket and a cosmetic prosthesis for the lower limbs are being fashioned. J Urol 1990. braking. References: 1. and interpersonal relations should be discussed and sought. 142:1193-1196. A clinical social worker skilled in interpersonal and family dynamics must provide this critical support for the acute problems and during difficult transitions.). Razor B: Modified Indiana pouch. 145:1-3.org/alp/chap22-01. Operative preparation includes adequate blood and blood product availability and coordination of the multispecialty operative team. Almost all patients undergoing TLA have had pain as a significant component of the disease process.oandplibrary. Rapid involvement of the patient and family in the rehabilitative process. and direction indicating. healing of intestinal anastomoses (from harvesting the urinary diversion conduit). and resolution of the noninfectious diarrhea that is related to the reduction in bowel length frequently seen in these patients. all controls must be designed for hand use. Psychological as well as physical problems are present. education. social workers. Return to the mainstream requires that the patient be able to move not only within the home environment but also into the community. Maneuvering on uneven surfaces and grass. mechanical (changes in position and massage) and electrical stimulatory (TENS. employment. Weinberg AC. J Urol 1989. flap ischemia. Phantom pain is far more complex an entity and may require a variety of pharmacologic (oral and epidural agents). The former. The specter of recurrent disease is present and makes long-term follow-up evaluation essential. The basic techniques for bed-wheelchair transfers have been mastered. is related to flap closure and ostomy formation. http://www. Postoperative pain can be divided into two categories: incisional and phantom. this pain was one of the major motivating factors to undergo the surgery. transcutaneous electrical nerve stimulation) modalities for control. potent oral analgesics (oxycodone with acetaminophen [Percocet] or hydromorphone [Di-laudid]) and mild oral analgesics (acetaminophen with codeine) will be adequate for perioperative pain management. FOLLOW-UP EVALUATION The primary surgical procedure and the initial recovery require about a 2-month hospitalization.asp[21/03/2013 21:56:24] . feeding. Kock pouch and modified Indiana pouch. Weinberg AC. and difficulties with the urinary diversion. in a significant number.22A: Surgical Procedures | O&P Virtual Library supplemental lipids can bridge the nutritional hiatus during the return of bowel function. expected benefits. The health care team includes nurses. This may include modifying a car or van with the special apparatus necessary to load the wheelchair and allow the amputee to be securely positioned in the vehicle (see Fig 22A-7. In some. across curbs. During this period. the patient will need an advocate and support person. only a small number of translumbar amputees are able to be completely independent outside of the home. and socialization. and in inclement weather is difficult and at times frightening for these patients. the tumor will recur with a likelihood of incurable metastatic disease. Long-term goals of driving. it is important to counsel them regarding employment options. Even with all these features. The steps in preparing and fitting the prostheses are outlined elsewhere (see Chapter 22B). a dietician. Early in the preoperative evaluation and throughout the postoperative convalescent and rehabilitative phases. Of course. Early postoperative problems are large fluid volume shifts. 6. Prosthetic. et al: Translumbar amputation. Lee JKT: Retroperitoneum. Ling D. Terz JJ. Cancer 1990. Bradley WG (eds): Magnetic Resonance Imaging. Chapter 22A . St Louis. pp 1156-1163.oandplibrary. Mosby-Year Book. Schaffner MJ. 4. 1983. Contact Us | Contribute http://www. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 22A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Page CP: Hemicorporectomy. sensate flap for the hemipelvectomy defect. Liang MD: The quadriceps musculocutaneous flap: A reliable.org/alp/chap22-01.22A: Surgical Procedures | O&P Virtual Library 3. 30:226-230.Atlas of Limb Prosthetics: Surgical. Larson DL. in Stark DD. Goodkin R. 65:2668-2675. Aust JB. J of Surg Oncol 1985. Plast Reconstr Surg 1983.asp[21/03/2013 21:56:24] . 5. 72:347-353. Prosthetic. In fact. inability to tolerate an upright posture. nonambulatory system is used after primary healing is complete and while the rehabilitation options are being analyzed. Prosthetic. reprinted 2002.). Click for more information about this text.22B: Prosthetic Considerations | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 22B Chapter 22B . Rosemont. IL. The prosthetic management of a translumbar amputee involves several key decisions. OVERVIEW The translumbar (hemicorporectomy) amputee requires a special degree of care from the entire medical and prosthetic management team since this level of amputation represents a heroic effort to save the patient's life in the face of severe trauma. edition 2. C.P. and poor upper-limb strength. or cancer.org/alp/chap22-02. Donning. ©American Academy or Orthopedic Surgeons. and sitting techniques are all similar for both paraplegic and translumbar patients. and Rehabilitation Principles Translumbar Amputation (Hemicorporectomy): Prosthetic Considerations Greg Gruman. ambulation may be easier for the translumbar amputee since the weight of modern prosthetic limbs is but a fraction of the weight of the missing portions of the body. Michael. including instances of independent household and limited community am-bulation. However. American Academy of Orthopedic Surgeons. As would be expected. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. All are important factors in developing a prescription and treatment plan and require close consultation with the prosthetist. both can preclude ambulation until resolved.asp[21/03/2013 21:56:29] . A semireclined custom seating system may be considered in such cases.Ed.Atlas of Limb Prosthetics: Surgical. including the choice of a static or ambulatory system. Since translumbar amputation (TLA) has only been performed in recent decades and is There is a tendency for the prosthetist. doffing.. Reproduced with permission from Bowker HK. John W. therefore rarely encountered in clinical practice. http://www. Greater acceptance will occur if the amputee is allowed to fully acclimate to the sitting device prior to the introduction of an ambulatory system. 1992. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. standing. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). and many variants have been detailed in the literature. Prosthetic. SITTING PROSTHESIS Most authors advise provision of a static sitting support system prior to consideration of This ambulatory prostheses. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. the patient will have good support from spouse and family and will have completed a realistic goal-setting The purpose of preprosthetic therapy is strengthening of the entire upper part of process. C. The static sitting prosthesis is a good diagnostic tool for assessing amputee tolerance and cooperation. One key factor is the amputee's interest in and physical potential for ambulation. and Rehabilitation Principles. Physical barriers to prosthetic fitting can include gross obesity. the surgeon will ensure that the patient understands both the outcome of the procedure and the potential for rehabilitation. the literature reports numerous cases of successful prosthetic fitting following TLA. Ideally.oandplibrary. Furthermore. depression as well as significant medical complications are commonly encountered . the body due to primary dependence on the upper limbs for mobility following amputation. infection. and suspension techniques. therapist. prior experience with paraplegics is very good preparation for working with the TLA survivor. and physician to feel overwhelmed when faced with this challenge ( Fig 22B-1. componentry options.P. It requires the full cooperation of both the professionals involved and the amputee himself to achieve success. Prior to performing the operation. M.O. free of the pressures induced by weight bearing. and arm length and is best determined by dynamic alignment of the prosthesis during hand walking.oandplibrary. some amputees will request prosthetic http://www. Prior to casting for the prosthesis. 8. total contact is the best approach Although earlier reports speculated about to reduce the pressure per square centimeter. 3. It is usually advisable to unweight the prosthesis at frequent intervals by pushing up with the arms. the axillae.22B: Prosthetic Considerations | O&P Virtual Library Initially. 5. Epoxy resin-based bandage can be used for the cast and reused later as a temporary prosthesis with the tilt table to increase the tolerance for weight bearing. it is necessary to fashion a latex strap (fastened with Velcro) to cover the "mail slots" and provide gentle pressure to reduce the soft-tissue herniation.org/alp/chap22-02. follows: 1. AMBULATORY PROSTHESES Having accomplished this degree of independence. Dankmeyer and Doshi have suggested that the proper height for the base allows placement of the palms flat on the floor with slight Ideally it will provide sufficient stability to allow the amputee to pick up small elbow flexion. the possibility of interfering with respiration. objects without tipping over and yet allow an easy weight shift to initiate ambulation. have summarized the goals of socket design for the translumbar amputee as Independent transfer in and out of the socket ( Fig 22B-3. The specific contour of the rocker depends upon such factors as body weight.) Sufficient stability to permit free use of the upper limbs and wheelchair mobility Minimum socket tolerance of two 4-hour periods daily Sufficient weight-bearing pressure distribution to prevent skin necrosis Allowance for adequate respiratory exchange No abdominal pain or nausea from pressure within the socket Prevention of eversion of the colostomy and ileal bladder drainage bags Easy access to drainage bags for self-care Pressure relief over the sternum and distal portion of the spine.). been noted in the literature. even when leaning forward or back in the socket 10. including the inferior borders of the scapulae. 9. Several areas need pressure relief. the amputee can gradually increase tolerance to an upright posture in the Several reports of return to gainful employment have device up to 8 hours or more daily. Over a period of analogous to the advice given paraplegics to avoid skin breakdown. It is desirable to use a proximally adjustable socket to accommodate weight loss or gain and to allow the amputee to partially redistribute the weight-bearing forces to increase comfort. It is generally recommended that the amputee be suspended from a casting frame to allow the It is important to place the design of an accurate weight-bearing cast in a vertical position. a paper by Grimby and Stener noted only minimal change in vital capacity with a new prosthesis designed to reduce rib contact. it is desirable to use a tilt table with various degrees of elevation so that the amputee may develop a tolerance for the casting procedure. The major weight-bearing area is the thorax assisted by containment of the abdominal tissues. it may be possible to omit the colostomy opening. The most common design utilizes "mail slots" to allow the collection bags to remain outside the socket. 7. or the abdominal skin will protrude. provided that the amputee can defecate daily when not wearing the prosthesis. In some cases.asp[21/03/2013 21:56:29] . Any openings in the socket must be carefully limited. Simons et al. weeks or months. 4. With flat drainage bags. The socket design must also accommodate the ostomy stomas and allow free access to these sites for self-care. the distal platform may be altered by adding a rocker bottom to allow smoother forward progression by using the arms for a swing-through gait. tissues carefully in the position they will occupy in the final prosthesis. Acceptable cosmesis 11. 2. and the brachial plexus complex. SOCKET DESIGN The socket design for the translumbar amputee must precisely identify weight-bearing and relief areas by using multiple transparent test socket procedures. torso height. any prominent spinous processes. the sitting device has a level distal surface to enhance safety and stability ( Fig 22B2. Ease in cleansing socket areas in contact with the body Due to the limited surface area available for weight bearing. 6. Once comfort and a few hours' tolerance for sitting upright have been achieved. The primary factors in the successful rehabilitation of the translumbar amputee are motivation and compliance: the highly motivated individual will succeed despite the difficulties. it is not possible to recommend particular components. have reported longterm follow-up with two patients who remained ambulatory and gainfully employed for several years following prosthetic fitting and note that "the appearance of body normality appeared to play an important part in motivating them towards seeking a life other than institutionalized Williams concurs and reports that "when the patient hopelessness and helpless invalidism.org/alp/chap22-02." Although ambulation with crutches or a walker is feasible." was fitted with his final prosthesis. the patient is released from the dead weight holding him down. the amputee found work in a nursing home and survived until 1980. knee. Each clinic team must therefore make an individual determination based upon their experience and judgement. The gait pattern may be swing-through using forearm As is the case with paraplegia. stance-control. This is accomplished by providing the greatest possible independence and freedom. Length can be increased in increments." The obvious loss of more than half of the body mass notwithstanding. relieved of his chronic infection and/or cancer.asp[21/03/2013 21:56:29] . Aust summarizes his long-term experience with this procedure in a recent paper as follows: "Freed of the nonfunctioning lower half. Successful ambulation has been reported with either free or locking hips joints. It is also possible to add components sequentially. clinical verification of various foot. Care must be taken not to pinch any protruding flesh where the suspenders cross the proximal edge of the socket. survival for more than 20 years has been documented. . and either articulated or solidankle foot mechanisms ( Fig 22B-4. it may be preferable to prescribe a separate ambulatory prosthesis with a new socket. transfers will be more cumbersome with prosthetic legs attached. Davis et al.) whereby the ambulatory prosthesis fastens on top of the sitting device.. Initially. and smooth rollover during stance phase. Due to the small number of cases reported.). including employment and ambulation to whatever degree the amputee is capable. sense of well-being. even in a wheelchair. his attitude toward life changed dramatically . Dankmeyer and Doshi have reported a clever alternative (illustrated in Fig 22B-6. and renewed enthusiasm for life.. Bradley Aust performed the first successful TLA in 1961. ankle. and experiences a new mobility. polycentric. Rather than encumbering the sitting prosthesis. gentle heel strike. J. http://www. thus allowing the amputee to leave the legs behind in the chair when transferring. most recent cases utilize realignable endoskeletal componentry because of its versatility and light Due to the ease of interchangeable components. endoskeletal designs permit weight.). and hip joint combinations during gait training ( Fig 22B-6. Suspension of the prosthesis is critical if the stresses of swing-through ambulation are to be tolerated. Goals for dynamic alignment include stability of knees and hips. CONCLUSION The survival period for translumbar amputees may sometimes be limited but has increased steadily as medical care has advanced.oandplibrary. Over-the-shoulder suspenders have proved to be the best option for this type of prosthesis. it is the upper portion crutches or swing-to using a walker.. or locking knees.). with hip and knee joints added as the amputee progresses. Legs. provided that transverse rotation units are incorporated into the prosthesis. as the patient's balance and strength permit. prosthetic feet may be added directly to the socket to create a "stubby" prosthesis similar to the well-known design for bilateral transfemoral (above-knee) amputees. of the body that provides the propulsive force for such ambulation. Success with a reciprocating gait by swiveling the torso has also been reported for both bilateral hip disarticulation and for translumbar amputation. Although successful exoskeletal fittings have been reported in the past ( Fig 22B-5. .22B: Prosthetic Considerations | O&P Virtual Library legs for cosmetic purposes or to permit limited ambulation. numerous successful fittings following TLA attest to the potential for rehabilitation of the person faced with this singularly difficult challenge. It is the mission of the clinic team to enhance quality of life during whatever time remains. apparently made a difference for which there was no substitute . . et al: Hemicorporectomy. 22:63-68. 16. 13. 2. et al: Rehabilitation after hemicorporectomy. Mackenzie AR. 164:514-521. 23:408413. Karasewich EG: Translumbar amputation for carcinoma of the vagina. Grimby G. Inter-Clin Info Bull 1966. Miller TR. 56:359-362. 5. 6. Dawson WJ. Frieden FH. 7. DeLateur BJ. 57:471476. Dankmeyer CH Jr. 50:11-16. Schaffner MJ. 17. Yang CJ: Translumbar amputation for nonneoplastic cause: Rehabilitation and follow-up. Williams RD. 111:1139-1143. et al: Fitting of a prosthesis on a patient after hemicorporectomy. 59:988993. 65:2668-2675. Pearlman SW. 97:133-136. Arch Phys Med Rehabil 1969. Jockimsen PR. Am J Proctol 1972. Br J Surg 1970. Mackenzie AR. et al: Hemicorporectomy for intractable decubitus ulcers. Easton JKM.oandplibrary. Arch Phys Med Rehabil 1969. Fish JC: Translumbar amputation. Friedmann LW. J Urol 1967. Arch Surg 1966. Berkowitz T. Arch Phys Med Rehabil 1963.Atlas of Limb Prosthetics: Surgical. 3. 15. Baker TC. 11. Randall HT. Stener B: Physical performance and cardiorespiratory function after hemicorporectomy. The most radical procedure. Chu DS. Taylor N. 19.asp[21/03/2013 21:56:29] . 35:11-18. 93:502-506. 14. Arch Phys Med Rehabil 1975. Orthot Prosthet 1968. 10. 23:416-418. Terz JJ. et al: Hemicorporectomy. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 22B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . et al: Translumbar amputation. Mackenzie AR. J Surg Oncol 1985. Prosthetic. Orthot Prosthet 1981. Lord GB. 50:259-291. 5:22-23. Aust JB. 44:335-337. Aust JB. 4. Lehman JF. Arch Surg 1976. Park YS: Hemicorporectomy for functional rehabilitation. Cancer 1990. Chapter 22B . McShane RH. 30:226-230. Mackenzie AR. Randall HT: Translumbar amputation for advanced cancer: Indications and physiologic alterations in four cases. 9. Goodkin R. Page CP: Hemicorporectomy. 62:83-86. Miller TR. Randall HT: Translumbar amputation for advanced leiomyosarcoma of the prostate.org/alp/chap22-02. Miller TR. Marin EL. Tosberg W. Doshi R: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. 8. 18. Miller TR. Davis SW. Contact Us | Contribute http://www. Arch Phys Med Rehabil 1981. Surgery 1966. Gertler M. 12.22B: Prosthetic Considerations | O&P Virtual Library References: 1. Simons BC. et al: Prosthetic management of hemicorporectomy. et al: Rehabilitation of the patient after hemicorporectomy. Cancer 1968. Scand J Rehabil Med 1973: 5:124-129. Leichtentritt KG: Rehabilitation after hemicorporectomy. Ann Surg 1966. the therapist should introduce the amputee to higher levels of activities beyond just learning to walk. The visiting amputee should be carefully screened by appropriate personnel and should have a suitable personality for this task.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 23 Chapter 23 . having the comfort of knowing what the future holds as well as what will be expected of them can ease the process. 1992. Rosemont. the amputee may look forward to resuming a productive life. Gailey. P. Clark.asp[21/03/2013 21:56:34] . joint contracture prevention. M. Click for more information about this text.S. First. Prosthetic. If available.T. any information on various prostheses or videos showing recreational activities may benefit the patient. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. P. in conjunction with other qualified members of the rehabilitation team. The physical therapist's role is threefold. Reproduced with permission from Bowker HK. Fear of the unknown can be extremely frightening to many patients. age. Once success is achieved. If the patient so desires. edition 2. Prosthetic. where amputees visit other amputees to help them throughout the healing process.Atlas of Limb Prosthetics: Surgical. The amputee must be patiently educated in the biomechanics of prosthetic gait. ©American Academy or Orthopedic Surgeons. yet rewarding phase of rehabilitation for all involved. Second. the amputee must be physically prepared for prosthetic gait training and educated about residual-limb care prior to being fitted with the prosthesis.T. a prosthesis may be introduced at this point to satisfy curiosity.org/alp/chap23-01. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Although the amputee may not be ready to participate in recreational activities immediately. Jr. as members of the rehabilitation team. The therapist must also keep in mind how much information the patient is psychologically prepared to hear. Third. as well as overall functional assessment. A visit from another amputee who has been successfully rehabilitated can assist in this process. the amputee must learn how to use and care for the prosthesis. This period also offers the therapist an excellent opportunity to explain the time frame of the rehabilitation process. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Many hospitals have affiliations with local support groups.Ed. Prosthetic. Additional considerations should be given to similarities between level of amputation. and Rehabilitation Principles.. gender. providing the names of support groups and disabled recreational organizations can furnish the necessary information for the individual to seek involvement when ready. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). and Rehabilitation Principles Physical Therapy Management of Adult Lower-Limb Amputees Robert S. often develop a very close relationship when working together with lower-limb amputees. reprinted 2002. The prosthetist and the physical therapist. and outside interests. The pragmatic aspect of the therapist's responsibilities presurgically will include discussing the possibilities of phantom limb sensation and discomfort. therefore. The prosthetist is responsible for fabricating and modifying the specific socket design and providing prosthetic components that will best suit the life-style of a particular individual. Specifically.oandplibrary. the therapist will attempt to develop a professional rapport with the patient and earn his trust and confidence. American Academy of Orthopedic Surgeons. PRESURGICAL MANAGEMENT Initial Patient Contact This time provides an opportunity for the therapist to introduce himself to the patient and. POSTSURGICAL MANAGEMENT Evaluation http://www.. Prosthetic gait training can be the most frustrating. Curtis R. IL. to prepare the patient for the events to come. thus improving the potential for an optimal gait. wheelchair management. The patient must be made aware that decreased pain. If the patient does not possess the necessary level of cognition. bed positioning. The therapist should be concerned with assessing the patient's potential to cognitively perform activities such as donning and doffing the prosthesis. Mental Status An accurate assessment of the patient's mental status can lend insight into the likely comprehension level for future prosthetic care. Coordination assists with ease of movement and the refinement of motor skills.asp[21/03/2013 21:56:34] . Sensation Evaluation of the amputee's sensation is useful to both the patient and therapist alike. balance.org/alp/chap23-01. and abduction. Strength Functional strength of the major muscle groups should be assessed by manual muscle testing of all limbs including the residual limb and the trunk. and coordination. http://www. ROM. The therapist can gain insight into the possible insensitivity of the residual limb and/or sound limb. A measurement of the residual limb's range of motion (ROM) should be recorded for future reference. This will help determine the patient's potential skill level to perform activities such as transfers. Balance/Coordination Sitting and standing balance are of major concern when assessing the amputee's ability to maintain the center of gravity over the base of support. adequate bed mobility is a basic requirement for higher-level skills such as bed-to-wheelchair transfers.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library Past Medical History A complete medical history should be taken from the patient or obtained from the medical records to provide the therapist with information that may be pertinent to the rehabilitation program. thus extra care should be taken to avoid them. sensation. The most common contracture for the transfemoral amputee is hip flexion. If the patient is unable to perform the skills necessary to maintain proper positioning. assistance must be provided. while knee flexion is the most frequently seen contracture for the transtibial amputee. Range of Motion A functional assessment of gross upper-limb and sound lower-limb motions should be made. After evaluating mental status. temperature. This may affect the manner in which the prosthesis is fabricated. residual-limb sock regulation. the therapist will have a good indication of what would be the most appropriate choice of assistive device to use initially with the individual amputee. which in turn can lead to gait difficulties. family members and/or friends should become involved in the rehabilitation process to help ensure a successful outcome. During the ROM assessment the therapist should determine whether the patient has a fixed contracture or just soft-tissue tightness from immobility that can be corrected within a short period of time. and ambulation with and without the prosthesis. As with most patients.oandplibrary. and light touch sensation can increase the potential for injury and tissue breakdown. skin care. Joint contractures are complications that can greatly hinder the amputee's ability to ambulate efficiently with a prosthesis. strength. and other functional activities of the amputee. Bed Mobility The importance of good bed mobility extends beyond simple positional adjustments for comfort or to get in and out of bed. safe ambulation. The patient must acquire bed mobility skills to maintain correct bed positioning in order to prevent contractures or excessive friction of the sheets against the suture line or frail skin. Both balance and coordination are required for weight shifting from one limb to another. external rotation. This may affect proprioceptive feedback for balance and single-limb stance. For example.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library Transfers Transfer skills are essential for early mobility.oandplibrary. The heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter as the intensity of training increases. hypertension. A hand mirror may be used to view the posterior aspect of the residual limb. headache.asp[21/03/2013 21:56:34] . Problem Detection/Skin Care Every patient should be instructed to visually inspect the residual limb on a daily basis or after any strenuous activity. diaphoresis. the dysvascular patient's prosthetic gait training could be delayed 3 to 4 weeks if an abrasion should occur. wheelchair skills should be taught to all amputees during their rehabilitation program. Additional functional transfers such as toilet. initially an individual may require a walker. arteriosclerosis.org/alp/chap23-01.). If the amputee experiences persistent symptoms such as shortness of breath. Patient Education: Limb Management Limb Care It is important that the patient understand the care of the residual limb and sound limb. either temporarily or permanently. peripheral vascular disease. the therapist should make note of any history of coronary artery disease. a very basic prosthesis may be indicated for transfers only. Ambulation With Assistive Devices Without a Prosthesis A traditional evaluation of the amputee's potential for ambulation is performed. solid plastic materials are cleaned with a damp cloth and foam http://www. The patient must be taught the difference between weight-bearing areas and pressure-sensitive areas and also be oriented to the design of the socket and the functions of the prosthetic componentry. shower. Prosthetic Management The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. The selection of an assistive device should meet with the amputee's level of skill. Reddened areas should be monitored very closely as potential sites for abrasions. further medical evaluation is strongly recommended. including strength of the sound lower limb and both upper limbs. forearm crutches may prove more beneficial as a long-term assistive device. Wheelchair Propulsion The primary means of mobility for a large majority of amputees. or generalized weakness can still be successful prosthetic ambulators when the additional support of a prosthesis is provided ( Fig 23-1a. arterial bypass surgery. Some patients who have difficulty in ambulating on one limb secondary to obesity. More frequent inspection of the residual limb should be routine in the initial months of prosthetic training. The energy conservation of the wheelchair over prosthetic ambulation is considerable with some levels of amputation. For transtibial amputees who are not ambulatory candidates. angina. myocardial infarction. and mental status. and car transfers must also be assessed before discharge to more completely determine the patient's level of independence. or peripheral edema. angioplasty. will be the wheelchair. Therefore. chest pain. coordination. as well as prescribed cardiovascular medications that may affect the blood pressure and heart rate. dyspnea. single-limb balance. while keeping in mind that with time the assistive device may change. congestive heart failure. but with proper training. pallor. blindness. the patient must understand that in most cases the prosthesis should not be worn until healing occurs. Cardiac Precautions for Amputees During the initial chart review. and Fig 23-1b. As a rule. If a skin abrasion occurs. arrhythmias. For example. the use of residual-limb shrinkers. bed mobility. and joint ROM.). application must be performed correctly to prevent (1) circulation constriction. the "rule of ten. Donning and Doffing of the Prosthesis Today. there is a wide variety of suspension systems for all levels of amputation. (4) provide skin protection. Since then. decrease the possible risk of back pain. with the seams horizontal and on the outside to prevent additional pressure on the skin. Controversy does exist concerning the use of traditional elastic bandaging vs. what is important is that the amputee become proficient in the method of donning and doffing his particular prosthesis. Regardless of individual preference." The rationale behind a 10-second contraction is that a maximal isometric contraction can be maintained for 6 seconds. (6) reduce phantom limb discomfort/sensation. To list just a few possibilities.asp[21/03/2013 21:56:34] . and (7) desensitize the residual limb with local pain. The following illustrations demonstrate the basic dynamic strength training program for transfemoral and transtibial amputees ( Fig 23-4. These dynamic exercises require little in the way of equipment. Residual-Limb Wrapping Early wrapping of the residual limb can have a number of positive effects: (1) decrease edema and prevent venous stasis by ensuring a proper distal-to-proximal pressure gradient. The methods of donning each of these combinations are too numerous for the scope of this chapter. while the transfemoral amputee has the choice of a nonsuction external suspension or a suction suspension socket that can be donned with an elastic bandage. however. Stump socks are available in assorted plies or thickness that permit the patient to obtain the desired fit within the socket. Currently.org/alp/chap23-01. and (3) edema ( Fig 23-2. The patient should also be reminded that routine maintenance of the prosthesis should be performed by the prosthetist to ensure maximum life and safety of the prosthesis.). and Fig 23-3. The exercises are relatively easy to learn and can be performed independently. there is a 2-second rise time and a 2-second fall time for a total of 10 seconds. (5) reduce redundant-tissue problems. thus permitting the therapist to spend patient contact time on other more advanced skills. (3) help counteract contractures in the transfemoral amputee. All amputees should consider performing abdominal and back extensor strengthening exercises to maintain trunk strength. Preprosthetic Exercise Strengthening Eisert and Tester first described dynamic residual-limb exercises in 1954. the transtibial amputee has the option of a hard socket with or without a soft insert. Advocates of elastic bandaging state that more control over pressure gradients and tissue shaping is provided. or a silicone sleeve. however. which could include auxiliary suspension. and assist in the reduction of gait deviations associated with the trunk. Sock Regulation Sock regulation is of extreme importance to prevent pistoning from occurring. Incorporating isometric contractions at the peak of the isotonic movement will help to maximize strength increases. such as desensitization. (2) assist in shaping.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library materials with rubbing alcohol. wet fit. a medial wedge. Socks should be applied wrinkle free. (2) poor residual-limb shaping. many institutions prefer commercial shrinkers for their ease and reproducibility of donning. A period of a 10-second contraction followed by 10 seconds of relaxation for 10 repetitions gives the patient an easy mnemonic to remember. their antigravity exercises have been the most favored method of strengthening the residual limb. They also offer benefits aside from strengthening.oandplibrary. pull sock. A thin nylon sock (sheath) should cover the residual limb to assist in reducing friction at the residuallimb/socket interface. and suction or suction silicone sockets. The patient should carry extra socks at all times in case of pistoning or extreme perspiration. http://www. A towel roll and step stool are all that is required. The list of possible general strengthening/endurance exercise activities is long: cuff weights in bed. a progressive general exercise program should be prescribed for every patient beginning immediately after surgery. joint mobilization. and any sport or recreational activity of interest. it will offset the negative affects of immobility by promoting movement through the joints. Regardless of age or present physical condition. however.asp[21/03/2013 21:56:34] .oandplibrary. come to sitting. Bed Mobility The severely involved patient may be taught to utilize a trapeze. Amputees who have already developed a loss of ROM may benefit from many of the traditional therapy procedures such as passive ROM. which may be perceived as threatened due to limb loss. continued use of these methods will only hamper the future rehabilitation process. If difficulties are experienced. wheelchair propulsion for a predetermined distance.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library Amputees who have access to isotonic and isokinetic strengthening equipment can take advantage of the benefits derived from these forms of strengthening with few modifications in their positioning on the machines. or the inability to ambulate with a prosthesis altogether. Unfortunately. while easier initially. should not be employed for the general amputee population because. The transfemoral amputee should place a pillow laterally along the residual limb to maintain neutral rotation with no abduction when in a supine position. the patient will begin to re-establish personal independence. soft-tissue mobilization. are two acceptable methods that incorporate all the necessary skills for efficient bed mobility. or adjust their position. followed by side lying to sitting or supine lying on elbows to long sitting. The amputee should select one or more of these. and other methods that promote increased ROM. The individual has the opportunity to experience and enjoy activities thought impossible for an amputee. and increased circulation. and progress to 1 hour or more a day. to maintain hip extension. continued throughout the preprosthetic period. swimming. All amputees must be made aware that continual sitting in a wheelchair without any effort to promote hip extension may lead to limited motion during prosthetic ambulation ( Fig 23-5. proper limb positioning becomes important. the amputee is still within an environment where assistance may be readily obtained either from the therapist or from a fellow amputee who has mastered a particular activity. side rail. myofascial techniques.). The best way to prevent loss of ROM is to remain active and ensure full ROM of affected joints. lowerand upper-body strengthening at the local fitness center. and finally incorporated as part of the daily routine. or human assistance when learning bed mobility. two to three times daily. the psychological advantage derived from activity and independence will continue to motivate the patient throughout the rehabilitation process. Range of Motion Prevention of decreased ROM and contractures is a major concern to all involved. Finally. each patient should be taught a safe and efficient manner in which to roll. begin participation to tolerance. This practice. Functional Activities Encouraging activity as soon as possible after amputation surgery helps speed recovery in several ways. loweror upper-limb ergometer work. A stump board will help maintain knee extension when using a wheelchair. a pillow is placed anteriorly under the residual limb for 20 to 30 minutes.org/alp/chap23-01. Log rolling. gait deviations. Limited ROM can often result in difficulties with prosthetic fit. ambulation with an assistive device prior to prosthetic fitting. Transtibial amputees should avoid knee flexion for prolonged periods of time. General Conditioning A decrease in general conditioning and endurance are contributory factors leading to difficulties in learning functional activities and prosthetic gait training. muscle activity. First. If the prone position is tolerable during the day or evening. Second. not all amputees have this option. Regardless of age. and therefore. The advantages of participation extend well beyond improving the chances of ambulating well with a prosthesis. dynamic residual-limb exercises. wheelchair aerobics. http://www. contract-relax stretching. aquatic therapy. http://www. Because of the loss of body weight anteriorly the amputee will be prone to tipping backward while in the standard wheelchair. Once confidence is gained within the parallel bars. In cases where an immediate postoperative or preparatory prosthesis is utilized. Once confidence in standing with double arm support is attained. parking and braking. skin irritation. single-limb balance must be learned initially to provide confidence during stand pivot transfers. eventually progressing to hopping activities. floor-to-wheelchair transfers. Allow enough time between taps or throws for the patient to regain a comfortable standing posture. In most cases. while unilateral and younger amputees will be more likely to utilize other assistive devices when not ambulating with their prosthesis. turns.5 seconds to allow for smooth and safe progression of an assistive device during ambulation.. Other amputees will require an assistive device while ambulating with the prosthesis.org/alp/chap23-01. Unilateral amputees initially are taught single-limb transfers where the wheelchair is positioned on the sound-limb side and the patient pivots over the limb while maintaining contact with either the bed or chair.).23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library Transfers Once bed mobility is mastered. the patient should be challenged by gently tapping the shoulders in multiple directions or tossing a ball back and forth ( Fig 23-7. Although this habit must be broken when learning prosthetic ambulation.). Bilateral amputees who are not fitted with an initial prosthesis transfer in a "head-on" manner. wheelies. and agility. subsequently both hands are removed as independent balance is achieved. with the front of the chair abutting the transferring surface. it is advised that transfers to both the sound and involved side be taught since the patient will frequently be in situations where transferring to the sound side will not be possible. Ambulation With Assistive Devices All amputees will need an assistive device for times when they choose not to wear their prosthesis or for occasions when they are unable to wear their prosthesis secondary to edema.asp[21/03/2013 21:56:34] . should be taught immediately. more advanced transfers may be taught to improve the patient's independence. Unsupported Standing Balance In preparation for ambulation without a prosthesis. and car.oandplibrary. Amputee adapters set the wheels back approximately 5 cm. Later. As the patient's single-limb standing balance improves. advanced wheelchair skills should be taught: ascending and descending inclines. In order to improve balance and righting skills. strength. especially when ascending ramps or curbs. the patient must learn to transfer from the bed to a chair or wheelchair and then progress to more advanced transfer skills such as to the toilet. and preparation for transfers. and curb jumping. the hand on the same side as the amputated limb should be removed from the bars. ambulation with assistive devices. The patient then slides forward onto the desired surface by lifting the body and pushing forward with both hands. a lateral sliding-board transfer will be necessary to minimize friction and to cross the gap between the chair and desired surface ( Fig 23-6. There are a variety of assistive devices to choose from. The degree of skill and mastery of the wheelchair varies depending on age. the patient should practice these skills outside the parallel bars.e. The time dedicated to wheelchair skills is dependent on the degree to which the amputee may potentially require the wheelchair. The wheelchair approaches the mat or chair. Until adequate strength of the latissimus dorsi and triceps is attained for this transfer. weight bearing through the prosthesis can assist the patient in the transfer and provide additional safety. thus moving the amputee's center of gravity forward to prevent tipping. all amputees must learn to compensate for the loss of weight of the amputated limb by balancing the center of gravity over the sound limb. i. One method of progressive ambulation starts with the amputee standing in the parallel bars while using both hands for support. and eventually hopping. depending on the amputee's level of skill. tub. Wheelchair Propulsion Wheelchair mobility is the first skill that will give the amputee independence in the world outside of the hospital room. Bilateral and older amputees may require greater use of the wheelchair. A patient should be able to balance for at least 0. Basic skills such as forward propulsion. or poor prosthetic fit. (3) coordination and skill with the assistive device. strength. Once comfortable with weight bearing equally on both limbs. In order to maintain the single-limb balance necessary during stance without a prosthesis. Single-Limb Standing Weight acceptance in the prosthesis is one of the most difficult challenges facing both therapist and amputee. varying according to body height. but with practice the speed will become slower and more controlled. including (1) decreased stance time on the prosthetic side. ambulating with an assistive device. the speed of the sound leg will increase when upper-limb support is removed. ).to 8-in. balance. the decrease in body weight will alter the body's center of gravity. fear. and coordination are the primary physical factors influencing singlelimb stance on a prosthesis. or single-limb hopping. If balance and strength are good to normal. Pregait Training Balance and Coordination After the loss of a limb. http://www. amputees must learn to maintain the center of gravity and their entire body weight over the prosthesis. (2) upper-limb strength. Initially. as well as from side to side ( Fig 23-8. Then ask the amputee to step slowly onto the stool with the sound limb while using bilateral upper-limb support on the parallel bars.). Ultimately.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library While safety is a primary factor in selecting an appropriate assistive device. A walker is chosen when a amputee has fair to poor balance. its height depending on the patients level of ability.) stool (or block). and coordination. and lack of confidence in the prosthesis must be considered when an amputee is demonstrating extreme difficulty in overcoming weight bearing on the prosthesis. there is greater difficulty in reorienting them to maintaining the center of gravity over both the sound and prosthetic limbs. Various methods of proprioceptive and visual feedback may be employed to promote the amputee's ability to maximize the displacement of the center of gravity over the base of support. The criteria for selection should include (1) unsupported standing balance. Orientation to the Center of Gravity and Base of Support Orientation of the center of gravity over the base of support in order to maintain balance requires that the amputee become familiar with these terms and aware of their relationship. To further increase this weight-bearing skill ask the patient to remove the sound-side hand from the parallel bars and eventually the other hand. Without the ability to maintain full single-limb weight bearing and balance for an adequate amount of time (0.oandplibrary.) apart. this skill can be employed with relatively little difficulty. which in this case is the foot of the sound limb. It is important to recognize the need to promote adequate weight bearing and balance on the prosthesis prior to and during ambulation. thus promoting increased weight bearing on the prosthesis ( Fig 23-10. (2) a shortened stride length on the sound side. mobility is a secondary consideration that cannot be overlooked. Average persons stand with their feet 5 to 10 cm (2 to 4 in. and Fig 23-9. the amputee can begin to develop confidence with independent standing and eventually with ambulation. As amputees become more secure in their single-limb support. forearm crutches may be used for ambulation with or without a prosthesis. Increased weight bearing will be a direct result of improved center of gravity displacement and will establish a firm foundation for actual weight shifting during ambulation. pain. Additionally. Have the amputee stand in the parallel bars with the sound limb in front of a 10.org/alp/chap23-01. The stool-stepping exercise is an excellent method by which this skill may be learned. and (4) cognition.asp[21/03/2013 21:56:34] . A quad or straight cane may be selected to ensure safety when balance is questionable while ambulating with a prosthesis.5 seconds minimum) the amputee will exhibit a number of gait deviations. Single-limb balance over the prosthetic limb while advancing the sound limb should be practiced in a controlled manner so that when required to do so in a dynamic situation such as walking. The amputee must learn to displace the center of gravity forward and backward. These exercises vary little from traditional weight-shifting exercises.to 20-cm (4. or (3) lateral trunk bending over the prosthetic limb. Strength. the amputee must shift the center of gravity over the base of support. with the one exception that concentration is placed on the movement of the center of gravity over the base of support rather than weight bearing into the prosthesis. The body's center of gravity is located just anterior to the second sacral vertebra. not everyone has the same gait pattern. Pelvic Motions The pelvis. including plantar flexion of the foot. If restoration of function to the remaining joints of the amputated limb is a goal of gait training. then the pelvic motions play a decisive role in determining the final outcome of an individual's gait pattern. Because of this. 3. which leaves inadequate space for the prosthetic limb to follow a natural line of progression. and rotates transversely. 1. Therefore. this is directly related to weak hip abductor musculature. ). control of the musculature of the residual limb is necessary to maintain balance over the prosthesis. The following are three contributing factors that may help the amputee achieve adequate balance over the prosthetic limb.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library The amputee's ability to control sound-limb advancement is directly related to the ability to control prosthetic limb stance. Vertical displacement is simply the rhythmic upward and downward motion of the body's center of gravity. Lateral shift occurs when the pelvis shifts from side to side approximately 5 cm (2 in.asp[21/03/2013 21:56:34] .). tilts horizontally. In addition. This transverse rotation assists in shifting the body's center of gravity from one side to the other. the gluteus medius. they become adept at maintaining their center of gravity over the sound limb and therefore have a habit of crossing midline with the sound foot. moves as a unit in four directions: it displaces vertically. That is to say. if the limb is abducted. Gait-Training Skills Sound Limb and Prosthetic Limb Training Another component in adjusting to the amputation of a limb is restoration of the gait biomechanics that were unique to a particular person prior to the amputation. New amputees will find it difficult to understand this concept at first but will gain a greater appreciation as time goes on. the muscle is placed in a compromised position and is unable to function properly. shifts laterally. ). The knee must flex 10 to 15 degrees during foot flat. Knee flexion during toe-off is created by other influences as well. 2. The transfemoral amputee is at a disadvantage because the knee must remain in extension throughout the entire stance phase to avoid buckling of the knee ( Fig 23-11. Amputees have to spend an inordinate amount of time in single-limb standing on the sound limb when they are on crutches and hopping without the prosthesis or during relaxed standing. The result is a gluteus medius gait where the trunk leans laterally over the side of the weak limb in an attempt to maintain the pelvis in a horizontal position ( Fig 23-12.). Third. The transtibial amputee has the ability to flex and extend the knee during the stance phase of gait. Prosthetic gait training should not alter the amputee's gait mechanics for the prosthesis.org/alp/chap23-01. However. and http://www. which is 5 to 10 cm (2 to 4 in. but instead. depending on the height of the individual. Each of these motions can directly affect the amputee's gait and result in gait deviations or increased energy consumption during ambulation. Horizontal dip of the pelvis is normal up to 5 degrees. ). the goal of gait training should be the restoration of function to the remaining joints of the amputated limb. Maintenance of the residual femur in adduction via the socket theoretically places the gluteus medius at the optimal length-tension ratio. While more frequently observed in transfemoral amputees. with the body's center of gravity. more specifically. Usually. Prosthetic developments in the last decade have provided limbs that more closely replicate the mechanics of the human leg. First. this altered base of support may also be seen with transtibial amputees ( Fig 23-12. Transverse rotation of the pelvis occurs around the longitudinal axis approximately 5 to 10 degrees to either side.oandplibrary. Second. 4. the patient must learn to utilize the available proprioceptive sensation at the residual-limb/socket interface to control the prosthesis. and full extension must be obtained during midstance. horizontal dip of the pelvis. The amount of lateral shift is determined by the width of the base of support. the mechanics of the prosthesis should be designed around the amputee's individual gait. The result is an abducted or circumducted gait with greater-than-normal lateral displacement of the pelvis toward the prosthetic side. the amputee must visualize the prosthetic foot and its relationship to the ground. it also helps to initiate the 30 degrees of knee flexion during toe-off that is necessary to achieve 60 degrees of knee flexion during the acceleration phase of swing. anything greater is considered a gluteus me-dius gait. pelvic girdle. Strengthening of all available musculature by dynamic residual-limb exercises (see "Preprosthetic Exercise"). Sound-limb stepping within the parallel bars is performed with the amputee stepping forward and backward. pelvic.org/alp/chap23-01. The therapist blocks the prosthetic foot to prevent forward movement of the prosthesis. with both hands on the bars. just as it would if someone were kicking a football. ). There should be little if any loss of efficiency with the motion. heel rise to heel strike. and that heel contact occurs within boundaries of the base of support ( Fig 23-16. eventually progressing to resistive movements when the therapist deems them appropriate ( Fig 23-15. This also affords the therapist an opportunity to palpate the anterior superior iliac spines (ASIS) in order to gain a feeling for the patient's pelvic motion. and limbs. he can begin to move the pelvis actively. 2. 4. 5. As the amputee ambulates within the bars. the therapist's hands on the amputee's ASISs. To restore the correct pelvic motion. Second. have the amputee remove the sound-side hand from the bars.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library gravity. the amputee places the prosthetic limb behind the sound limb while holding on to the parallel bars with both hands. the amputee is ready to combine the individual skills and actually begin walking with the prosthesis. http://www. Prosthetic-limb stepping in the parallel bars is similar to the activity described above except that the amputee uses the prosthetic limb. the swing phase of gait can be taught. Attention must be given to the pelvic motions. Finally.It is important that the amputee feel the difference between the pelvic motion on the prosthetic side and the sound side. The amputee is now ready to step forward and backward with the prosthetic limb. 3. that the line of progression of the prosthesis remains constant without circumducting. or any other movement awareness techniques may be performed for trunk. 7. No prosthetic foot permits active plantar flexion. which in most cases is close to normal for that individual ( Fig 23-14. ). First. These exercises encourage rotational motions and promote independent movements of the trunk. and/or lateral leaning of the trunk. pelvic. As the amputee becomes comfortable with the motion. 8. in many cases a posterior rotation of the pelvis will be observed. 9. Rhythmic initiation is employed to give the amputee the feeling of rotating the pelvis forward as passive flexion of the prosthetic knee occurs. One suggested method of training is as follows: 1. When ready. Return to sound-limb stepping with both hands on the parallel bars. This is a direct result of the inability to bear weight or balance over the prosthesis. ). sound-limb stepping without any hand support may be practiced until sufficient mastery of single-limb balance over the prosthetic leg is acquired ( Fig 23-17. ). The purpose of this activity is for the amputee and therapist to become familiar with the gait mechanics of the sound limb without having to be concerned about weight bearing and balance on the prosthetic limb.oandplibrary. As the amputee improves.asp[21/03/2013 21:56:34] . Feldenkrais. independent movements of the various joint and muscle groups are developed. Normalization of trunk. After adequate skill is perfected. As the therapist palpates the ASIS. and limb biomechanics can be taught to the amputee in a systematic way. and the amputee holding onto the bars. begin in the parallel bars with the therapist and amputee facing each other. all component movement patterns are integrated to produce a smooth normalized gait. revert to the previous splinter skill. there may be an increase in the speed of the step. release the sound-side hand from the parallel bars and eventually both hands. Once the amputee and therapist are satisfied with the pelvic motions. the therapist applies slight resistance through the hips to provide proprioceptive feedback for the pelvis and musculature of the involved lower limb. and horizontal dip greater than 5 degrees is abnormal. Cue the amputee in remembering the skills learned while performing the stool-stepping exercise (see "Pregait Training"). 6. the independent movements are incorporated into functional movement patterns of the gait cycle. When each of the skills described above is developed to an acceptable level. This is often the result of the amputee's attempt to kick the prosthesis forward with the residual limb. ). a decrease in step length. therefore restoration of transverse rotation of the pelvis becomes of great importance in order to obtain sufficient knee flexion ( Fig 23-13. The pelvis rotates posteriorly. Proprioceptive neuromuscular facilitation (PNF). but if there is. Pregait training exercises (see "Pregait Training"). and limb re-education patterns. Observe that the mechanics are correct and that the sound foot is not crossing midline as heel strike occurs. At this time. Initially. When both the therapist and the amputee are comfortable with the gait demonstrated in the parallel bars. 11. Because of this kinesthetic capability and the increased length of the lever arm. When the left leg steps forward. all of which can have a direct influence on the energy cost of walking. equal stance time. the prosthetic limb often compensates by taking a longer step. When adequate weight bearing through the prosthetic limb has been achieved. the amputee must practice ambulating with the chosen assistive device and maintaining pelvic rotation. the trunk and upper limbs rotate opposite the pelvic girdle and lower limbs. an adequate base of support. they may require practice to attain equal stride length and stance time. This may be the result of fear of displacing their center of gravity too far forward or backward over the prosthesis ( Fig 23-19.5 mph. Syme ankle disarticulates have a major advantage over transtibial amputees due to the ability to bear weight distally. and equal stride length. momentum. momentum. Maintenance of equal stride length may not be immediately forthcoming because many amputees have a tendency to take a longer step with the prosthetic limb than the sound limb. have the amputee begin to take longer steps with the sound limb and slightly shorter steps with the prosthetic limb. and symmetry of gait. Once the amputee feels comfortable with the motion. improved kinesthetic feedback.asp[21/03/2013 21:56:34] . Knee disarticulates have several advantages over transfemoral amputees. This allows them to have better kinesthetic feedback for placement of the prosthetic foot. excursion becomes greater. ).oandplibrary. he can actively take over the motion. thus permitting a more efficient gait due to increased forward momentum. verbal cueing may be necessary as a reminder to keep the sound foot away from midline in order that the proper base of support can be maintained. At that time. arm swing influenced by the speed of ambulation. Trunk rotation is necessary for balance. and symmetry of gait and is directly With acceleration of gait. By simply having the amputee take a longer step with the sound limb and a moderate step with the prosthetic limb. As the amputee walks. Arm swing provides balance. as well as the cause and level of amputation. Normal cadence is considered to be 90 to 120 steps per minute. Restoring trunk rotation and arm swing is easily accomplished by utilizing rhythmic initiation or passively cueing the trunk as the amputee walks. Although these advantages do provide an opportunity for decreased rehabilitation time. depending on many factors such as age and motivation. increased speed of gait is accomplished without increased asymmetry. Trunk rotation will be absent in amputees utilizing a walker. especially on the prosthetic side. ). enhanced muscular control. The therapist may or may not continue to provide proprioceptive input to the pelvis ( Fig 23-18. This principle also applies when increasing the cadence. but those ambulating with crutches or a cane should be able to incorporate trunk rotation into their gait. Amputees who will be independent ambulators as well as those who will require an assistive device can benefit to varying degrees from the above systematic rehabilitation program. Variations Naturally. Trunk rotation and arm swing are the final missing components in restoring the biomechanics of gait. As the amputee begins to ambulate independently. minimal prosthetic gait training is required. The therapist stands behind the amputee with one hand on either shoulder. including a longer lever arm. the right shoulder is rotated forward and vice versa. Most patients can be progressed to the point of ambulating out of the parallel bars. or 2. the knee disarticulate must learn all the same skills as a transfemoral amputee. the same procedure as described above is practiced out of the bars. the therapist gently rotates the trunk. Many amputees have a decreased trunk rotation and arm swing. Similarly.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library 10.org/alp/chap23-01. amputees who walk at slower speeds will demonstrate a diminished swing excursion and hence less gait efficiency. Hip disarticulates and transpelvic (hemipelvectomy) amputees have the additional responsibility of learning to master the skills of a mechanical hip joint as well as the knee joint http://www. the time and degree of prosthetic training required is individual to each amputee. and greater distal-end weight bearing. During human locomotion. with the amputee initially using the therapist's shoulders as support and progressing to both hands free when appropriate. When an amputee increases his speed of ambulation. thus increasing the asymmetry. Although Syme ankle disarticulates are able to progress rapidly with weight shifting and other basic gait skills. With the prosthetic foot firmly on the step. The gait-training procedures are essentially the same as for transfemoral amputees. In some cases the mechanical hip joint may dictate that a slight vaulting action is necessary in order to clear the ground. knowledge of pressure and relief areas. Transfemoral Amputees: Step Over Step Timing and coordination become critical factors in executing stair climbing step over step. Advanced Gait-Training Activities Stairs Ascending and descending stairs is most safely and comfortably performed one step at a time (step by step). body weight is transferred to the prosthetic limb. the transtibial amputee who does not have the ability to dorsiflex his foot/ankle assembly must generate a stronger concentric contraction of the knee and hip extensors in order to successfully transfer body weight over the prosthetic limb. the prosthetic-side hip must flex at an accelerated speed to achieve sufficient knee flexion to place the prosthetic foot on the next step above. Amputees of all levels should be educated in residual-limb sock regulation. care of the prosthesis. Descending stairs is achieved by placing only the heel of the prosthetic foot on the stair below and then shifting the body weight over the prosthetic limb. very strong transfemoral amputees can ascend stairs step over step. thus passively flexing the knee. hold both crutches in the hand opposite the handrail. The sound limb must quickly reach the step below in time to catch the body's weight. Transtibial Amputees: Step Over Step When ascending stairs. the residual limb must exert a great enough force to fully extend the hip so that the sound foot may advance to the step above. As the sound-side hip extends.asp[21/03/2013 21:56:34] . Crutches When using crutches with stairs. Even fewer. and the sound limb is lowered to the same step. with or without a railing. Most transfemoral amputees who have mastered this skill descend stairs at an extremely fast pace. the body weight is shifted to the prosthetic limb as the sound limb firmly places the foot on the stair. or use http://www. Step By Step This method is essentially the same for all levels of amputees. both ascending and descending stairs step over step for transfemoral amputees is so difficult and energy demanding that the majority who master these skills still prefer the step-by-step method. the body weight is shifted to the sound limb. usually with the toe against the step riser. This compensates for the lack of dorsiflex-ion within the foot/ankle assembly.oandplibrary. When descending stairs. A few exceptional transfemoral amputees can descend stairs step over step. Once the prosthetic limb is securely in place. Descending stairs is very similar to normal descent with one exception: only the prosthetic heel is placed on the stair. The same process is repeated for each step.org/alp/chap23-01. When ascending stairs. Some transfemoral amputees will actually hit the approaching step with the toe of the prosthetic foot to achieve adequate knee flexion. much faster than would be considered safe for the average amputee. As the transfemoral amputee approaches the stairs. The trunk is slightly flexed over the sound limb as the knee extends and raises the prosthetic limb to the same step.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library and foot/ankle assembly. while hip disarticulates and transpelvic amputees are limited to the step.bystep method. the prosthetic limb is the first to ascend the stairs by rapid acceleration of hip flexion with slight abduction in order to achieve sufficient knee flexion to clear the step. or by the "jackknifing" method. The process is repeated at a rapid rate until a rhythm is achieved. Most transtibial amputees have the option of either method. In fact. and residual-limb donning and doffing techniques. which lowers the prosthetic limb to the step below primarily by eccentric contraction of the quadriceps muscle. Prosthesis wearers with knee joints have the added dilemma of the weight line falling posterior to the knee joint. Uneven Surfaces A good practice with gait training is to have the amputee ambulate over a variety of surfaces. During descent the prosthetic limb leads but remains slightly posterior to the sound limb. They prefer this method since it simulates a more normal appearance as opposed to the sidestepping or zigzag method. He can begin with simple weight shifting in the parallel bars and later perform higher-level activities such as unassisted sidestepping around tables or a small obstacle course that requires many small turns. grass. During early rehabilitation this skill provides the amputee with a functional exercise for strengthening the hip abductors and. the amputee can step up or down curbs with either leg. For most amputees. uneven terrain. the new amputee will have difficulty in recognizing the different surfaces secondary to the loss of proprioception. later in the rehabilitation process. Amputees with prosthetic knees must exert a greater-than-normal force on the posterior wall of the socket to maintain knee extension. the body weight should be slightly more forward than normal to obtain maximal dosiflexion with articulating foot/ankle assemblies or to keep the knee in extension. with an opportunity to progress into multidirectional movements. To promote an increased awareness. the amputee must realize that it is important to observe the terrain ahead to avoid any slippery surfaces or potholes that might result in a fall.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library both crutches in the traditional manner. and this causes a http://www. sidestepping is the most common alternative regardless of the grade of the incline. spending time on different surfaces and becoming visually aware of the changes help to initiate this learning process.asp[21/03/2013 21:56:34] . Initially.oandplibrary. or walking sideways. The sound limb should lead and provide the power to lift the body to the next level. while the prosthetic limb remains slightly posterior to keep the weight line anterior to the knee and act as a firm base. When ascending and descending hills. again acting as a form of support so that the sound limb may lower the body. the weight line falls posterior to the knee. resulting in a flexion moment. and varied carpet heights. Sidestepping Sidestepping. Curbs The methods described for stairs are identical for curbs. pelvic rotation with additional acceleration may be required in order to achieve maximal knee flexion during swing. Additionally. can be introduced to the amputee at various times throughout the rehabilitation program. Depending on the level of skill. including concrete. Ramps and Hills Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion present within most prosthetic foot/ankle assemblies. primarily because of the lack of plantar flexion in the foot/ankle assembly. Descent of an incline usually occurs at a more rapid pace than normal because of the lack of plantar flexion resulting in decreased stance time on the prosthetic limb. Backward Walking Walking backward is not difficult for transtibial amputees but poses a problem for amputees requiring a prosthetic knee since there is no means of actively flexing the knee for adequate ground clearance. In addition. The prosthetic knee remains in extension.org/alp/chap23-01. Most amputees find it easier to ascend and descend inclines with short but equal strides. the amputee will find sidestepping to be the most efficient means. descending inclines is even more difficult than ascending. When ascending an incline. For hip disarticulates or transpelvic amputees. Depending on the grade of the incline. gravel. Place a 5. remind the amputee to maintain knee extension by applying a force with the residual limb against the posterior wall of the socket ( Fig 23-21.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library flexion moment with possible buckling of the knee. the speed of movement should increase.oandplibrary. ). This method is effective but hardly the most aesthetic means of maneuvering. However. second. by crossing the sound limb 45 degrees over the prosthetic limb. the weight line is automatically thrown forward. For example. and second. further emphasizing the need for independent movement between the trunk and pelvis ( Fig 23-22. Single-Limb Squatting Single-limb balance is taught during the early stages of rehabilitation for crutch walking. and likewise. Turning to the prosthetic side is performed almost exactly the same way as turning to the sound side with one exception: slightly more weight is maintained on the prosthetic toe in order to keep the weight line anterior to the knee.asp[21/03/2013 21:56:34] .org/alp/chap23-01. As ability improves. or just simply turning around are often overcome by "hip-hiking" the prosthesis and pivoting around the sound limb. elevators. Simple braiding is one leg crossing in front of the other. The level of skill in turning will vary among amputees. heel to toe with one foot in front of the other. The prosthetic foot is placed well behind the sound limb. Braiding Braiding (cariocas) may be taught either in the parallel bars or in an open area depending upon the person's ability. perform the turn in two steps. With increased speed the arms will be required to assist with balance. thus preventing knee flexion. If necessary. Multidirectional Turns Changing direction during walking or maneuvering within confined areas often magnifies an amputee's difficulty in controlling the prosthesis. Situations such as crowded restaurants. The most comfortable method of backward walking is by the amputee vaulting upward (plantar-flexing) on the sound foot to obtain sufficient height so that the prosthetic limb that is moving posteriorly can clear the ground. with the majority of the body's weight being born on the prosthetic toe. One exercise that will reinforce turning skills is follow the leader. ).to 10-cm (2. and complete the turn by stepping in the desired direction with the prosthetic limb and leading with the pelvis to ensure adequate knee flexion ( Fig 23-20. first in front of and then behind the sound limb. With a little practice most amputees become quite proficient in backward walking. the prosthetic limb can alternate. The amputee is asked to walk in three different ways: first. http://www. and the turn is completed by stepping in the desired direction with the sound limb. Tandem Walking Walking with a normal base of support is of prime importance. two key factors for a smooth transition should be remembered: first. thus keeping the weight line anterior to the knee. rotate the sound limb 180 degrees. where the amputee follows the therapist who is making a series of turns in all directions and with various speeds and degrees of difficulty. Those with poor balance may be limited to unidirectional turns and require a series of small steps to complete the turn. All functional ambulators should be taught to turn in both directions regardless of the prosthetic side.to 4-in. The trunk is also maintained in some flexion in order to maintain the weight forward on the prosthetic toe. The sound limb is then brought back. trunk rotation will increase. As the amputee's skill improves. tandem walking can assist with balance and coordination and improve prosthetic awareness for the amputee. Simply move the prosthetic limb over the sound limb 45 degrees. usually at a slightly faster speed and a somewhat shorter distance. with one foot to either side of the line. and third. The prosthetic limb is rotated as close to 180 degrees as possible without losing balance (135 degrees is usually comfortable). maintain pelvic rotation in the transverse plane. When turning to the sound side.)-wide strip on the floor. ). and vice versa. with one foot crossing over in front of the other so that neither foot touches the line and yet the left foot is always on the right side and vice versa. From this position the amputee has the choice of remaining quadruped or assuming a sitting posture. the amputee and therapist must work closely together to determine the most efficient and safe manner to successfully master this task. forward momentum is decelerated. During foot descent. As the center of gravity passes over the prosthesis during the stance phase. Falling Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons but also as a means to perform floor-level activities. followed by a shorter stride with the sound leg. with the ipsilateral arm backward and the contralateral arm forward. half squats with a chair underneath the individual are recommended in case balance is lost. the hip should be flexed and then begin to extend as the knee is rapidly extending and reaching forward for a full stride ( Fig 23-23. amputees must first discard any assistive device to avoid injury. as with all gait-training and advanced skills. Rarely. is running taught in the rehabilitation setting. In order to give the prosthetic leg sufficient time to advance. commonly referred to as the "hop-skip" running gait pattern. Syme ankle disarticulates and transtibial amputees do have the ability to achieve the same running biomechanics as able-bodied runners if emphasis is placed on the following principles.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library hopping. The fundamental principle is to have the amputee use the assistive device for balance and the sound limb for power as the body begins to rise. the inability to run is the single most common factor limiting participation in recreational activities. During late mid-stance to toe-off. The knee flexion not only permits greater shock absorption but in addition creates a backward force between the ground and the foot to provide additional forward momentum. When first attempting this skill. the foot's forces are traveling forward and the reaction force of the ground must therefore be in a backward or opposite direction (Newton's third law). They should land on their hands with the elbows slightly flexed to dampen the force and decrease the possibility of injury. the hip on the amputated side should be flexed and moving toward extension with the knee flexed and the prosthetic foot passively dorsiflexing. and yet it is the most desired skill. and other skills. Lowering the body to the floor in a controlled manner is initiated by squatting with the sound limb followed by gently leaning forward onto the slightly flexed upper limbs. Transfemoral amputees and knee disarticulates traditionally run with a period of double support on the sound limb during the running cycle. Forward swing and the float phase are periods when the hip should be rapidly flexing and elevating the thigh. Many amputees who do not have a strong desire to run for sport or leisure do have an interest in learning how to run for the simple peace of mind of knowing that they could move quickly to avoid a threatening situation. with http://www.oandplibrary. the ipsilateral arm should be fully forward (shoulder flexed to 60 to 90 degrees). If the amputee is exposed to the basic skills of running during rehabilitation. Running. further decreasing the impact of the fall. The speed that a transfemoral amputee runner may achieve will be hampered because every time either foot makes contact with the ground. Depending on the type of amputation and the level of skill. they should roll to one side. Floor to Standing Many techniques exist for teaching the amputee how to rise from the floor to a standing position. The typical running gait cycle begins with a long stride by the prosthetic leg. Single-limb squatting is considerably more difficult but can help improve balance and strength.org/alp/chap23-01. In other words. the force produced by hip extension should deflect the keel so that additional push-off will be provided by the prosthetic foot. The result is that each time the foot contacts the ground. the sound leg takes a small hop as the prosthetic limb clears the ground and moves forward to complete the stride. During falling. ). As the elbows flex. then the individual may make the decision to pursue running at a later date. At ground contact. if ever.asp[21/03/2013 21:56:34] . The arms should again be opposing the advancing lower limb. while the contralateral arm is simultaneously extended. Extreme arm movement can initially be difficult for the amputee concerned with maintaining balance. the hip should be forcefully driven downward and backward through the prosthesis as the knee extends. If the prosthetic foot is of the dynamic-response type. takes time and practice to master. Running Skills For most amputees. Seasoned runners often reduce knee flexion resistance to permit the prosthetic shank to bounce off the socket and thus return to the extended position at an accelerated rate. In addition. For example. or another amputee who can teach from experience how to perform various higher-level recreational skills. Frank Angulo for his time and talents in creating the illustrations in this chapter. recreation is any play or amusement used for the refreshment of the body or mind. shuffleboard. The ability to run "leg over leg" has been achieved by a number of transfemoral amputees who have developed this technique through training and working with knowledgeable coaches. That is to say. the term recreational activities need not exclusively mean athletics such as running or team sports. followed by a typically shorter stride with the sound leg. necessary to help the amputee participate in shuffleboard. or playing cards as a means of socializing or relaxing. The transfemoral amputee has an additional consideration when learning to run. If the sole purpose of instructing running is to permit the individual to move quickly in a safe and sure manner. the primary goal of the rehabilitation team should be to make this transitional period as smooth and successful as possible. the physical therapist must work closely with the rehabilitation team to provide comprehensive care for the amputee. Acknowledgment We would like to thank Mr. The degree of success the amputee experiences with ambulation may directly influence how much the prosthesis will be used and how active a life-style is chosen. the hopskip method is often more easily taught and less demanding physically on the amputee. ). decreased and asymmetrical arm swing. the hop-skip method is most frequently suggested. or various methods of kneeling for gardening. decreased pelvic and trunk rotation. Recreational Activities By definition. Collectively. References: http://www. equal stride length and stance time may be achieved. The "leg-over-leg" running style does permit the transfemoral amputee to run faster for short distances but at a greater metabolic cost. these adjustments decrease the amount of time required for the prosthetic swing phase.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library every stride the amputee is slowing down when running with the "hop-skip" gait. coaching.oandplibrary. and excessive trunk extension. many people enjoy recreational activities such as gardening. To date. many of these deviations will decrease and possibly be eliminated ( Fig 23-24. CONCLUSION In summary. Providing the amputee with information on how to contact these groups is the first step to mainstreaming the patient back into a life-style complete with recreational skills as well as activities of daily living. Another problem with present knee units that transfemoral amputees must contend with is maintaining the appropriate cadence during swing. the therapist can teach physical splinter skills such as weight shifting. An individualized program must be constructed according to the level of ability and skill of each patient. In fact. while increased resistance in flexion decreases the amount of heel rise with beginning runners. During running. less resistance in extension permits faster knee extension. With training. no knee system permits flexion during the prosthetic support phase. Again with training.asp[21/03/2013 21:56:34] . problems that may occur include excessive vaulting off the sound limb to ensure ground clearance of the prosthetic limb. While the "leg-overleg" style is preferred. The transfemoral amputee takes a full stride with the prosthetic leg. and this results in the residual limb having to absorb the ground reaction force during initial ground contact. Therefore. there are many national and local recreational organizations and support groups that provide clinics.org/alp/chap23-01. This running pattern is a more natural gait where the double-support phase of the sound limb is eliminated and forward momentum maintained by both legs. A comprehensive rehabilitation program should include educating the amputee on how to return to those activities that are found pleasurable. Hydraulic knee units offer the ability to adjust the hydraulic resistance during knee flexion and extension. Initially. The primary skills of preprosthetic training help build the foundation necessary for successful prosthetic ambulation. 35:695-704. Murray MP. Peizer E. Contact Us | Contribute http://www. 5. Eisert O. S & S Publishing. ed 2. Am J Phy Med Rehabil 1967. 46: 335-360.org/alp/chap23-01. 4.23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library 1.asp[21/03/2013 21:56:34] . Davis GJ: A Compendium of Isokinetics in Clinical Usages and Rehabilitation Techniques. Wright DW. Prosthetic. J Bone Joint Surg [Am] 1964. Mason C: Human locomotion.Atlas of Limb Prosthetics: Surgical. Wise.oandplibrary. 10:48105. 16:290333. 1985. Drought AB. Tester OW: Dynamic exercises for lower extremity amputees. Chapter 23 . Arch Phys Med Rehabil 1954. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 23 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . La Crosse. 3. Bull Prosthet Res 1969. Murray MP: Gait as a total pattern of movement. 2. Kory RC: Walking patterns of normal men. P. assistive devices are necessary to stand and walk. C. ©American Academy or Orthopedic Surgeons. Motorcycle accidents. Persons with high-level amputations or congenital limb deficits that present a similar functional loss can occasionally walk without a prosthesis by using crutches and a swing-through gait. In most cases. Zettl. IL. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Ernest M. Such ambulation is seen very occasionally in children and young adults. rehabilitation can be surprisingly successful and rewarding in these infants and children. Improved medical management is continually increasing life expectancy throughout the industrialized world. The surgeon.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 24A Chapter 24A . there were 112. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Mobility by ambulation with prostheses profoundly improves the quality of life as compared with a wheelchair existence. or about 50% of surviving patients. the complications of diabetes. Prosthetic. and 50% of these were in patients with diabetes. American Academy of Orthopedic Surgeons. the independence and mobility achieved by aggressive Reproduced with permission from Bowker HK. The 3year survival rate after a major amputation for diabetes or vascular disease is about 50% and is essentially unchanged from the mid-1960s to the early 1980s. Most of those sustaining bilateral traumatic lower-limb amputations are adolescents and young adults. pedestrian involvement in car or train accidents.D.oandplibrary. medical. peripheral vascular disease. As people live longer. can be expected to lose the second limb by 2 to 3 years following the first amputation. http://www.500 nontraumatic lower-limb amputations in the United States. and muscle control. and severe burns are generally responsible.asp[21/03/2013 21:56:40] . and rehabilitative care further results in a life expectancy of months and often years as a bilateral lower-limb amputee.org/alp/chap24-01. and the rehabilitation team have at their disposal today a wide variety of prosthetic and assistive aids for providing comfortable standing and walking. Bilateral lower-limb amputations are much more frequent currently than in the past largely secondary to an aging population with an increased incidence of peripheral vascular disease and diabetes mellitus. Many simple as well as ingenious means have been used by the amputee to move from place to place. The quality of surgical.Atlas of Limb Prosthetics: Surgical. studies have shown that approximately 25% of the original group. With appropriate prosthetic management. Click for more information about this text. edition 2. sense of balance. The current high quality and availability of military and emergency medical care allows survival for many patients whose severe trauma would have been fatal in previous decades. Bilateral congenital leg amputations and limb deficiencies encompass a small but often difficult group. Often the amputees self-designed and made devices that best suited their needs. Burgess. The remarkable degree of functional restoration now possible can often permit the bilateral leg amputee to participate in a life-style that socially and vocationally overcomes his physical handicap. especially in war or natural disasters. M. The bilateral lower-limb amputee has throughout recorded medical history presented a special challenge for the rehabilitation team to provide a degree of mobility that would allow a more normal place in society. There are also an increasing number of bilateral lower-limb amputees as a result of trauma. Joseph H. Loss of both lower limbs is also encountered in trauma centers throughout the industrialized world. and Rehabilitation Principles Special Considerations: Fitting and Training the Bilateral Lower-Limb Amputee Douglas G. This requires very good trunk and upper-body strength. Prosthetic rehabilitation potential is usually excellent. Prosthetic. Since these disease states are systemic. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Rosemont. Prosthetic. In 1985. reprinted 2002. Smith. Even if prosthetic ambulation is not expected to continue into adult life. M. and other chronic medical diseases progressively increase the frequency of lower-limb loss. the prosthetist. and Rehabilitation Principles.D. 1992. On the other hand. ambulatory potential. Most unilateral transtibial amputees who were successful prosthetic ambulators will master bilateral amputee gait if a transtibial or more distal amputation can be performed on the contralateral limb. State-of-the-art plastic and microvascular reconstructive surgery is on occasion justified to maintain residual-limb length. Even in the bilateral amputee. Careful preoperative assessment of the patient's potential and setting realistic goals can help direct surgical level selection and postoperative rehabilitation wisely. and overall medical condition must be evaluated to determine whether the distalmost level is really appropriate for the patient.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library prosthetic rehabilitation in the early years improves the general health and social development of these children. a geriatric patient with a previous transfemoral amputation might be a nonambulator but still have excellent independent transfers and bathroom skills. it is not necessary to have both legs symmetrical. The success of rehabilitation decreases dramatically if transfemoral or higher-level amputations need to be performed. Contemporary prosthetic fitting of the bilateral lower-limb amputee can be categorized into immediate postsurgical prosthetic fitting (IPPF). The surgical management of these difficult cases requires a full knowledge of the principles of modern prosthetic management. In each of these instances it is usually better to elect amputation at a higher level to permit improved prosthetic substitution and patient comfort. The amputation site becomes the new interface for human contact with the environment and must be as functional and comfortable as possible ( Fig 24A-2. Although optimum function is usually the primary concern in amputation. If the patient capable of independent transfers develops contralateral foot gangrene. the patient's activity level. Speed of recovery is frequently indicative of how well the patient will be able to perform predetermined rehabilitation goals. he might be best served by preserving all possible length and prosthetic fitting. a bedridden patient with hip and knee flexion contractures might be better served with a knee disarticulation or very long transfemoral amputation than with a transtibial amputation. minimize complications. early postsurgical prosthetic fitting. even in nonambulatory patients. In nonambulatory patients. Syme ankle disarticulation and knee disarticulation levels have a bulbous end and result in a less aesthetic appearance in the final prosthesis. and all length possible that is suitable for prosthetic fitting should be preserved ( Fig 24A-1. This is particularly true when the amputations result from burns. there remain a few regions where it is not advisable to amputate. the very short transtibial amputation above the attachment of the patellar tendon. This is particularly important in the management of the majority of amputees we are treating today. transfers. the cosmesis of the prosthetic limb replacement must also be considered.). Even if a patient is a bilateral transtibial amputee. Such skills are extremely important in the bilateral amputee and should be given careful preoperative evaluation. http://www. and the very short transfemoral amputation in the subtrochanteric region. PROSTHETIC FITTING AND REHABILITATION Rapid prosthetic rehabilitation of the multiple-limb amputee ensures the best results in returning to an active. and nursing care. however. if the goal is to continue independent transfers and bathroom activities. not only because healing may be compromised but also because prosthetic substitutions are unsatisfactory at these few levels in the lower portion of the leg. For example. The psychological and economic benefits to this patient approach are also quite appreciable. vision.org/alp/chap24-01. the elderly.oandplibrary. the goal is to achieve healing at the most distal level that can be prosthetically fit and allow successful rehabilitation. cognitive skills. In ambulatory patients. There is absolutely no added benefit to having both lower limbs amputated at the same level. independent life-style. are rarely justified. In the geriatric age group. Bone lengthening procedures. and improve sitting balance. SURGICAL DECISION MAKING Retention of maximum limb length by amputation at the distalmost suitable level is particularly important for the bilateral amputee. the goal is to obtain wound healing. These areas include the lower fifth of the leg down to but just above the Syme-level ankle disarticulation.).).asp[21/03/2013 21:56:40] . Patients with high cosmetic expectations might be dissatisfied with these levels ( Fig 24A-3. the prevention of contractures. Removable cast sockets. Although managed differently. If a cast socket inadvertently comes off the limb. Regular-interval full-cast changes between 7 and 10 days are adequate for dressing changes unless wound problems require more frequent attention. and final gait training become important considerations in the definitive prosthetic phase.). The early prosthetic fitting techniques employed are the same as for the IPPF. and early mobilization through the use of rigid dressings dominate the immediate and early phases. and residual-limb or phantom pain can be exaggerated in spite of soft compression In all probability. the surgeon may defer application of a rigid dressing 1 to 3 weeks postsurgically to or near the time when sutures are removed from the surgical incision.asp[21/03/2013 21:56:40] .24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library preparatory prosthetic fitting. weight-bearing increments are also accelerated accordingly. In a worst-case scenario. As the name implies. The team consists of a surgeon. manually applied. the patient has dressings such as an elastic bandage or shrinker sock. have been unsuccessful.). At this stage. Early Postsurgical Prosthetic Fitting Under certain conditions.oandplibrary. IPPF can be implemented in any hospital setting that has a trained team of professionals available. previous unilateral amputees who later become bilateral and simultaneous bilateral amputees both benefit from early rehabilitation with controlled weight bearing. Patients with simultaneous bilateral amputations must be advanced more slowly and carefully than the previous unilateral amputee who can tolerate unrestricted weight bearing on the mature. been adequately documented in the literature. previously amputated limb ( Fig 24A-4.org/alp/chap24-01. Removable rigid dressings must be continuously monitored and require the complete cooperation of a reliable patient. and available componentry make the correct selection and application more critical than ever before as the patients proceed through these various phases of prosthetic management and training. plaster of paris socket) with a pylon extension and prosthetic foot in the operating room have The primary consideration is achieving rapid. considerable postsurgical edema is usually evident. a nurse. This is accomplished by controlling postsurgical edema without restricting circulation.e. Cosmesis. Although we prefer immediate use of rigid dressings. especially in the young traumatic amputee. durability. in our experience. been restricted to bed rest or limited to wheelchair mobility. Damage to the residual limb may result with associated pain for the patient. Actual ambulation activities are delayed until the incisions have healed and sutures have been removed. Use of a tilt table is necessary for the bilateral amputee. which leads to physical decompensation and muscle weakness. Improved wound healing. a physical therapist. IPPF with controlled weight bearing is the initial patient treatment of choice. The they are removable and can come off the residual limb at the most inappropriate time. Carefully controlled static weight bearing can be initiated the first postoperative day or whenever the patient is physically capable of tolerating the procedure. with bathroom scales or other pressure-monitoring devices utilized to help regulate weight bearing. http://www. to delay until suture removal is very common in the bilateral amputee. Immediate Postsurgical Prosthetic Fitting Ideally. increasing weight bearing and initial gait training predominate in the preparatory prosthetic phase. frequent cast changes may be indicated until this condition stabilizes. and definitive prosthetic fitting. need for daily wound inspection contradicts our position of undisturbed tissue support and immobilization. optimal wound healing. Tissue support minimizes inflammatory reaction and reduces phantom pain. it should not be pushed back on. If considerable edema is evident at the initial application of the cast socket. Increased sophistication of current fitting techniques. wound healing can be compromised as a result of this delay.. The psychological benefits are significant as the patient wakes up with a prosthesis in place of the amputated limb and rehabilitation starts immediately. If prosthetic pylons have not been utilized initially. Maturation of the residual limb by comfortably. and other auxiliary personnel as might be required. materials. simulated weight-bearing activities are administered by the therapist or the patient himself through the cast ( Fig 24A5. The details and benefits of applying a rigid dressing (i. A new cast socket must be applied without delay. The reduction in edema that results from simulated weight bearing decreases postoperative discomfort. As wound healing progresses and is monitored at the various cast change intervals. a prosthetist. or any combination of the above. A patient must learn to walk before he can expect to run. If used in this context. Improved combined biomechanical fitting principles and static and dynamic test socket procedures with flexible socket construction further enhance patient comfort and acceptance. Likewise. adolescents. adjustable sockets may warrant consideration in particular situations when in the opinion of the team this approach is pref-erable. Since it is the surgeon's intent to preserve all joints and all useful length in the residual limb. transfemo-ral.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library Soft compression dressings supplemented by an elastic bandage or shrinker sock are less effective in achieving rapid wound healing. and active and sedentary geriatric amputees. While many amputation levels are similar or the same. The economics of this practice are realistic and obvious. Such prostheses are also indicated for evaluating a patients potential to safely ambulate or to demonstrate to a patient the energy and skill requirements associated with the use of prostheses. are useful if the volume of the residual limb is expected to decrease rapidly in the near future or if a gradual reduction of joint contractures will require repeated prosthetic realign-ment. if this is even physically possible. and hip disarticulation. athletes. adults. Individual patient needs vary greatly among infants. especially in the geriatric patient. The bilateral amputee greatly benefits from this approach ( Fig 24A-6. Commercially available. Recent developments in computer-aided design and computer-aided manufacture (CADCAM) open the door to new and exciting possibilities to better serve the multiple-limb All this demands greater knowledge and skills on the part of not only prosthetists amputee. who are responsible for formulating the prosthetic prescription.org/alp/chap24-01. Patient comfort will make the decisive difference between acceptance and rejection of the prosthesis and is therefore a high priority. Preparatory Prosthetic Fitting Preparatory prostheses. and friends of patients also play an important role since they influence patients' expectations and reactions to their prostheses and management. the http://www. ankle. It delays the recovery period unnecessarily and invites further complications in the form of joint contractures and general physical decompensation. Parents. Residual-limb edema associated with discomfort and phantom pain is frequently evident with this form of patient treatment. but also the entire clinic team. prefabricated. also referred to as intermediate or training prostheses.asp[21/03/2013 21:56:40] . lightweight components made from titanium and carbon fibers combined with sockets fabricated with thermoplastic materials or acrylic resins result in a lightweight prosthetic construction that reduce energy consumption during ambulation activities. High-strength. preparatory prostheses are indeed justified and present the best diagnostic and economic tool for measuring a patient's mobility capabilities. These are misnomers since all prostheses wear out mechanically or require replacement due to deteriorating fit. There are different requirements between males and females and important considerations to be made for vocational and recreational activities. the components of choice should be the same as those anticipated for the definitive prosthesis to minimize the retraining and relearning required. Never before in the history of prosthetics have pros-thetists had so many sophisticated materials and components at their disposal to serve their patients better and more effectively. the prosthetic socket configuration as well as design anticipates the patients requirements and is the critical contact point of the human anatomy and the mechanical substitute. children. the individual patient requirements are vastly different and must be accommodated to be effective in the overall. knee disarticulation. transtibial. Bilateral amputations can be of an equal level such as foot. Component choice is carefully prescribed in consideration of the particular patient's needs. Each new patient requires individual assessment and evaluation to determine his exact personal needs. Radiographs or xeroradiography can isolate or pinpoint residual-limb fitting problems. total rehabilitation of the patient. This is common in simultaneous bilateral amputees who cannot advance their weight bearing as quickly as unilateral patients.oandplibrary. It is frequently prudent to utilize definitive foot-shinknee components for the preparatory prosthesis and carry them over into the definitive device. Whenever possible. relatives. Definitive Prosthesis Definitive prostheses are sometimes erroneously called "permanent" or "final" prostheses.). spouses. Limited ambulation is accomplished in time. periodic lengthening of the stubbies is permitted until the height becomes nearly comparable with full-length prostheses. The initial prosthetic socket extends to the thorax for stabilization to allow an upright position and can be fit for sitting as early as 4 to 6 months. The socket is mounted on a stable platform to which casters can be mounted for mobility. children. and the rocker bottom provides a broad base of support that teaches trunk balance and provides stability and confidence to the patient during standing and ambulation. regardless of age. and prosthetic fitting have been advocated. Recently we have switched to aluminum tubing that is fitted into a larger-size tubing. The rocker-bottom platforms have a long posterior extension to prevent the tendency for the patient to fall backward initially. Knee components are usually omitted for infants since stability and balance are still developing. plastic tubing can be utilized in endoskeletal designs and results in very lightweight. surgical intervention. The shortened anterior portion allows smooth rollover into the push-off phase. at which time the transition is attempted. standing. the prosthetic socket is combined with cosmetically enhanced thigh-shank-foot components that allow sitting. The use of stubbies as the initial prosthesis is recommended for all bilateral knee disarticulation or trans-femoral amputees. Total-contact socket designs using a sock interface with the classical Silesian bandage or a modified version thereof has been the most frequent method of suspension. it is possible to fit select infants with total-contact suction This eliminates most auxiliary suspension suspension as early as 18 to 24 months of age.asp[21/03/2013 21:56:40] . This requires the prosthetist to design and custom-fabricate what is needed.oandplibrary. Depending on the full extent of the anomaly. Any suspension considerations must resolve the problems of diapers and thus should be moisture resistant and washable. Miniaturized. More frequent socket replacements as a result of suction socket fittings are not as significant as anticipated and should not be a deterrent. A miniaturized version of the total elastic suspension (TES) belt has also proved to be an effective option. The use of stubbies results in lowering of the center of gravity. In our experience. This system is appropriate even for infants. infants may face continuous treatment throughout their lifetime to manage the disability. growth without remaking the entire prosthesis. medical problems that require continued treatment and monitoring and may interrupt prosthetic management. Our current. Flexible or rigid pelvic band and hip joint suspension or shoulder harness suspension is seldom indicated in infants. children with congenital limb deficiencies present major challenges to the entire rehabilitation team. Since structural strength requirements are very minimal. The system utilizes a prosthetic sock that is impregnated circumferen-tially at the midportion with a narrow band of flexible silicone that forms an effective seal on the inner socket wall and results in socket suspension. cosmetic appliances.org/alp/chap24-01. Stubbies consist of prosthetic sockets mounted directly over rocker-bottom platforms that serve as feet.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library prosthetist is presented with the challenge of varied amputation level combinations where prosthetic designs must interact effectively. thus allowing telescoping length adjustments for growth. initial knee disarticulation infant prostheses consist of flexible This allows for socket replacements due to thermoplastic sockets mounted in rigid frames. when the socket is mounted on a swivel walker for selfinduced mobility. Some upper-limb components such as manually locking elbow joints can be integrated into lower-limb infant prostheses. Recently. Following bilateral hip disarticulations. As a result. infants are being fitted with lower-limb prostheses as early as 8 months of age or when they attempt to accomplish a seated or an upright position. INFANT AMPUTEES While statistically a very small group. who are considered candidates for ambulation and who lost both legs simultaneously. commercially available prosthetic components are very limited for infants. The prerequisite is that parents be able to apply the prosthesis correctly. Even high-level amputees as a result of lumbosacral agenesis have been fitted with specially designed prostheses. Early diagnosis. and some Often these patients have multiple limited ambulation on the principles of a swivel walker. The majority of infants. As the patients confidence and ambulation skills improve. and young adults with bilateral knee disarticulation or transfemoral amputations can generate the energy required to ambulate when wearing http://www. the introduction of the hypobaric suspension system has provided another suspension option. As hip flexion contractures lessen and balance improves. the posterior rocker extensions can be shortened accordingly. needs. typical. Whatever system is chosen. PTS socket configuration is also useful for short and very short residual transtibial limbs and where pistoning must be held to a minimum. it is advisable to use residual limb. Lightweight exoskeletal designs are also quite acceptable for use in infants.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library stubbies without needing assistive devices such as crutches or canes. Such assistive devices severely compromise upper-limb function and should be avoided where possible since this alone is a major deterrent to using full-length prostheses. with the introduction of new petrochemical-based materials that are lightweight and strong. The need for slightly more frequent socket replacements is a small price to pay to allow improved function and comfort for the active youngster. Assistive devices may be needed for safety and support once the patient has accomplished the transition to fulllength prostheses. Thus. as well as the conventional suspension systems such as hip control belts. suction suspension whenever this is possible in both transfemoral and trans-tibial fittings. but diminishes with advancing age when some become marginal users or abandon the prostheses altogether. including high-level bilateral lower-limb amputees. for they denote a very active.org/alp/chap24-01. sports. at a minimum. waist belts. and recreation activities like any other child. and every effort should be made to achieve this without sacrificing comfort or function. in favor of wheelchair mobility. engineers. The majority of children with bilateral knee disarticulation and transfemoral amputations can generate the required energy to develop ambulatory capabilities by using stubbies without assistive devices such as walkers. except for cosmetic use. concerns that frequently accompany these congenital limb deficiencies. then knee disarticulation is required on one or both limbs ( Fig 24A-9.D. have very high physical activity levels. can be used to make a waterproof prosthesis. CHILD AMPUTEES Most children. Prostheses in need of major servicing and repairs are a joy to the entire clinical team. The Aqua-Flex. Prosthetic prescription should include side joints and thigh lacers. http://www.). ).). not so much to distribute weight as to provide increased medio-lateral knee stability ( Fig 24A-7. British Columbia. The use of the silicone suction socket (3S) technique has been reported and expanded to include all levels of amputation.). special socket modifications and techniques are indicated to accommodate the deformity ( Fig 24A-8. Fortunately. such as in skin graft or burn patients. Hypobaric suspension can also be utilized in children. the use of stubbies as the initial prostheses is recommended for rehabilitation of all bilateral knee disarticulation and transfemoral amputees who are considered candidates for ambulation and who lost their legs simultaneously. As discussed in the infant section. and cuff suspensions. or canes ( Fig 24A-10. it must fill the needs and abilities of the patient and parents without making it technically too complex and thus frustrating. and manufacturers have finally started to meet the challenge of providing componentry for this very active group of young children. Prosthetic researchers. They are encouraged to participate in play. When the knee flexion contracture exceeds 15 to 20 degrees. durability must be considered in the design for this active group of amputees. Occasionally a patient with bilateral tibial hemimelia is encountered after bilateral Syme ankle Knee instability and flexion contractures are major disarticulation or transtibial amputations.oandplibrary. well-adjusted child who is using the prostheses to their maximum potential. Canada. This high performance level is not always sustainable through adulthood. suppliers. Some noteworthy examples of these new developments are the hip disarticulation and trans-femoral endoskeletal system with adjustable knee friction and extension assist from Otto Bock and the Child Play Seattle LightFoot from M. If the congenital limb deficiency is so severe that knee instability or flexion contractures prohibit prosthetic fitting. Parents like cosmetically pleasing prostheses. and the choice should depend on what is considered most appropriate for a particular patient and parent. Comfort and control of the prosthesis are directly proportional to good socket retention on the This becomes critical in the bilateral amputee. the challenge of prosthetic durability can be met better today than ever before. As a result many of the children place profound physical demands on their prostheses. crutches.N.I. Unstable knee joints may require the addition of side joints and thigh lacers or. a patellar tendon supracondylar (PTS) socket design. For this reason.asp[21/03/2013 21:56:40] . Many components are still customdesigned and hand-fabricated by prosthetists to meet their individual patients needs. an all-plastic transfemoral pediatric knee-shin setup from Ford Laboratories in Richmond. Surlyn and certain polyethylenes cracked and buckled under rigorous use and required frequent replacement. Similarly. so long as the amputee is able to don and doff the prostheses effectively without assistance. There is an abundance of knee joint components available that aid in stability and function. ). swimmers. provides excellent suspension and minimizes the problem of excessive perspiration of the residual limbs that is commonly encountered in bilateral prosthesis use. including semiflexible transtibial and transfemoral sockets. knee components. The 3S socket design. is preferable for bilateral amputees. refinements of socket fit through repeated static and dynamic test socket procedures. A few.asp[21/03/2013 21:56:40] . For maximum durability. or a combination of these levels accomplish a near-normal gait. makes for more functional prostheses ( Fig 24A-12. and uneven terrain. most adults with acquired bilateral transfemoral amputations fail to become consistent wearers of full-length prostheses but continue the use of stubbies for their daily ambulation activities. Special foot alignment and resistance is required for the bilateral amputee for security and balance..24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library ADOLESCENT AND YOUNG ADULT AMPUTEES This group of amputees frequently proves the prosthetic team wrong when told of physical limitations associated with multiple amputations. skiers. improved negotiation of inclines. Early flexible inner sockets lacked durability. ischial containment transfemoral sockets provide more comfort during ambulation and when seated by providing increased clearance in the perineum. ). or they have tried the transition but prefer to remain with their previous socket designs ( Fig 24A-13. ). Experience has proved that patients can excel safely if given the opportunity rather than being told that they are unable to do so ( Fig 24A-11. demonstrate the dangers of stereotyping amputees with outdated classifications. Suction suspension. Knee disarticulation or transfemoral amputees with contralateral transtibial or more distal amputation also become accomplished ambulators but frequently prefer a cane or other assistive device. and feet to determine the best functional combination for their needs. The simultaneously acquired bilateral knee disarticulation or transfemoral amputee requires fitting with stubbies as the initial prostheses. All of these enhance stability and control of prostheses and improve gait. This is an expensive and time-consuming process but ensures the best results. There is an abundance of materials and componentry available from which to select what is most suitable for a particular amputee. as well as improved impact absorption and reduction of torque and shear forces. including proper alignment of components. It must be noted. Dynamic-response foot and ankle components have a profound impact on socket comfort and the functional capabilities of all lower-limb prosthetic users. exoskeletal design has the advantage over endoskeletal systems. In our experience. Either these patients have not yet made the transition to ischial containment socket designs. These runners. Most bilateral amputees who have lost one knee limit their daily ambulation activities and have sedentary jobs. persons with bilateral partial-foot amputations. Most bilateral amputees perform these extracurricular recreational activities with conventional prostheses. etc. declines. Syme ankle disarticulations. Similarly.org/alp/chap24-01. that there are numerous successful bilateral transfemoral amputees utilizing quadrilateral or modified quadrilateral suction or semisuction prostheses. however. They may elect to wear the full-length prostheses for special events or cosmetic reasons http://www. Postfitting realignment procedures are performed much more conveniently and expediently with endoskeletal designs than with exoskeletal systems that require major labor-intensive reworking procedures to achieve alignment corrections. the endoskeletal system has a distinct advantage and is therefore favored by many females. more competitive amputee athletes may have special prostheses designed to aid their accomplishments in competitive sports events. Bilateral young transtibial amputees usually become excellent ambulators with a relatively normal gait without the use of external aids.oandplibrary. mountain climbers. rowers. Amputees have noted improvement in proprioceptive feedback. as previously discussed. Flexible brim. They should be allowed to evaluate different socket designs. For cosmetic appearance. including the Icelandic Roll-on Suction Socket (ICE-ROSS) system. Improved working techniques and better materials have reduced these problems and given the prosthetist a wider choice of options. basketball players. The news media constantly remind us of the stunning accomplishments of amputee athletes. including bilateral high-level lower-limb amputees. Delayed wound healing. Adults with acquired bilateral hip disarticulation rarely become effective ambulators. weaken the patient. bring on depression. Diabetes. is physically slim and fit. The use of SACH There are some possible variations in the rocker bottoms of stubbies. The challenge of rehabilitating these patients is frequently complicated by the presence of other illnesses. GERIATRIC AMPUTEES The great majority of bilateral lower-limb amputees today are the elderly who lose their limbs secondary to diabetes and vascular disease between the ages of 55 and 95 years. and impaired vision are complicating factors that require careful consideration when evaluating patients. Different knee mechanisms can and should be utilized as required. which require much higher energy output. ). chronic infection. inclines. The accomplished user of bilateral transfemoral prostheses typically uses a cane and has midthigh or longer amputation levels. are cumbersome. diabetes appears to be the leading cause of second limb loss. balanced thigh musculature. and has high endurance and good motivation. than the geriatric bilateral amputee. Negotiation of stairs. Use of a stance-control or manual-locking knee is reserved for the shorter of the residual limbs. dismissing these patients as poor prosthetic candidates is a grave mistake and compromises the rehabilitation potential when immediate postsurgical treatment is delayed. arthritis. This experience is very common with the use of full-length transfemoral prostheses and restricts the majority to ambulation with stubbies only. understand and follow instructions for proper use of the prosthesis. Bilateral transfemoral prosthetic users require a great deal of gait training by a qualified physical therapist. Lack of exercise and mobility will encourage joint contractures. and uneven terrain are complex challenges that must be learned and practiced by the patient to become an accomplished ambulator ( Fig 24A-16. Chronologic age alone should not determine whether an amputee is a prosthetic candidate. slow him down. slowly healing lesions. but it is possible for the patient to stand in these prostheses and initiate voluntary mobility on the principles of a swivel A particularly strong patient can also accomplish a swing-through gait with the aid walker.asp[21/03/2013 21:56:40] . Full-length prostheses are usually designed to shorten the patient's stature slightly because balance is improved by lowering the center of gravity ( Fig 24A-15. No patient group benefits more from immediate postsurgical prosthetic fitting. ). and neuropathy warrant additional consideration. ). In general. ). but the principles and training are very similar ( Fig 24A-14. which can be months or perhaps years. but they must be tested and evaluated during trial ambulation.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library only. the time interval between the first and second limb loss. We must give the patient the benefit of the doubt and provide at least http://www. cause loss of independence. The patient must be able to achieve a seated and standing position independently and in less-than-ideal locations. kidney disease.org/alp/chap24-01. makes learning to ambulate easier for the patient than if both limbs are lost simultaneously ( Fig 24A-20. A 90-year-old patient can be in better physical shape than While the patient must be able to a 50-year-old and use prostheses accordingly. Foot and ankle components should be of the same type and function for both limbs and have a stiffer plantar flexion resistance than is required in unilateral cases. Specially designed and fitted sockets to allow for more comfortable seating can be provided. ) and more recently the Flex Walk Foot fitted to tennis shoes. but they still may request special-purpose prosthetic fittings. We have utilized rocker bottoms incorporating the Greissinger foot multiaxial ankle system ( Fig 24A-17. He prefers stubbies over full-length prostheses. ). including early fitting of preparatory or definitive prostheses. Sometimes patients are wrongly diagnosed as prosthetic noncandidates and denied prostheses. Larger foot size may improve support and stability. feet with the toes pointing posteriorly has been advocated by some for a smoother gait. This patient was usually involved in recreational or sports activities prior to the amputations. and may even become life-threatening. cardiovascular disease. of crutches ( Fig 24A-19. Fortunately. ). respiratory disease. and end-bearing capacity of the knee disarticulation makes bilateral full-length prosthetic use easier than for the bilateral transfemoral amputee.oandplibrary. One triple amputee with a very short transfemoral amputation on one side is capable of briskly walking 2 miles daily for exercise. Full-length functional prostheses are primarily for cosmetic appearance while seated in a wheelchair. declines. this may not be always the case immediately preceding or following amputation when systemic toxicity from an infected limb may cause the patient to act temporarily confused or unaware of the ongoing proceedings. The amputee must also be trained to return to the standing position from the ground as occasionally would be required after a fall. The longer lever arm. Of these complicating factors. and instill a constant fear of falling ( Fig 24A18. Side joints and thigh lacers are infrequently required for an unstable knee or very short residual transtibial limb. Older patients require much more time. Preoperative and postoperative patient education is an important adjunct to rehabilitation. are a great benefit to patients in learning about their disability and in being able to discuss matters with other amputees that they may be reluctant to discuss with clinic team members. Hyperbaric socket suspension offers another excellent option. Prosthesis design and componentry must be based on careful individual evaluation of all pertinent factors. are primarily for cosmetic effect while using a wheelchair. Teaching a patient proper hygiene and care of the residual limbs and the prostheses is vital. SHOES FOR AMPUTEES It is noteworthy that Kegel reports the recent development of special dress shoes for amputees that are very lightweight. Velcro closures should be substituted. Their input is important. Another option is to provide flexible. ). Bilateral transfemoral prostheses are too difficult to manage for most geriatric patients and. or other alternatives must be utilized. roll-on silicone liners that allow donning and doffing while seated. Use of a transfemoral and transtibial prosthetic combination is limited to only a few very energetic patients and then for only limited use around the house.asp[21/03/2013 21:56:40] . Spouses and other family members should be encouraged to participate during fitting and training sessions. They should be of relatively simple design and not contain superfluous components that may be of questionable benefit to limited ambulators. Any type of prosthesis is inappropriate if the patient is unable to don and doff it properly. A neo-prene suspension sleeve is an excellent means of auxiliary socket suspension if the patient can apply it properly. the bilateral geriatric amputee can seldom master the conventional donning technique. and their concerns should be addressed in detail. and encouragement." This new development remedies this need. now available in many localities.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library preparatory prostheses to evaluate ambulation potential. http://www.org/alp/chap24-01. tennis. and have a soft compressible heel to dampen impact at heel strike. Occasionally geriatric patients with bilateral congenital deformities are encountered who have remained active ambulators. ). Kegel states that "there are shoes available for soccer. this may require that special pull-on loops be attached to the socket or liner for patients with arthritis of the hands. They greatly complicate donning the prosthesis. Similarly. An amputee with transtibial amputation and a more distal level on the contralateral side almost routinely achieves ambulatory status with or without a walking aid ( Fig 24A-22. For these rare patients. Even stubbies are often too difficult for this group to master. Amputee support groups. The shoes are manufactured by Bally and look like any other regular dress shoe. If the patient cannot handle buckles. a patient must be able to properly install a wedge suspension system in a PTS design. ). Little frustrations can lead to total rejection of the prostheses and must be avoided. Prostheses for geriatric amputees should be made as light as possible with contemporary techniques. patience. wet-fit method. flexible. in which the patient liberally applies a special liquid lubricant that allows donning the prosthesis. The most sophisticated prosthesis with hydraulic or pneumatic swing-phase control. and it is a very rare exception to find someone willing to try and to succeed in ambulating with them regularly ( Fig 24A-21. rotators or torque absorbers. and even small improvements give encouragement and aid in progress. skiing and other special requirements. Even if prostheses are used only to assist in transfer activities. This lubricant rapidly dries into a powder that allows retention of the socket by suction. custom-designed prostheses are required. They thrive on praise. The basic rule is to keep them as simple as possible. understanding. For transtibial prostheses. The majority of bilateral geriatric transtibial amputees master ambulation with the aid of a walker or cane. if requested.oandplibrary. Lightweight construction can prolong prosthetic use and ambulation ( Fig 24A-23. An alternative method that merits consideration is use of the liquid-powder. they are justified. and should be avoided if other alternatives exist. but none for prostheses users. They are frequently forgetful and need to be reinstructed frequently. and energy-storing foot is totally inappropriate if we are dealing with a marginal ambulator who uses the prosthesis on a very limited indoor basis. Although suction socket suspension is the preferred means of suspension. Socket design must be such that the patient can don and doff the prosthesis independently. Diabetes Care 1989. Am J Surg 1977. Balakrishnan A: Technical note-tilting stubbies. 5:589-593. Poggi DL. Berlemont M: Notre experience de l'appareillage precoce des amputes des membres inferieurs aux establissements Helio-Marins de Berck. 8. Fillauer C: A patellar-tendon-bearing socket with a detachable medical brim. 15. 14. 9. 40:38. David JK.oandplibrary. Baumgartner R. prosthetic. / Vase Surg 1987. Frantz GH: The juvenile amputee. Orthot Prosthet 1987. Ebskov G. King PS. et al: A device to control ambulation pressure with immediate postoperative prosthetic fitting. Arbogast JC: The Carbon Copy II-From concept to application. Los Angeles. Sohrab K. Rehabil Res Dev 1985. Langlotz M: Amputee stump radiology.org/alp/chap24-01. Ekus L: Total suction for toddlers too! J Assoc Child Prosthet Orthot Clin 1987. 20. 10. Bull Prosthet Res 1971. Burgess EM: Contralateral limb and patient survival after leg amputation. J Bone Joint Surg [Am] 1953. J Prosthet Orthot 1988. Hans Huber Publishers. 35:659664. Zettl JH. Bray J: Total Contact Plastic Suction Socket Manual. Childs C: The SAFE foot. Berry D: Composite materials for orthotics and prosthetics. J Pediatr Orthop 1987. 133:469-473. Josephsen P: Incidence of reamputation and death after gangrene of the lower extremity. and rehabilitation techniques currently available. Grimm Z: Physical management and functional restoration of the lower extremity http://www. 4. Burgess EM. 13. ed 6. 22. Orthot Prosthet 1971. 10:153-160. Romano RL. Bodily KC. the bilateral lower-limb amputee can often achieve a remarkable degree of functional ambulation. Aitken GT. 146:280-282. Vermilion BD: Rehabilitation of the bilateral amputee. Bull Prosthet Res 1973. 25. Gottschalk FA. Am J Surg 1983. Washington. Burgess EM. Prosthet Orthot Int 1980. 5:85-86. Fishman S. Bulletin TR 10-6. et al: Development and preliminary evaluation of the VA Seattle foot. 1981. J Bone Joint Surg [Am] 1967. et al: Does socket configuration influence the position of the femur in above knee amputation? J Prosthet Orthot 1989. Tilney NL. Boontje AH: Major amputations of the lower extremity for vascular disease. Bild DE. 4:77-80. Campbell J.asp[21/03/2013 21:56:40] . Zettl JH: Amputations. 18.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library SUMMARY The bilateral lower-limb amputee presents complicated problems for mobility and ambulation. Stuttgart. 49:1531-1540. Evans WE. The Management of Lower Extremity Amputations: Surgery. J Prosthet Orthot 1989. 5. Ann Med Phys 1961. Gerhardt JJ. Breakey JW: Prefabricated below-knee sockets for the maturing stump. Prosthet Orthot Int 1980. Romano RL. 1:92-103. Rehabilitation. Krebs DE: Icelandic-Swedish-New York above-knee prosthetic sockets: Pediatric experience. US Government Printing Office. Prosthet Orthot Int 1980. 1982. Fillauer CE. Selby JV. Edelstein JE. 2. et al: Natural history of the leg amputee. Doshi R: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. 29. 34:3. 22:75. Atken GT: Complete absence of the lumbar spine and sacrum. Sinnock P. 1969. Immediate Postsurgical Prosthetic Fitting. Prosthet Orthot Int 1981. References: 1. 12. et al: Lower -extremity amputation in people with diabetes: Epidemiology and prevention. 4:4. 23. J Assoc Child Prosthet Orthot Clin 1987. Stills M. DC. Gerhardt JJ. J Prosthet Orthot 1980. UCLA Prosthetic and Orthotic Education Program. Arbogast R. Fowlks EW. 2:94-102. 27. Dankmeyer CH Jr. By applying the surgical. 16. J Bone Joint Surg [Am] 1971. 25: 26-34. 28. 7:557-562. 22:21. Hayes JP. 22:20. Burgess EM. The tremendous developments of recent years offer these individuals much greater functional potential. 4:87-89. 19:42-51. Hittenberger DA. 21. West Germany. 7. King PS. 26. 17. 4:97100. Couch NP. 6. 35:11-18. Immediate and Early Prosthetic Management. Banzinger E: Surlyn socket design for the young child. Pritham CH. et al: Amputations of the leg for peripheral vascular insufficiency. 24. 12:24-31. 11. 19. 3. 1:32-36. Orthot Prosthet 1981. Zettl JH. 53:874-890. Frantz CH. Fillauer KO: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. 1981. Nitschke R: Principals of the PTS BK prosthesis. in Bannerjee SN (ed): Rehabilitation Management of Amputees. 1980. Project 431. Orthop Technik 1991. Littig D. 42. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies. Kruger LM: Lower limb deficiencies. Mazet R. Louis. in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics. et al: The UCLA CAT-CAM Above Knee Socket. 46. 10:61-71. Arch Phys Med Rehabil 1980. Marshall K. Kegel B. 33. 54. Orthop Prosthet Appliance J 1967. 57:652-654. Harris RI: The history and development of Syme's amputations. 116:93-98. Inter-Clin Info Bull 1973. 1987. Malone JM. et al: The Influence of Prostheses Wearing on the Health of the Geriatric Amputee . 51:1135-1138. 48. Lippert FG III. in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics. J Bone Joint Surg [Am] 1969. Education and Welfare. Orthop Technik 1991. Kotb M. Moore W. Starr TW: Physiologic suspension factors in below-knee amputees evaluation. pp 627-630. 12:7-15. Mosby-Year Book.asp[21/03/2013 21:56:40] . Macfarlane PA. 38. Jackson JR. 31. 35. St Louis. 59. Surgical and Prosthetic Principles. pp 229-245. a device to monitor weight bearing for lower extremity amputees. 28:23-29. St. Goldstone J. 37. ed 3. 36. Keagy BA. Moore NB. McCollough NC. Pellicore RJ: The juvenile amputee program: Its social and economic value. 57.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library 30. Mensch G: Physiotherapy following through-knee amputation. Department of Health. Los Angeles. 60:18-24. St Louis. Moore AJ: Load cell. et al: Prosthetic Management for High Level Lower Limb Amputees. Clin Prosthet Orthot 1985. 5. Lehneis HR. amputee. Phys Ther 1981. 39. Mooney V. 56. Kegel W: The prosthetic shoe. 1981. 41. pp 522-552. 40. Ellis P: Physical therapeutic management for lower extremity amputees. Arch Phys Med Rehabil 1979. et al: Gait comparisons for below-knee amputees using a Flex-Foot versus a conventional prosthetic foot. Clin Prosthet Orthot 1985. Orthot Prosthet 1977. Mosby-Year Book. Dotzer R: Prosthetic management of the lower limb after traumatic amputation. Lambert CN. 22:81-84. 00:449-451. J Vasc Surg 1986. Washington. DC. 50. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. 9:9-14. Orthot Prosthet 1974. et al: Therapeutic and economic impact of a modern amputation program. Putnam S. Irons G. Kegel B: Prostheses and assistive devices for special activities. Jendrzrjezk DJ: Flexible socket systems. J Bone Joint Surg [Am] 1972. J Prosthet Orthot 1991. Office of Vocational Rehabilitation. 55. Marquardt E: The multiple limb-deficient child.org/alp/chap24-01. Kuchler-O'Shea R. 6:4. Shurr DG. 47. Mauch HA: Stance control for above-knee artificial legs: Design consideration in the S-N-S knee. Leal JM. Schiller FJ. 1963. Sarmiento A: Bilateral below the knee amputation in patients over fifty years of age. Arch Surg 1981. 7:79-87. Phys Ther 1977. Surgical and Prosthetic Principles. 9:27-30. Nielsen DH. Baltimore. Philadelphia. 43. Jennings JJ. et al: A lightweight above-knee prosthesis with an adjustable socket. pp 165-236. Institute of Rehabilitation Medicine. Webster JC. 1982. 1981. Burgess EM. et al: Lower extremity amputation: The control series. in Moore WS. in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics. J Assoc Child Prosthet Orthot Clin 1987. 4:321-326. p. Schwartz JA. 34.oandplibrary. Moore WS. 21:33. 50:1217-1223. Lundt J. 51. 44. Artif Limbs 1961. New York. Mensch G. Bull Prosthet Res 1968. Burgess EM: Recreational activities of lower extremity amputees: A survey. 31:35. 52. Prosthet Orthot Int 1983. Mal-one JM (eds): Lower Extremity Amputation. 1989. Malone JM. Dunn OJ. Huang C. Williams & Wilkins. 49. 16:1. Kokegei D. Schwartz M: Prosthetic training of a three-year-old acquired quadrimembral amputee. UCLA Prosthetics Education Research Program. http://www. et al: Rehabilitation for lower extremity amputation. Surgical and Prosthetic Principles. 32. et al: Amputation: Energy cost of ambulation. WB Saunders Co. Manella KJ: Comparing the effectiveness of elastic bandages and shrinker socks for lower extremity amputees. Hamilton RC. 42:434-440. Hoyt C.3:150-161. 45. 61:256-264. J Rehabil Res Dev 1983. Lehneis HR: A thermoplastic structural and alignment system for below-knee prostheses. 61:334-337. 58. 53. Bull Prosthet Res 1979. Kegel B. Mosby-Year Book. Ferber I. 38:29-33. Lilling M. 81. Harvey JP. 87. Wash. 86. Nielsen CC. 89. Sullivan RA. 62. Wiesbaden. Weiss M: Myoplasty. Weiss M: The Prosthesis on the Operating Table From the Neurophysiological Point of View: Report of Workshop Panel on Lower Prosthetics Fitting. Shannesse Hospital. Wu Y. Vinnecour K. 11:11-19. 5:87-91. Staats T: Advances in prosthetic techniques for below knee amputations. et al: Technical notes: Scotchcast PVC interim prosthesis for below knee amputees. 69. Mooney V. 78. MacBride E. 64. Inter-Clin Info Bull 1972. 13:63-69. 80. Inter-Clin Info Bull 1977. Varnau D. Orthopedics 1985. Block MA: The later life of the diabetic amputee: Another look at the fate of the second leg. 71. Orthot Prosthet 1985. Prosthet Orthot Int 1988. Russell JE: Congenital absence of sacrum and lumbar vertebrae: A case report. Snelson R: Fabrication and application of transparent polycarbonate sockets. Brncick MD. 16:7-12. 18:40-45. Wilson AB Jr. Radcliffe C. Grune & Stratton. Medical Engineering Research Unit. 8:249.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library 60. 70. Tenth World Congress of the International Society. 17:520. 10:27-38. 88. 77. Zettl JH. Instructional Course and Manual. 1991. J Prosthet Orthot 1991. Berkeley. Prosthet Orthot Int 1989. 53:241-249.org/alp/chap24-01. J Bone Joint Surg [Am] 1971. Waters RL. Michael JW: Energy storing feet: A clinical comparison. Orthot Prosthet 1972. 1966. Durr Fillauer Inc. Germany. Krick HJ. Bull Prosthet Res 1981. InterClin Info Bull 1977. Jurgensen C. 1:242-249. Whitehouse FW. Presented at the World Commission on Research in Rehabilitation. 22:21. Ohio Willow Wood Co. Mooney V. Diabetes 1968.oandplibrary. Saunder CG: Computer Aided Socket Design Teaching Manual. et al: Energy cost of walking amputees: The influence of level of amputation. 73. immediate fitting. 67. Carbon Copy System HI. Antonelli D. et al: Comparison of postoperative stump management: Plaster vs soft dressings. 3:191-200. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. 1978. Prosthet Orthot Int 1981. Vancouver. Burgess EM: The Syme's amputation: A new prosthetic approach. Elliott J: Fitting and training children with swivel walkers. 166:1585-1586. 12:77-90. DC. Swanson VM: Technical note: An alternative below-knee ultra lite technique. 16:1-6. Flanigan DP: Rehabilitation of the lower-extremity amputee with emphasis on a removable below-knee rigid dressing. New York. et al: Prosthetic rehabilitation of elderly bilateral amputees. J Prosthet Orthot 1989. Nitschke RO: A variable volume socket for below knee prostheses. 79. Clin Prosthet Orthot 1987. Watkins AL. in Gangrene and Severe Ischemia of the Lower Extremities. University of California Biomechanics Laboratory. Wolf E. et al: The enhancement of prosthetic fit through xeroradiography. Keagy RD. Liao SJ: Rehabilitation of persons with bilateral amputations of the lower extremities. Washington. O'Shea R. Perry J. 74. et al: An innovative removable rigid dressing technique for http://www. Wu Y. Tenn. Pohjolainen T. Motlock WJ. 26:1-13. Sowell TT: A preliminary clinical evaluation of the Mauch hydraulic foot-ankle system. 75. Artif Limbs 1966. J Bone Joint Surg [Am] 1976.asp[21/03/2013 21:56:40] . Celikyol F: Prosthetic fitting of the congenital quadrilateral amputee: A rehabilitation-team approach to care. 1966. 84. 58:42-46. Wu Y. Clin Prosthet Orthot 1985. 91. Orthot Prosthet 1984. J Assoc Child Prosthet Orthotic Clin 1987. Foort J: The Patellar-Tendon-Bearing Be-low-Knee Prosthesis. JAMA 1958. Prosthet Orthot Int 1988. 61. 65. 63. 66. ambulation. 85. 11:154-168. 90. 83. Seattle. Schwartz M: Prosthetic gait training for a three-year-old quadrimembral traumatic amputee. Schuch MC. 1984. Romano RL. 82. 72. 76. National Academy of Sciences. 12:105-106. Krick HJ. Clin Prosthet Orthot 1987. 68. Saadah ESM: Bilateral below-knee amputee 107 years-old and still wearing artificial limbs. 1985. 12:271-278. Chattanooga. Schuch CM: Modern above-knee fitting practice. Luth M. 9:15. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. Psonak RA. Alaranta H. 9:1-9. 39:14. Swedish Flexible Socket Technical Manual. Wikstron J: Primary survival and prosthetic fitting of lower limb amputees. Int J Rehabil Res 1989. Kalter TL: Factors affecting the use of prosthetic services. 1961. Atlas of Limb Prosthetics: Surgical. 61:724-729. in Moore WS. Zettl JH. WB Saunders Co. 93. Am J Phys Ther 1971. 11:128-134. 95. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. et al: Mechanical assessment of polyurethane impregnated fiberglass bandages for splinting.org/alp/chap24-01.24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library below-the-knee amputation. 92. 1989. Chapter 24A . Malone JM (eds): Lower Extremity Amputation. Contact Us | Contribute http://www. Burgess EM. Romano FL: The interface in the immediate postsurgical prosthesis. 10:52-66. 94.8:10-12. Zettl JH: Immediate postoperative prostheses and temporary prosthetics. Wardlaw D.asp[21/03/2013 21:56:40] . and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 24A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Prosthetic. 51:144. 96. Prosthet Orthot Int 1987. Philadelphia. pp 177-214. Bull Prosthet Res 1972. Wytch R.oandplibrary. Mitchell CB. Bull Prosthet Res 1969. Zettl JH: Experience with endoskeletal prostheses for lower extremities. J Bone Joint Surg [Am] 1979. 54 cm (1 in. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. and adjustment of speed. ease in turning. WINTER SPORTS Snow Skiing The concept of amputee skiing originated in Austria and Germany in 1948. The resultant increase in socket flexion. may raise the socket's posterior brim in relation to the patellar tendon bar. it is important that the skier's center of gravity be located ahead of the ball of the foot for proper balance. Theodore Roosevelt Sports often improve the physically challenged persons attitude toward himself by changing a negative attitude for what his body cannot do to pride in what it can do. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. The bilateral transfemoral amputee could use short prostheses without knee mechanisms or can switch to a sled or monoski. which most ski boots are designed to encourage. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. where you are. the prosthetic field has improved extensively and is much more willing and able to accommodate the specialized needs of todays amputee. Prosthetic. First. addresses are given for more detailed information. An overall physical fitness program is essential before engaging in any new sport. with regional qualifiers followed by a national event.org/alp/chap24-02.) wedge under the heel of the ski boot to achieve the desired forward cant. edition 2. however. Now amputee skiing is being taught in organized classes in most states under the umbrella organization of National Handicapped Sports (NHS). Fortunately. the skier with an amputation may require certain adaptations. R. This text is written to facilitate the clinicians role in helping individuals with lower-limb amputation find the appropriate sport for their level of ability." In 1967. and Rehabilitation Principles. Most transfemoral amputees ski on the intact leg only and use the three-track skiing technique. and outriggers. Reproduced with permission from Bowker HK. ©American Academy or Orthopedic Surgeons. A conventional prosthesis can be adapted by placing a 2. The Transtibial Skiing Prosthesis To achieve skiing proficiency. While individuals with two sound legs maintain balance by increased ankle dorsiflexion and a forward lean. the National Amputee Ski Association was formed in the United States. as well as research. two skis. Every adaptation mentioned will not necessarily work for every individual.) behind http://www. 1992. To relieve this excess pressure on the hamstring tendons. While some of the adaptive procedures are widely applicable. IL. The information presented is based both on firsthand experiences of individual amputees. The socket is then moved forward in a linear manner so that the anterior part of the brim falls approximately 2. the prosthetist can make a ski prosthesis. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Prosthetic. and Rehabilitation Principles Special Considerations: Adaptations for Sports and Recreation Bernice Kegel. with what you have. Rosemont.oandplibrary.24B: Adaptations for Sports and Recreation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 24B Chapter 24B .Atlas of Limb Prosthetics: Surgical. The Swiss subsequently introduced "crutch skiing. Prosthetic. The unilateral transtibial amputee has two options available for skiing. Where appropriate.54-cm (1-in. The bilateral transtibial amputee skis with a four-track technique and uses two prostheses. Do what you can. Click for more information about this text.asp[21/03/2013 21:56:47] . thus causing excessive and painful pressure on the hamstring tendons. He can ski with or without a prosthesis.P. the prosthesis is aligned in the conventional manner.T. others are not. reprinted 2002. Competitive events are held annually. American Academy of Orthopedic Surgeons. 24B: Adaptations for Sports and Recreation | O&P Virtual Library the toe of the prosthetic foot ( Fig 24B-1. ski stabilizers can also be attached to the tail http://www. While riding the chairlift. The SACH foot permits the selection of a sufficiently soft plantar flexion resistance. several stump socks are usually adequate. The ski tote has a thick felt pad to protect clothing from the ski's sharp edges. and is compatible with virtually every lower-limb prosthesis. Transfemoral amputees may prefer to have a modified socket fabricated. The interface used should offer as much protection and cushioning as possible. When skiing. The skiing prosthesis is often fabricated with a thigh lacer and waist belt pickup strap. The skier can do a snowplow. and a strong. and train. The overall length of the prosthesis is reduced to equal the length of the intact lower limb when the ankle is dorsiflexed roughly 25 degrees. one-piece carrying strap. approximately 3 or 4 in. To reduce the reaction time between leg movement and movement of the prosthesis. Some skiers choose to cut a hole in their ski pants. They hold the tips of two skis together for those who lack the leg power to do so. Moving the socket forward has a detrimental effect on cosmesis and causes an anterior bulge on the front of the leg. another option is nickelplast. or it can be left in the lodge. exercising the residual limb helps to maintain proper circulation. Even though the skis are hooked together. Residual-Limb Protection Those who ski without a prosthesis are advised to pad the residual limb for protection against cold and injury.oandplibrary. is available in a variety of sizes. parallel ski. Some skiers like to attach a removable pylon to the socket so that they can walk around on the snow when not skiing ( Fig 24B-2. and for this reason. The insert acts like a protective layer of fatty tissue and distributes pressure evenly. a conventional prosthesis is still needed for walking and after ski activity. The skier can now adjust his center of gravity more easily. thus making it easier to rest by kneeling and then to get up from the ground. If necessary. An inverted figure-of-8 suprapatellar cuff may also be added. Ski Stabilizers Ski stabilizers are frequently used in four-track skiing and also for skiing with two skis and two poles. flexibility of movement is allowed while maintaining a constant position of the skis.. A and B). Additional suspension techniques are the active sleeve or neoprene sleeve.asp[21/03/2013 21:56:47] . Ski stabilizers can be handcrafted with bungie cord or purchased commercially. The lower third of the socket to the base of the foot should be reinforced with carbon fiber to prevent breakage caused by the skier leaning forward over the tip or tail of the skis when adapting to different terrain. For the beginning skier a solid-ankle cushion-head (SACH) foot may be adequate. This protective device is made to match the knee length of the intact leg. Flexion and extension at the knee and hip are basic to the activity of skiing and create a rather unusual residual limb-socket interaction. For transtibial amputees. Skis The three-track skier needs a good-quality ski because all body weight is on one ski. apart at the tip of the skis. A lightweight ski boot is usually recommended.org/alp/chap24-02.). The skiing prosthesis is specialized. dynamic-response feet may be more appropriate. The flexibility of the Greissinger foot in the sagittal plane enables the skier to bend more deeply over his skis. minimal piston action is important. For more proficient skiers who desire greater flexibility. A "three-tracker's ski tote" was developed to allow the skier with amputation to carry his ski over the shoulders while using outriggers. If displacement of the silicone is of concern. such as that provided by the silicone gel insert. which improves control at higher speeds. wear the waist belt on the outside of their clothing. the pylon is detached and stored in a padded backpack. three Velcro closure straps (adjustable to any binding length) to hold the ski in place. and thread the pickup strap through the hole so that they can easily make adjustments to the suspension. These suspension mechanisms also help prevent one from losing a prosthesis while sitting on the chairlift. should avoid crowded ski runs because of the amount of space needed by the sit-skier and tetherer. The outriggers should be adjusted to a length that allows the skis to hang 2. The lift is slowed while the sledder is pushed to the loading area with a skier on either side of him. He should be sure to rest in places that are clearly visible to other skiers. the skier finds that he has more energy remaining to ski. The sledder must use the upper part of the body to pull himself through the snow with ski poles. Metal claws attached to the tail end of the outrigger skis provide additional braking action. It is important when sit-skiing to find a hill with a good slope.5 to 5 cm (1 to 2 in.24B: Adaptations for Sports and Recreation | O&P Virtual Library end of the skis ( Fig 24B-3.oandplibrary. Each lifter grabs one side of the sled and lifts it as the chairlift continues to move up from behind. They are made from a pair of Lofstrand crutches attached to 50-cm ski tips and allow approximately 30 degrees of motion at the junction. this disk prevents the outriggers from sinking in soft snow. so the skier should practice indoors on a dry surface until the movements are mastered.org/alp/chap24-02. Blood circulation could become impaired and the hands get very cold. As soon as the sled is on the chairlift. When loading the sledder in his sled. and in using them. which is essentially a sled ski-skateboard combination. The amputee merely squeezes a cord located at the handgrip. When the Flipski is in the walking position. The securing mechanism is designed for quick attachment and removal. particularly when learning in a tethered situation. Another option is to sit-ski in a lightweight molded fiberglass kayak-like sled ( Fig 24B-5. Neither lifter should be carrying ski poles. The sit-skier usually skis with a partner or "tetherer. The sit-skier should be aware that due to his close proximity to the snow.) above the snow surface when the skier is standing erect and holding the outrigger handles. and the ski flips up to lock in a vertical position and produce a walking crutch. The sit-skier also realizes that he cannot see other skiers as well as standing skiers can. Without enough momentum it is more difficult to initiate turns with the sled. To provide better friction. visibility on the mountain is decreased. Mittens are suggested since they are warmer than gloves.asp[21/03/2013 21:56:47] . Two general types of outriggers are available: those that allow the ski tip to flip up for walking (Flipski) and those that do not (standard). but this needs to be done with the aid of a lift attendant. the tetherer and one other skier approach the double chairlift. The skier should be wearing a ski boot and ski when making this length test.). and hand exercises should be done. Transferring into a sit-ski from a wheelchair can be difficult. trail bike tires for wheelchairs are suggested. the three-track skier puts considerable pressure on his hands. Some amputees add a semicircular disk just behind the vertical part of the crutch. Ski Instruction Skiing for the Bilateral Transfemoral Amputee. The amputee lowers himself into the sit-ski and then adjusts a waterproof cover over the lower portion of the body. The sit-skier.). the securing mechanism is attached to the chair from the rear of the sled. provided that access to a machine shop is available. Another factor to consider is flat areas. The sledder must cross-country ski to reach the next fall line. For getting around in wheelchairs on the snow. The sit-skier should have the chairlift securing mechanism out and ready to use by laying it across his lap." The tetherer does not control the ride unless the sit-skier needs help. short segments of bicycle chain can also be wrapped around the wheelchair wheels. Some bilateral transfemoral amputees are able to ski on short prostheses and skis. The sledder is set down on the chair alongside the skier who is closest to the lift terminal. The Outrigger Outriggers are specially adapted ski poles that are a cross between a crutch and a miniski and enable a person to balance and maneuver better than with standard poles. A way to practice on land would be to make a "roller sled" and poles. The Flipski makes it easy for the amputee to get around when not actually skiing. The Flipski changes from a skiing outrigger to a skid-resistant walking crutch ( Fig 24B-4. When using outriggers. The fact that the weight of the sit-skier rests far back in the chair ensures a http://www.). It is possible to load a sit-ski on a chairlift. and the use of short ski poles. The skier closest to the lift line waits for the next chair. Turning is done via a combination of leaning. Manufacturing one's own outriggers is feasible. weight shifting. and the sit-skier should have his poles inside the sit-ski. An alternative stop that can be executed is the swing hockey stop. This is a much faster device than the sit-ski. http://www. The sitskier will be turned sideways to the ski slope. The pole is planted with the arm outstretched to the side and slightly behind the skier.) behind the heel plate.. (2) the kayak method. To avoid backsliding. long underwear. With the use of short outriggers the user can maneuver the ski to carve a turn. and this technique is usually used on steep hills with large moguls.asp[21/03/2013 21:56:47] . but a long pole or two poles tied together are used. thus preventing backsliding ( Fig 24B-7. When the unloading area is approached. Downhill sit-skiers should wear safety helmets. and down parka are recommended.24B: Adaptations for Sports and Recreation | O&P Virtual Library safe ride. Most skiers find that using a prosthesis 2 to 3 cm shorter than standard will increase turning power. The monoskis frame mechanism is constructed of aircraft tubing and cables to provide a suspension over the ski. turtleneck sweater. Each sit-ski is equipped with an evacuation harness should the necessity arise for the sled to be lowered to the ground.). A T-shirt. The sit-skier should choose layered clothing for extra warmth. Both poles are held by both hands. and (3) the short swing. When using the spike method. The swing uses two longer poles and is more difficult. The monoskier can "unweight" himself with an outrigger while being aided onto the chairlift by a ski partner. By far the most popular and promising device available at the present time is the monoski ( Fig 24B-6. The first thing to learn when sit-skiing is how to turn. the skier needs to lean forward to prevent the ski from spinning and heading the skier down the hill backward. It consists of a bucket or shell that rides on a specially reinforced ski that is capable of withstanding great pressure. Monoskis were introduced in the United States in 1985. If the prosthesis is too long.oandplibrary. Cross-Country Skiing The Disabled Nationals Competition now hosts 5-.org/alp/chap24-02. The tetherer can also stop the sitski in several different ways. who is following behind the sit-ski. extending the leg backward adequately can be difficult. a prosthesis with a thigh lacer or Ac-tivsleeve is helpful in providing more control while turning. merely snow-plowing will be effective. and 25-km races. the securing mechanism released. It is difficult to do smoothly. The kayak method is similar to the short-spike method. This backsliding prevents the skier from keeping on top of his skis and results in a loss of kick and forward leg drive. The amputee moves his hips by using the muscles of the lower portion of his torso. Sit-skiing as a competitive event has been in existence in the United States since 1979. the skier with lower-limb amputation can compensate for this by developing a strong upper body to obtain a longer stride.8 cm (1½ in. the skier leans forward and then leans and plants the opposite pole to turn in the opposite direction. 15-. For the skier with a transtibial amputation. For each technique. As the sled turns. This nylon strap effectively stops the prosthesis from being lifted more than a few inches off the heel plate. The frame mechanism pivots upward and allows the seat portion to slide onto the chairlift without interrupting normal operation. waterproof mittens are desirable. The quickest way to stop the sit-ski is to roll it on its side. similar to a kayaking paddle.A and B). The assistant stays slightly behind the sit-skier to prevent the chairlift from hitting the sit-skier in the back of the neck. Three of the most common methods are (1) spikes or brass knuckles. The tetherer. The assistant may need to help push the sit-ski away from the chair. swings out to the side and down next to the sit-skier. a piece of elastic nylon can be looped over the top of the foot and attached to the ski at approximately 3. The instructor holds on to the tethering rope to make sure that the sledder reaches a safe area before beginning down the slope. Another challenge is maintaining control of the ski when it is extended to the rear. Since sit-skier's hands are often in the snow. water-resistant windbreaker. and the sit-ski pushed off when it is closest to the ground. short poles are used. While the strap also limits stride length. many sit-skiers can load and unload from the chairlifts without stopping or slowing the lift. With practice. the lift is slowed. The user can unload from the chairlift without assistance from others. If going at a slow speed. the knees have to be bent more than 90 degrees.24B: Adaptations for Sports and Recreation | O&P Virtual Library Selection of terrain is important. The prosthetic ankle is constructed to lock at 90 degrees (neutral) for walking and at 120 degrees (30 degrees plantar flexion) for swimming. The swimmer http://www. thereby eliminating the need for a stool or grab bars. Double poling is used. increased stability when diving. The backstoke is usually the easiest to accomplish. The VAPC Swim/Walk Ankle The Veterans Administration's Prosthetic Center (VAPC) of New York developed the swimwalk ankle ( Fig 24B-9.A and B). which is worn while in the water The decision to use a prosthesis while swimming depends on the individual. the three intact limbs do most of the work. Snowmobiling Snowmobiling is possible for most amputees. small spikes are mounted on the back of the hand with a Velcro and leather strap.. An alternative would be to use a plantigrade postoperative foot (Kingsley). while experienced skiers prefer longer ones for more push length per stride. For steep. If the seat is too low. 3. Swimming without a prosthesis Peg legs for use on the beach and possibly for swimming as well Sockets attached directly to swim fins ( Fig 24B-8. it is helpful to install a rope along the side of the trail so that the skier can pull himself up when necessary.long pushes for flat terrain and short jabs for uphill.) The swimming leg. 2. In addition. which causes discomfort in the popliteal area. which would allow the amputee to change readily from street shoes to tennis shoes for other activities. uphill trails. Several options are available: 1. Carrying a 6-m (20-ft) length of rope is helpful. Most transtibial amputees prefer a snowmobile with a relatively elevated seat. Many amputees choose to custom-make their own footrests. 4. and the trail should be 5 to 8 ft wide. the rope can be attached to a partner around the waist.asp[21/03/2013 21:56:47] . this prosthesis can be used in the shower.org/alp/chap24-02. Keeping one's prosthetic foot on the footrest can be difficult. the ability to climb a ladder out of a swimming pool. One disadvantage to swimming without a prosthesis is that the amputee may have difficulty getting the prosthesis back on after swimming because the residual limb may become slightly edematous. Swimming with a prosthesis is an excellent way to exercise the residual-limb musculature. Poles vary in length between 50 and 135 cm. Each position is controlled by a spring-loaded pin that automatically locks in place. Cross-country skiing in a sit-ski is a vigorous activity. with hard packed snow. The Beach or Utility Prosthesis This prosthesis is used for walking along the beach. Some people are also embarrassed to appear in public without a prosthesis. who can then serve as a tow. The prosthesis is waterproof and can be worn with or without a shoe.) In addition. A buddy system is strongly recommended. or wading through streams while fishing. some adaptations need to be made to the heel to allow the amputee to walk barefoot. If a SACH foot is used. The ideal surface for sit-skiing is relatively flat. against which they brace their prosthesis. The cross-country sled skier should experiment to determine the most efficient pole length for his needs. with the main difficulty being the ability to maintain one's direction of choice. standing in a pool. (This does not necessarily mean that one will swim more proficiently with a prosthesis. and some protection against injury to the residual limb are other reasons to use a prosthesis. Beginning skiers usually use short poles. The ideal footrest provides good support but does not limit leg movement. When swimming without a prosthesis. It is especially appealing because it offers access to remote areas that may not be otherwise accessible. WATER ACTIVITIES Swimming provides a freedom of motion to the physically challenged that they are often deprived of in daily activities. For control going downhill.oandplibrary. A removable "heel leveler" fabricated from polypropylene molded over the SACH foot can be used. If the terrain gets too arduous. Many amputees perform competitively without a prosthesis. The amputee can then swim out of the chair while being tethered to the chair by a 20-ft tether cord. the prosthetic ski should be kept 3 to 6 in. which is a multiposition sports ankle designed to allow the amputee to participate more easily in swimming. The pin can be removed to allow full ankle mobility. The backrest can be used as a life vest. it will usually be wrenched off by the force of the water. . Activankle can be used with most endoskeletal prostheses and can also be mounted in any Symes-style SACH feet. Water ski bras can also be used to provide better control of two skis. If using two skis. When the airspace fills with water. Aquatic Wheelchairs The Turfking chair is designed to be used both on the beach and in the water. A hole drilled through the ankle block allows the airspace between the two walls to partially fill with water during swimming and to drain when on land. a commercially available Hydro Slide works well. This filling process increases the weight of the prosthesis and therefore reduces its buoyancy enough to permit effective swimming action. A transfemoral swimming leg can be similarly designed.org/alp/chap24-02. such as screws and tubes. a light harness can be made out of waterproof material. are constructed of stainless steel. Many amputees prefer to ski without a prosthesis. Once up. Once up and stable. The limb is weighted to facilitate proper balancing between the shank and the toe of the prosthesis. A broad. which is ideal for this activity. rear pontoons give lateral stability. For convenient storage. If a supracondylar cuff is used. the toe will point at the correct angle to provide an effective swimming "kick. has a friction lock especially designed for walking or sitting on the beach. so it is waterproof and resists corrosion in salt water.A-C). Because of their increased strength characteristics. acrylic resins rather than polyesters are generally used to fabricate the limb. When in the water. The commercial equivalent to this unit is the Activankle ( Fig 24B-10. The Hydro Slide http://www. The occupant can also release a small anchor to hold the chair in one place. the residual limb should not wave about but be kept close either to the side or in front of the sound leg. A quick-release knee lock mechanism and a waterproof nylon axle are used. For the bilateral amputee. with the specialized prosthetic leg placed behind the intact leg. Propulsion in the water is by hand-operated flippers. and downhill skiing. ). the amputee may disassemble the prosthesis into two parts by removing the axle.oandplibrary.asp[21/03/2013 21:56:47] . The draining process is rapid and does not cause any cosmetic problem. ). The prosthetic knee can be outset and externally rotated to allow space for clearance of the knee of the opposite limb. By "hugging" the sound leg. thus minimizing fatigue. This leg is available for veterans but is not commercially available. Another alternative would be to start off on two skis but to place the residual limb in the socket without tightening the suspension mechanism. the amputee could release not only the second ski but the prosthesis as well. rowing. All other components. it should be constructed of a pliable plastic material that is impervious to water. ahead of the other ski. If the skier starts with the artificial limb trailing behind. The knee mechanism. The VAPC unit is constructed of polypropylene. The amputee can walk into the water and change the foot from a walking to a swimming mode. A locking pin is used to maintain stability when walking. The waterproofed prosthetic leg can be made a little shorter to place weight further back on the ski. square-backed ski will give the largest planing area and best stability for a beginning skier. For maximum control. The Turfking can also be used while fishing ( Fig 24B-12. Waterskiing The transtibial amputee often skis on one ski. the muscles of the residual limb reinforce those of the sound limb. A deep slalom ski fin is helpful. is fitted to the ankle joint. The Kingsley Syme foot. Materials that are corrosion resistant like Dupont's Delrin and stainless steel are used. Some suction socket wearers manage to keep the limb on with no harness at all. For suspension." The swimmer may also wear a swim fin with this device.24B: Adaptations for Sports and Recreation | O&P Virtual Library can easily activate this prosthesis via a ring located in the posterior portion of the device's calf area. which is completely functional in water. Otto Bock-style Swimming Leg The German firm provides technical information on how to construct the Otto Bock transtibial swimming leg with an airspace between the two walls of the prosthesis shanks ( Fig 24B11. the fin should be placed between the heel of the binding and the rear of the ski. and the Kanski. When the control cord is pulled. attaching the top portion of a plastic stacking chair to the canoe seat may be useful. The seat can be installed or removed from a standard boat without the use of special tools. River banks are often steep. and its posteroproximal brim is fabricated to allow maximum knee flexion with minimal or no discomfort in the area of the hamstring tendons. safe. It can rotate freely from port to starboard and allow the sailor to tack in a comfortable. This prosthesis is waterproof and buoyant. When returning to the boat. as well as portage and self-rescue. Because canoes are lightweight. Scuba The major challenge is getting oneself and one's equipment to the water. as close to the center as possible. a hydraulic hoist (Hydro Hoist) may be useful. Once in the boat. The hoist lifts the boat out of the water onto pontoons. The Able Sailor consists of a contoured seat that sits on a semicircular track and runs on rollers. although some amputees can manage alone by diving from a boat. and that the wheelchair is secure should the craft capsize. thus enabling him to helm the boat much as his able-bodied counterpart would. Also for this reason. They then assist the diver into the boat. the amputee may chose to use a peg leg. and slippery. and boat to the launching area. It is lightweight. the diver removes the gear in the water so that people on board the boat can pull it aboard. even a person confined to a wheelchair can support one end of the craft to help transport it to the water. The legs are placed in the canoe first. Some people use a seatbelt to secure themselves. Virtually no body movement is required to steer the craft because the tiller is within easy reach of the helmsman. For sailing. Boarding a canoe is simpler from a sitting than a standing position. Because of this. Boating Skills required for this activity include the amputee transporting himself. with a rope attached to the buckle release. ). A slide hooked onto the main beam connecting the three hulls eases the transfer from wheelchair to cockpit. and after that the rest of the body is positioned into the craft. the person with lower-limb amputation might very likely consume less oxygen than the able-bodied diver because the use of arm muscles demands less http://www. and workable environment. that the user is able to transfer the chair into and out of the canoe. the rower can remove the tubing. The "Able Sailor" is a device that allows the leg-disabled sailor to change sides within a boat without assistance. For rowing. both spray skirt and seatbelt release at the same time. the Veterans Administration has designed an ankle unit that permits free ankle movement while in the boat but allows a stable foot for facility while walking on the dock. rocky. Other devices designed specifically for the disabled are the monoski ( Fig 24B-13. it is important to ensure that the wheelchair fits into the canoe being used. the water ski seat. Lateral motion of the boat is prevented. For extra back support.org/alp/chap24-02. Kayakers may fear being trapped during a capsize because of the protrusion of the prosthetic foot.24B: Adaptations for Sports and Recreation | O&P Virtual Library resembles a surfboard. and easy to install. and the amputee utilizes it either in the sitting or kneeling position. For getting into a boat from a wheelchair. thus making almost any boat adaptable for sailing by a disabled sailor. In most cases this requires assistance. Lowering the seat height slightly may help to lower the center of gravity. The amputee slides from the wheelchair to the gunwale to the pilot's seat. equipment. Stability during walking is obtained by using rubber tubing instead of dorsiflexion and plantar flexion bumpers as used in single-axis prosthetic feet ( Fig 24B-14. An airplane kind of buckle is recommended. The rope hangs outside the spray skirt so that when it is pulled. thus improving balance. Once in the boat the amputee usually encounters no significant problems. The gunwale is now level with the wheelchair seat. For wheelchair users planning overnight trips. the seat runs free to the opposite side of the boat.asp[21/03/2013 21:56:47] . the British-designed trimaran the Challenger can be handled safely by the physically challenged. some amputees prefer to strap their prosthesis to the boat rather than to their body.oandplibrary. The National Ocean Access Project (NOAP) universal adaptive seat was developed for the United States yacht racing union's championship race for disabled persons in Boston in September 1990. built of fiberglass. With an efficient arm stroke. ). Most amputees keep their prostheses on since hopping any distance while carrying equipment is exhausting. Terry Fox's marathon "Run of Hope" across Canada provoked an interest in running and brought about the development of the prototype for the Terry Fox running prosthesis. The telescoping pylon. Other runners used crutches but no prosthesis.oandplibrary. For the ablebodied. One can also play from a wheelchair by using a thick pillow under the buttocks." Buddy breathing. The field is broken down into seven divisions based on type of amputation and two special divisions. GOLF The unilateral lower-limb amputee has relatively few problems playing golf.24B: Adaptations for Sports and Recreation | O&P Virtual Library oxygen than the use of leg muscles. ). Such individuals are encouraged to use webbed neoprene hand fins. ). the golfer gets out of the chair and sits on the ground.org/alp/chap24-02. the side-by-side method is difficult because it requires that both hands be used to pass the regulator from one diver to the other. . Golf can also be played from a sitting position in an electric cart equipped with a swivel seat. A better prospect is for the divers to position themselves one on top of the other.asp[21/03/2013 21:56:47] . On approaching the green. crutch. skip. This reduced angle is helpful because of the flat swing plane induced by the seated position. which is incorporated into the shank section of a transfemoral prosthesis. or one can play from a standing position while leaning against the golf cart for support. is frequently necessary. While the diver on the bottom provides the locomotion. followed by two steps on the sound limb. The National Amputee Golf Championship event has been in existence for 41 years and fields about 130 participants. These fins are called "power gloves. The person with a right-leg amputation who is also right-handed is at a disadvantage. The Swivel Golf Shoe developed by the War Amputations of Canada has some merit ( Fig 24B-15. . Golfers operating from a seated position should use clubs that have a flatter lie than normal. Subsequent research at the University of Washington showed that lower-limb amputees are http://www. Some amputees prefer to play without their prostheses. Nylon (DAW) sheaths may also be used to decrease friction and protect the skin at the residual limb-socket interface. It is very important that the prosthetic shank used have a rotational component. The right-handed golfer who has left-leg amputation should begin his swing with the foot rotated inward. He may tend to keep all weight on the left leg during a swing. ). skip. running was considered an impossibility for the amputee. The amputee golfer should also consider terrain. Walking 18 holes will cover approximately 5 miles. For divers who are unable to propel themselves with their legs. RUNNING Ten years ago. The amputee may achieve a little less distance due to the lack of follow through in his swing and difficulty in rotating on the prosthesis. in piggyback fashion. Diehards were limited to a hop-skip-and-run technique where they begin with one step on the prosthetic leg. Some amputees prefer not to wear golf shoes with spikes because this further decreases their ability to rotate on the prosthetic limb. The National Amputee Senior Golf Championship (over 50 years of age) has been in existence for 14 years. Electric golf carts are worth considering. The knee mechanism used has a stanceand swing-phase control ( Fig 24B-17. . This is a device built into a regular golf shoe to provide the golfer with more rotation ability on his prosthetic side. which has a "pogo stick" effect. Bending over to "tee up" requires a greater-than-normal sense of balance. Even better is the octopus adaptor and other dual regulators that allow both the diver on top and bottom some locomotion. ladies and juniors. the diver on top manages the breathing apparatus. skip. With proper instruction and equipment together with a well-developed arm stroke. or sharing air from a single tank. The bilateral transfemoral amputee who experiences difficulty maintaining balance might consider modifying a standard camera tripod by placing a bicycle seat on top (where the camera would normally be). the person with amputation can scuba dive well as long as the hands are free. buddy breathing is done face to face when descending and side by side when swimming. In this way the golfer can sit on the seat while bearing some weight on his legs ( Fig 24B-16. and even riding a cart leaves about 2 miles covered on foot. functions by absorbing some of the ground impact and by shortening the prosthesis on weight bearing. The technique is similar to running with a prosthesis-crutch. It may be better for this person to play left-handed. It appears that the three-wheeled sports chair is here to stay ( Fig 24B-21. modification of the prosthetic foot may be necessary to prevent the foot from hitting the brake pedal while operating the rudder pedal. His 100-m time is within 1.3 seconds. Bill Duff wheeled 5. similar to the action of the quadriceps muscle ( Fig 24B-20. and the distal end is attached to the proximoante-rior shank section of the prosthesis. The choice of an aircraft depends on the ability to get in and out. and vertebral column. Other aircraft being flown by amputees include the Mooney Ranger and the Beechcraft Muscatee Bonanza. For children. During running. Rick Hansen completed his "Man in Motion World Tour" in a wheelchair. Amputees are moving toward narrow mediolateral and flexible sockets. These feet provide varying amounts of push-off at the beginning of swing phase. Struts on high-winged aircraft such as the Cessna 172 interfere with wheelchairs.000 miles from Los Angeles to New York and created even more publicity for wheelchair racing. He was recently inducted into the Colorado Aviator Hall of Fame. The proximal end of the cable is attached to a belt similar to a Silesian bandage.asp[21/03/2013 21:56:47] . . above the knee and inhibits water from entering the socket when swimming or showering. ). For those who fly without hand controls. with a time of 1:50:06.org/alp/chap24-02. Activsleeve is made of natural rubber with a ribbed design at the top of the sleeve and a straight tubular design. The women's division was won by Connie Hanson. To reduce some of these difficulties. but very little strength. In other words. They usually extended the knee on the prosthetic side during heel contact and thus reduced the shock absorption function of the residual limb and placed unnatural stress on the knee. FLYING There are some 10. The transfemoral amputee Jeff Keith. The Navy Prosthetics Research Laboratory in Oakland. and the 400 m in 56. Another adaptation is to attach a webbing strap to the rudder controls http://www. but an amputee who can stand can move around them. Amputees in wheelchairs do best with a low-wing Piper Cherokee. has designed a two-part SACH foot. The ribbed portion creates a seal around the thigh to produce a suction-type suspension. this force reaches two to three times body weight. which has a door beside the wing and a baggage area large enough to accommodate the wheelchair. California. the 200 in 24. Recovery of the limb with so little knee flexion could only be accomplished by additional contraction of the quadriceps muscles and resulted in unnecessary fatigue. 24 years old. The Grumman American and Ercoupe also have low wings. ). In 1985.25 seconds. Flying requires skill and judgment. power is being transferred to the knee joint directly from the action of hip flexion. the vertical ground reaction force is rarely greater than body weight. was wearing a Seattle foot on his prosthesis.000 pilots with physical disability in the nation's skies. Dennis Oehler. ). thus being much more effective choices for the athlete. In 1989 it was 14:02. who won it in 1:36:04. The Cessna Cardinal does not have wing struts and may work well. The 1989 winner was Philippe Couprie. When flying. hip. Restricted range of motion of the intact limb and the knee and hip during swing phase was also seen. Rode Rodewald is a wheelchair pilot who soloed on a trip that took him around the globe in 1984. Four intact limbs are not necessary.8 seconds of the able-bodied world record ( Fig 24B-19.24B: Adaptations for Sports and Recreation | O&P Virtual Library capable of running short distances at speeds of 4 to 5 m/sec and of maintaining paces of approximately 3 m/sec for distances of a half mile or more. In 1977 the time differential between men and women was 1:06:51. the Oklahoma cable above-knee running system involves using upper-limb cable systems to help bring the shank of the prosthesis forward more efficiently during the swing phase of running. Activsleeve can be worn as low as 3 to 4 in.37 seconds. It is now 14 years since wheelchair athletes first entered the Boston Marathon. an amputee sprinter from the United States.oandplibrary. These amputees were running with conventional prostheses. who completed a cross-country run from Boston to Los Angeles in 1984. The Activsleeve suspension system is helpful in reducing pistoning for the transtibial amputee ( Fig 24B-18. and the design of racing chairs has developed into a fine art. 26 years of age. This averages 3 minutes and 40 seconds to the mile.A and B). dynamic-response feet emerged. the toe section can simply be removed and then replaced for normal walking later on ( Fig 24B-22. but a sliding canopy requires entrance over the side. so discomfort on the medial part of the brim and rotation of the socket are less of a problem. Transfemoral sockets have also improved. ). For walking. At toe-off. which is very popular with the active amputee population. is able to do the 100 m in 11. Between January and July 1989. tension in the cable causes a dynamic extension moment at the knee. Wheelchair road racing has become a well-established entity. and the formation was held for 4. An ambulatory rider. For free-fall jumping. and reins do not require modification. The transfemoral amputee needs to build a knee length extension to his residual limb by using either a residual-limb protector or an old socket. http://www. SKYDIVING Most amputees jump without a prosthesis and use protective padding for the residual limb. He then jumps in the same way as a transtibial amputee. flattening the medial aspect of the calf. Amputees with bilateral transfemoral amputations or hip disarticulations usually need buckettype devices. bridle.24B: Adaptations for Sports and Recreation | O&P Virtual Library to allow them to be operated in a push-pull fashion with the sound leg. might need a twoto three-step mounting platform. Possible modifications to the prosthesis are lowering the popliteal brim. They can buckle to heavy-duty square D's under the saddle skirt slightly behind the D's used for the breastplate or martingale.000 riders a year in the United States and Canada. In 1981. They fit only on English saddles. The transtibial amputee can either bend both knees to his chest or extend the hips and bend both knees to a right angle. Western saddles are more stable but do not have the safety stirrup options. It is best to use Devonshire boots (stirrups that look like a boot toe) or safety stirrups that come with a safety latch to release in the event of a fall. although the gluteal tissue often gets pinched between the prosthesis and the saddle. If wearing their prosthesis. especially when navigating on the ground after a jump. Saddle. The outside of the prosthesis needs to be checked so that there are no rough edges that could irritate the flank of the horse. although caution is needed to prevent the toe from being trapped. This socket-stirrup assembly will need to release the limb in a fall ( Fig 24B-23. the amputee might need some type of "residual-limb stirrup" to facilitate balance on the horse.org/alp/chap24-02. the amputee may have difficulty maintaining a stable position because the body surface presented to the air must be symmetrical. BICYCLING Transtibial amputees ride easily with a prosthesis. It took them 15 attempts to accomplish.oandplibrary. A very short residual limb would also be reason for riding without the prosthesis. ). they will also usually need a string or strap from the heel of the boot to the upper part of the prosthesis or to the waist to keep the knee flexed. Transfemoral amputees do need to have the ability to abduct the residual limb at the hip joint. and aligning so that the heel is canted inward and the toe upward and outward. The main concern with stirrups is that they do not trap the prosthetic foot in a fall.66 seconds. The use of the arms may also be necessary to prevent spinning. may also be used to keep the knee flexed at a desirable angle. Transtibial amputees generally wear a prosthesis for riding. Now the North American Riding for the Handicapped Association (NARHA) serves about 4. A detachable pylon is also helpful. Unilateral amputees need them only rarely. A locking device. Some put the prosthetic heel on the pedal for a more effective push. Others use a toe clip to keep the prosthesis on the pedal. especially for transfemoral amputees. Transfemoral amputees can ride with a prosthesis. Ordinary static line jumping requires no adaptation for disability. Mounting from a wheelchair may require a ramp (16 by 4 ft with a platform 4 X 6 ft). as on the Mauch S-N-S knee. Rubber inserts for stirrups and rubber-soled boots may help keep the prosthetic foot in place. but rolled leather hand holds can be attached across and in front of the pommel of an English saddle to help the beginner maintain balance.seats with leather sockets. If riding without a prosthesis. HORSEBACK RIDING Scandinavia and Great Britain pioneered in promoting riding for the handicapped. especially one with left-sided amputation.asp[21/03/2013 21:56:47] . a group of amputees called "Pieces of Eight" performed an eight-way free-fall formation. sound leg on one pedal. Second Skin is available from most sporting good stores. The front rider can stop and rest. and Monte Stratton. Catcher is a good choice if the amputee has a strong arm. Both riders activate the front hub brake by backpedaling. The cycle seat slides back and forth or can be locked in one position. right-sided amputees may bat left-handed. can get down on his haunches with the prosthetic leg to the side. extra padding on the saddle. The Rowcycle is a hand-operated mix between a bicycle and a rowing machine that uses arm and back muscles. Most transtibial amputees play any position. BASEBALL Many amputees play baseball. usually with a prosthesis and always on an able-bodied team. Some amputees defer to a substitute runner after they get on first base. ). The racing handlebar position may be uncomfortable. a hip disarticulation amputee. The Sunburst and the Counterpoint are two-wheeled tandem bikes combining armand footpowered recumbent cycling in the front and standard cycling in the back ( Fig 24B-25. A toe strap is often used on the sound side and the bike operated in a push-pull fashion. Prostheses without hip joints and pelvic bands allow more comfortable straddling of the saddle. A hip disarticulation amputee may chose to ride with his abdomen on the saddle. and can get up quickly. but works. Shortstop could be a difficult position because of decreased lateral mobility. The Mauch S-N-S hydraulic knee is effective for bicycling. Hand-powered. while the back rider continues to pedal. To prevent friction between limb and socket. The front rider pedals with any combination of arms or legs. This can be obtained by using the stance control. ). BASKETBALL http://www. which turns the front wheel. the skateboard provides a recreational outlet and can be an appealing alternative to the wheelchair. The assembly weighs about 17 lb and fits into most auto trunks ( Fig 24B-24. either separately or together. Bicycle shoes also help with the upstroke. a transfemoral amputee who pitched for the Chicago White Sox. Both hands must be kept on the handlebars while exerting power because the arms and hands compensate for the imbalance of one-legged power. It is steered by the weight-shift rotation of the seat. The wheelchair Cycl-one is a hand-operated device that attaches directly to a standard wheelchair and allows the rider to travel at 10 to 15 mph. Some avoid using the prosthesis because they feel that it offers no additional power. Pitcher and first baseman are other possibilities.org/alp/chap24-02. Foam-covered endoskeletal prostheses must be protected from pedal damage. This is precarious. One size can be used by the child or adult. Two notable people are Bert Sheppard. Spenco Second Skin (made from a breathable hydrogel) can be held in place with tape and a stump sock. Other options to consider are removing the unused pedal or crank. For stationary bicycles. For young children with bilateral limb deficiencies. a transtibial amputee who successfully pitched for the Washington Senators. a twowheeled cycle with two small caster wheels projecting from each side of the frame.oandplibrary. has ridden across America twice on his bicycle and has set the world handicapped cross-country record at about 15 days. hand-controlled tricycles may work for the child amputee. opposite hand on the other pedal.24B: Adaptations for Sports and Recreation | O&P Virtual Library Transfemoral amputees have several options. A good-quality bike with many gear options is obviously desirable.asp[21/03/2013 21:56:47] . gives balance and stability to the bike for boarding. and turning the saddle slightly away from the sound leg. The back rider controls the rear caliper brake with a hand lever. and conventional handlebars may be better. Gear levers must be handlebar mounted and operable with three fingers while the palm and other fingers continue to grip the handlebar. Batting with the stronger leg behind is best. the Schwinn Air-Dyne is recommended because it allows arm as well as leg operation. The free-swinging mode is best unless a legstrengthening resistance is required. but transfemoral amputees are usually too slow for the outfield. The center of gravity is adjustable and allows the rider to "pop wheelies" for quick turns. The Handbike. David Kiefer. and sound-side hand on the handlebars. Others wear the prosthesis for cosmetic needs and use the prosthetic leg as a landing strut. or an ointment like Ampu-Balm or Amp-Aid. at a lower level. but probably not for a whole game. ) originated in the Seattle area and has now expanded into national and international competitions. When handedness and prosthesis are opposite. A "pogo stick"-type crutch is in the prototype stages of development. ). The outrigger skate aid is another possibility ( Fig 24B-28.asp[21/03/2013 21:56:47] . The player moves along a course made up of 12. adult model. a walker-type device. SOCCER Amputee soccer ( Fig 24B-26. The 1991 championships were held in the Soviet Union. Since there are so few disabled teams. or 18 baskets on variously shaped backboards. Players use standard Canadian forearm crutches and no prosthesis. Occasionally an amputee will play by hopping without a prosthesis. When turned over it becomes a portable seat. This type of prosthesis would also work for the sport of curling. A prosthesis similar to that described for rowing may be helpful. Homemade pads can be constructed from foam rubber in a heavyweight plastic bag and sealed with waterproof tape. can be helpful to the beginning skater ( Fig 24B-27. The suspension system on the prosthesis needs to be secure to support the extra weight of the skating boot. for those in wheelchairs. Spenco Second Skin. Wheelchair basketball is very well established and features over 150 men's teams and a few women's teams. There are also summer wheelchair basketball camps. A kneeling stool called an Easy Kneeler is available. The transfemoral amputee might consider a total elastic suspension (TES) belt in addition to a suction socket.org/alp/chap24-02. with teams coming from England. BOWLING An ambulatory amputee can bowl by standing at the foul line or using a twoto four-step approach. it is wise to use a nylon sheath. ).oandplibrary. which is difficult to achieve because the prosthetic ankle does not allow sufficient plantar flexion. Goal keepers are arm amputees. children's model and a 35-in. each requiring a different and increasingly difficult shooting strategy. Steps may be short and jerky. the Soviet Union.24B: Adaptations for Sports and Recreation | O&P Virtual Library The United States Amputee Athletic Association sponsors a tournament featuring six to eight teams for stand-up basketball competition in which conventional rules apply. It is a pure shooting sport that involves no running or contact. A new sport well suited to wheelchair players and able-bodied alike is bankshot basketball. The Activsleeve would be a good choice for the transtibial amputee because it creates a suction-type suspension. the bowler may prefer to stand with feet together about a meter behind the foul line and lean forward to advance the ball. Most use a prosthesis with a dynamic-response foot and additional prosthetic suspension. SKATING The transtibial skiing prosthesis can be adapted for roller or ice skating. There is a 28-in. The game can be played alone or competitively. The pad for the sound leg should be thicker to raise the hips and allow more toe clearance on the prosthetic side. and Brazil. and gardeners with transtibial amputations may feel pressure in the popliteal fossa area. This crutch will help absorb some of the force absorbed by the upper limbs and has more padding than a regular crutch. El Salvador. The skating boot may be difficult to put on without a nylon hose or plastic bag over the prosthetic foot to help it slide. Once in the kneeling position. One solution is to use planter boxes supported so they can be reached at waist level or. the upper portion of the body seems to be pushed forward. 15. Knee pads can be fabricated by a pros-thetist. To protect the skin from friction. The Hein-A-Ken Skate Aid. A right-handed bowler with a right amputation (or a left-hander with a left prosthesis) is in the best situation-he can slide to the foul line on the sound leg and release the ball in the usual way. GARDENING Gardening usually requires kneeling. A figure skating blade is mounted http://www. most people play on able-bodied teams. Canada. preferably one with considerable rotation capabilities. a nylon sheath is invaluable for decreasing friction. No crutches or other assistive devices are allowed. the highest point in North America. Wheelchair tennis tournaments have been held since 1975. no prosthesis is allowed. but the competitor must take off from ground level on one foot. The ice pick is covered with a sheath when not in use. with or without a prosthesis. a hip disarticulation amputee. lawn bowling. such as those used by the bilateral transtibial amputee Hugh Herr in all his expeditions. England. Transfemoral amputees generally prefer to climb without their prosthesis and to rely on specially adapted forearm crutches for added grip and stability. as well as full outward rotation of the leg for grip on the medial border of the shoe. multiaxial pelvic band and thigh rotation system placed under the socket to increase mobility. Two of these outriggers improve support and balance. This crutch was modified by Drew Hittenberger.asp[21/03/2013 21:56:47] . Her crutches featured a convex basket with spikes at the lower end that are used as crampons ( Fig 24B-29. but crutches are not allowed. or shotput must be airborne before contact is made with the barrier. ice climbing crampons can be adapted to clip to the prosthetic shank.oandplibrary. The only modification of the rules is that the wheeler gets two bounces before he has to return the ball. such as those used by Don Bennett when he climbed Mount Rainier. A modified ice pick is attached to the forearm portion of the crutch ( Fig 24B-29. stand-up basketball. An ankle unit such as the stationary-ankle. A book entitled A Man and His Mountains by Norman Croucher is about a bilateral transtibial amputee who has climbed and led expeditions in almost all the major mountain ranges in the world. air pistol. In August 1984. while the outriggers are used for propulsion. RACKET SPORTS Most amputees wear a prosthesis. The disadvantage of this method of climbing is the limited use of the hands for handholds and the necessity for the amputee to carry his prosthesis on his back for use on level ground. javelin. or shotput. and table tennis. a modular polycentric knee.B). For tennis. It is made of titanium components to reduce weight and features a conventional socket. Bennett's challenge a few years later.94 m. Ice sledding is a good alternative for the bilateral amputee.P.24B: Adaptations for Sports and Recreation | O&P Virtual Library to a forearm or similar crutch. For long jump. For swimming. For table tennis. Individuals with bilateral transfemoral amputations who are wearing prostheses may throw from behind a hip-high barrier. followed Mr. Levesque and Gauthier-Gagnon have designed a transfemoral prosthesis for rock climbing. Events usually include swimming. it is very easy for the able-bodied and disabled to play together. For high jump. McKinley.org/alp/chap24-02. she went on to climb Alaska's Mt. In this sport. http://www.A). weight lifting. Other events may include sit-down volleyball. participants jump without a prosthesis from a standing position at the take-off line. For the trans-tibial amputee. Wheelchair tennis and racquetball are two of the most up and coming wheelchair sports. It provides grip close to the knee by using an additional prosthetic foot close to the knee joint. Competition in the United States began in 1981. Sarah Doherty. but the discus. a prosthesis is worn if the competitor wears one for everyday use. Croucher has received the Man of the Year Award and the International Award for Valour in Sport. track and field. Arnold Boldt is an amputee from Canada who dominates in this sport. ). a protruding foot just above the knee axis. . wearing a prosthesis is optional. flexibleendoskeleton (SAFE) foot may be useful because it adapts well to uneven terrain. the National Foundation for Wheelchair Tennis was formed. Bilateral amputees can compete from a wheelchair. . If a prosthesis is used. MOUNTAIN CLIMBING Climbing is possible. a prosthesis is worn. javelin. C. COMPETITIVE SPORTS The first World Amputee competition was held in 1979 in Stoke Mandeville. Skates on the lower limbs maintain continual contact with the surface. For discus. and in 1980. He is able to jump 1. doubles play reduces the amount of running required. and a SACH foot ( Fig 24B-30. and pentathlon. volleyball. Labelle H: Running patterns of juveniles wearing SACH and single-axis foot components. Beaufort Books. . Stretching Inc. Spain in September 1992. For wheelchair sports. Disabled USA 1982. 9:43-44. 15-16. 70:128-134. The foot needs to have some flexibility so that it stays flat. To do the squat and dead lift. . Avon. guided by Dr. Korea. 8:2223. Anderson B. participants are weighed in the nude without prostheses 1 hour before the event. Burgess EM: Below knee amputee running gait. Arlon has proved to be a more adequate laminating material than fiberglass or acrylic. the Paralympic Games began in 1960. Alexander MJL: The high jump technique of an amputee. Sports Spokes 1980. Oppelt R: Ice skating therapy.oandplibrary. Brenner RR: Bankshot basketball. Aids to Make You Able. Palaestra 1986.700 participants from 45 countries. Disabled Sport Resources Directory (DSRD). NASTAR enables amputees to compare themselves with others in the world with similar disabilities or to top professional skiers. Donnelly D: USMS Adapted Swimming Handbook. Miller DI. The prosthesis needs to be fabricated from material that will tolerate the torques and stresses applied to it by the excess weight. Brouwer BJ. United States Masters Swimming. USOC. Conn. 61:66-84. 141. Allard P. http://www. in Aids to Make You Able. Am J Phys Med 1982. Those with amputation then add l/16th of their body weight for each transtibial amputation. 6:8-9.org/alp/chap24-02. In August 1985 the top eight 1. Fifteen hundred-meter exhibition events were also held at the 1990 Goodwill games in Seattle. Mary Margaret Newsom. Sports Spokes 1984. Chadderton HC: Otto Bock Curling Limb. Colorado Springs. Nassau County. National Handicapped Sports would be the best resource. The eighth Paralympics were held in October 1989 in Seoul. CO 80909-5760. Ludwig Guttman. While the base of support has to be wide. For competitive snow skiing. Bornell DG: Stretch and Strengthen. Boulder Ave. Palmer Lake. Self-Help Devices and Ideas for the Disabled. 1750 E. l/9th of their body weight for each transfemoral amputation. Wheelchair sports in America.000 athletes from 60 countries participated in the games and established 971 new world records. it also has to remain vertical without causing too much stress on the knee ligaments. 1981. Davis WN: Skiing. Ontario. 13-17. Dummer G. New York. 1981. Physician Sports Med 1978. Collins VT: Soaring. Leatherman J: Racquetball-wheelchair style. Education Services. Colo. Canoe 1976. 52:52-53. W Davis General Publishing Co Ltd. Adams R. Enoka RM. Don Mills. the ideal technique? Cahper J 1981. Donoho K. Fragment 1983. Axelson P: Adaptive Technology for Skiing. a good-quality prosthesis is of extreme importance. a prosthesis offering a wide base of support is important. Brant MK: Kayaking with a prosthesis. Arch Phys Med Rehabil 1989.24B: Adaptations for Sports and Recreation | O&P Virtual Library For weight lifting. Approximately 4. BIBLIOGRAPHY Aboulafia DI: In the beginning . Rehabil World 1984. 6:71-81. and l/6th of their body weight for each hip disarticulation. New York. Hakala M.asp[21/03/2013 21:56:47] . For amputees who choose to weight lift in nondis-abled events. A division for the physically challenged was added to the National Standard Race (NASTAR) program during the 1985-1986 season. The next Paralympic event will be in Barcelona. was the site of the 1984 International Games for the Disabled and drew 1.500-m male and the top eight 800-m female wheelchair track athletes in the world competed in an exhibition event at the Los Angeles Olympics. Champaign. Burgess EM: The extra-ambulatory limb concept as it applies to the below-knee amputee skier. 64:37-40. Palaestra 1989. Fla. 6:14. Graves JM. 8:18-20. 1987. Harcourt Brace Jovanovich Inc. Evergreen. International Perspectives on Adapted Physical Activity.. Clin Prosthet Orthot 1982. 1:104-109. Products to Assist the Disabled Sportsman.asp[21/03/2013 21:56:47] . Colo. Krebs DA: Adaptive Recreation Equipment for the Physically Challenged. 1990. Thousand Oaks. 1987. McGowan J: Paraplegics and Skydiving: A Personal Guide. LaBlanc KP: Fabrication of the water-resistant recreation B/K prosthesis. 25-29.. Wash. J Prosthet Orthot 1989. Clin Prosthet Orthot 1987. Orthot Prosthet 1984. Riley R: Amputee athlete. Access to Recreation Inc. Ill. Human Kinetics. Kegel B: Amputee soccer. Cordillera Press Inc. Hughes HN. Owens D: Teaching Golf to Special Populations. A water sports symposium for the physically challenged. 1986. JL Pachner Ltd. Frieden L: Go For It! Orlando. Orr L: Cross country sled skiing. Demarco E: New design and construction for a swimming prosthesis. 37:42-49. 5(suppl):167-170. Cleveland. Indianapolis. Fleiss D: Devices to enable persons with amputation to participate in sports. Gauthier-Gagnon C: An improved downhill skiing prosthesis. Overland Press. Gorski R: Diving for the deep. Arch Phys Med Rehabil 1983. 7:2.. 1989. NHS/Invacare. 1989. Kegel B. Mensch G. 1988. Bull Pros-thet Res 1973. Kelley JD. Benchmark Press Inc. St Petersburg. Paciorek M. Helmuth G: A modified prosthetic foot for pilots. Ellis P: The Terry Fox running prosthesis. 10:129-134. Clin Rehabil 1989. Ballinger J: Continental Quest: An Account of the First Wheelchair Crossing of North America. Medic Publishing Co. Phys-iother Canada 1984. Phys Ther Forum. Sports and recreation for those with lower limb amputation or impairment. Arch Phys Med Rehabil 1980. Marano C. J Rehabil Res Dev Clin Suppl 1985. West Point. Wyse Public Relations. Kegel B: Physical fitness.oandplibrary. Ill. Burgess EM: Recreational activities of lower extremity amputees: A survey. Hittenberger DA: Extra-ambulatory activities and the amputee. Redmond. 61:258-264. Ellis PE: Running patterns of transfemoral amputees-A clinical analysis. Leisure Press. Lake Zurich. McCann BC: Classification of the disabled for competitive sports: Theory and practice. NY. Jones JA: Sports and Recreation for the Disabled. Mensch G. Calif. James McGowan. Peterson J: Summer splash. Fla. Orthot Prosthet 1975. Levesque C. 6:17-19.24B: Adaptations for Sports and Recreation | O&P Virtual Library Fitness is for Everyone. 1:1-25. 1984. 36:245-246. Kegel B: Sports for the Leg Amputee. O'Leary H: Bold Tracks: Skiing for the Disabled.org/alp/chap24-02. Saadah ESM: Rehabilitation of a below-knee amputee with a diving limb. Int J Sports Med 1984. Prosthet Orthot Int 1986. Sports Spokes 1983. Webster JC. Orthot Prosthet 1983. McBee F. 10:126-131. 29:33-34. http://www. 11:109-113. 38:45-49. Kegel B. A Resource Manual. Rubin G. Disabled USA 1982. Canada. RESOURCE LIST Able Sailor Systems and Hardware. Clin Prosthet Orthot 1987. CA 92675. Simmons R: Reach for Fitness: A Special Book of Exercises for the Physically Challenged. PO Box 10. Ontario.U.oandplibrary. PO Box 2781. Products to Assist the Disabled Sportsman. 3857 Birch St. A Magazine for People With Mobility Impairments. Cheever Publishing Inc. The Garden and the Handicapped Child. 11:169-172. National Foundation of Wheelchair Tennis. Warner-Books Inc. East Ardsley.asp[21/03/2013 21:56:47] . Suite 502. London. 70:330-335. 5223 S. DC. 126:20-21. Mission Hills. Fragment 1980. Water Sports for the Disabled. Woking. PO Box 4811. IL 61701. Suite 111. East Lansing.LD. CONSUMER LITERATURE Abilities: Canada's Journal of the Disabled. (714) 661-2132. National Library Service for the Blind and Physically Handicapped. Clin Prosthet Orthot 1987. Newport Beach. England. 8:7. 33012 Lighthouse Ct. (Scuba Quarterly Undersea International Digest). Physical Education. Mississauga. Accent on Living. Majestic Press Inc. The Forum of Sport. 1986.24B: Adaptations for Sports and Recreation | O&P Virtual Library 3:269-251. Sports 'N Spokes. 401 Linden Center Dr. 5090 Explorer Dr. Chadderton C: Swivel golf shoes. National Handicap Motorcyclist Association. Bloomington. Lorel Ave. AZ 85015. CA 92660. Mainstream. Paralyzed Veteran's of America. Library of Congress.org/alp/chap24-02. 1983. NY 10128 http://www. Thomann J: Flying lite-Ultralight aircraft. 411. No. 1986. JL Pachner Ltd. 3. Two-Bounce News. Jackson Heights. above-knee running system. New York. (714) 439-6128. Carthage. Ill. CA 92025. EP Publishing Ltd. Sports. Phoenix. 32-04 83rd St. CA 92672. CA 91345. PO Box 5311. Washington.K. Aviary Rd Pyrford. Sabolich J: The O. Chicago. Palaestra. 5201 North 19th Ave. The Gimp Exchange. CO 80524. Sports Spokes 1983. Sports prosthetics. Games and Outdoor Recreation for Handicapped Persons. Disabled Living Foundation. Mobility. PO Box 700. MI 48823. NY 11370. IL 62321. Escondido. SJ Capistrano. L4W 9Z9.Q. Hittenberger DA: Energy-storing prosthetic feet. Viau A. Disabled Outdoors Magazine. (602) 246-9426. 1983. Wing DC. Arch Phys Med Rehabil 1989. S. Ltd Colgrims Mede. (309) 3782961. ed 1. Surrey GU22 8th Great Britain Achilles Track Club 9 East 89th St New York. Ability Magazine. 116 West El Portal. (303) 484-3800. Handicapped Scuba Association. Suite 104. IL 60638. Human Kinetics. Outdoors Forever.C. Sherrill C: Sport and Disabled Athletes. Fort Collins. Champaign. and Recreation for the Disabled. San Clemente. (805) 366-1552. Coaching Director Suite 107.24B: Adaptations for Sports and Recreation | O&P Virtual Library (212)967-9300 Activsleeve Rampro. Stevens 1102 Bergan Rd Oreland. AZ 85204 (602) 831-4262 American Wheelchair Table Tennis Association Jennifer Johnson 23 Parker St Port Chester. East PO Box 250218 Little Rock. Executive Vice President 1900 Association Dr Reston. WI 53051 (414) 781-6876 American Wheelchair Pilot's Association c/o Dave Graham 1621 East 2nd Ave Mesa. Box 377 Sand Springs. VA 22122-1190 (703) 550-7495 American Special Recreation Association c/o John Nesbitt. Inc PO Box 3256 Santa Monica. NC 28256 (704) 598-0407 Amputee Soccer International Bill Barry. OH 43606 (419) 537-2755 Adolescent Amputee Camp Physical Therapy Department c/o Gay Gregg Children's Hospital of Pittsburgh 125 DeSoto St Pittsburgh. Adaptive Sports Program Kinesiotherapy Clinic c/o Dr Leonard Groninger University of Toledo 2801 West Bancroft St Toledo.oandplibrary. VA 22091 (703) 476-3561 American Amputee Foundation. Suite 1900 PO Box 190 Newington.asp[21/03/2013 21:56:47] . Program Administrator. Ed.S. NY 10573 (203) 629-6283 Amputee Competitive Sports U. Recreation and Dance Programs for the Handicapped c/o Dr Razor. IA 52240 (319) 353-2121 American Therapeutic Recreation Association. D Recreation Education Program University of Iowa Iowa City. Amputee Athletic Association Jan Wilson. AR 72272 (501) 666-2523 American Canoe Association Disabled Paddler's Committee 8580 Cinderbed Rd. PA 19075 American Alliance for Health. Jr 11705 Mercy Blvd Savannah. Inc c/o Peg Conley 3417A Sapula Rd. 1110 North 175th St Seattle. OK 74063 (904) 644-6014 American Waterski Association Phil Martin.org/alp/chap24-02. PA 15213 (412) 647-5480 Advisory Panel on Water Sports for the Disabled The Sports Council 70 Brompton Rd London SW3IEX England American Academy of Sports Medicine for the Physically Disabled Dr Philip J. Beckmann. GA 31419 (912) 927-5406 http://www. GA 30211 American Wheelchair Bowling Association Daryl Pfister N54 W 15858 Larkspur Lane Menomonee Falls. WA 98133 (206) 546-3770 Amputee Sports Association c/o George C. Executive Director PO Box 560686 Charlotte. CA 90403 (213) 828-6781 Suspension system helpful in reducing pistoning and suction-type suspension for the transtibial amputee. Physical Education. Chairman Disabled Ski Committee 681 Bailey Woods Rd Dacula. Inc c/o Jack M. FL 33133 U. Head of Instruction Box 41 Bryson City. PA 19130 (215) 763-5815 Sailing Accessories.asp[21/03/2013 21:56:47] . 1979 Research and Utilization Institute Human Resources Center Albertsen.oandplibrary. NY 12471 (914) 658-3141 Boating Information American Canoe Association Committee for Disabled Paddlers 8580 Cinderbed Rd. Ph.org/alp/chap24-02. NC 28713 (704) 488-2175 Norwegian Arctic Tours PO Box 700 Enfield.. NY 11507 Disabled Sailing Association of British Columbia 1300 Discovery St Vancouver. CA 92028 (619) 725-6195 or (619) 723-8003 Baseball Information National Wheelchair Softball Association John Speake. MA 02146 Rifton Equipment Division of Community Playthings Society of Brother. Suite 1900 PO Box 1190 Newington. CO 80110 (303) 756-4050 Mr. CA 92345 Bicycle Information For Fun Cycles Corporation 966 N. Inc 2712 Irwin Rd Redding.D. VA 22122-1190 (703) 550-7495 Boating for the Handicapped/Guidelines for the Physically Disabled by Eugene Hedley. Association for Disabled Sailors Keith Lark. BC V6R4L9 Canada 222-3003 Environmental Travelling Companions (ETC) Fort Mason Center Landmark Bldg C San Francisco. Harper Mfg 3125 W. Kenneth Kozole. Elm St Orange.24B: Adaptations for Sports and Recreation | O&P Virtual Library Amputees in Motion International c/o Jerry Dahlquist PO Box 1736 Fallbrook. IL 60611 New England Handcycles. Inc Rifton.S. OTR Clinical Rehabilitation Engineer Rehabilitation Engineering Program Room 1441 Northwestern University 345 E Superior St Chicago. RI 02840-0009 (305) 858-5550 (401) 849-8898 Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami. CA 90740 (213) 431-4461 http://www. MN 55422 (612) 437-1792 Bert Sheppard 8014 Bangor Hesperia. CA 92667-5471 (714) 997-1952 Harper Handbike. Inc 228 Winchester St Brookline. Hampden Ave Englewood. CA 94123 (415) 474-6772 Nantahala Outdoor Center Bunny Johns. NH 03748 Philadelphia Rowing Program for the Disabled (PRPD) Attn: Sean Riordan/Pat Standley 858 Bailey St Philadelphia. CA 96002 (916) 221-7197 Shake-A-Leg PO Box 1002 Newport. Commissioner PO Box 22478 Minneapolis. President Southern California Chapter 901 Fathom Ave Seal Beach. Alberta TOL OCO Canada British Disabled Water Ski Association Warren Wood. ID 83209 (208) 236-391 The Counterpoint (or Sunburst) Angle Lake Cyclery Matt Dekker http://www. MA 02178 (717) 439-3246 United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown. Dowling. Executive Director PO Box 697 Breckenridge.24B: Adaptations for Sports and Recreation | O&P Virtual Library Wilderness Inquiry 11 1313 Fifth St SE. CO 80424 (303) 453-6422 British Amputee Ski Association Box 1373 Banff. Hog) c/o Thomas Whittaker Box 8118 Idaho State University Pocatello. TX 75261 (214) 659-2000 Breckenridge Outdoor Education Center Mike Mobley. PA 19057 (215) 945-1964 Wheelchair Athletics of America Judy Einbinder 8114 Buffalo Speedway Houston. Surrey KT212 SN England California Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido. DC 20210 (202) 653-5044 Competitive Wheelchair Sports Achilles Track Club 9 East 89th St New York.asp[21/03/2013 21:56:47] . NY 10128 (212) 967-9300 International Wheelchair Road Racing Club Joseph M. CT 06902 (203) 967-2231 National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs. the Warren Ashtead. MN 55414 (612) 379-3858 Boy Scouts of America Scouting for the Handicapped c/o John E. CO 80909 (719) 635-9300 National Wheelchair Marathon c/o Bob Hall 15 Marlborough St Belmont. Chairman Washington.oandplibrary. Box 84 Minneapolis.org/alp/chap24-02. CA 92025 Canadian Wheelchair Sports Association 1600 James Naismith Dr Gloucester. PA 17011 (717) 761-7400 Committee on Recreation and Leisure President's Committee on Employment of the Handicapped c/o Gerald Hitzhusen. TX 77025 (713) 668-5376 Cooperative Wilderness Handicapped Outdoor Group (C. Hunt PO Box 16030 Dallas-Ft Worth Airport Dallas. President 30 Myano Lane Stamford. Ontario Canada K1B5N4 (613) 748-5685 Committee for Handicap Sailing Baerum Seilforening Strandalleen 8 1320 Stabelk Norway Committee on Athletes with Physical Disabilities Dr Michael Asken Cowley Associates Plaza 21 425 North 21st St Camp Hill. Vice President 2080 Ennabrock Rd North Bellmore. Scouting for the Handicapped Service c/o Cindy Ford 830 Third Ave New York.oandplibrary. AZ 85204 CA Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido. GA 31419 Golf for Life Shirlee C. President Mike Doanals. CA 92021 (619) 442-3425 http://www. NY 10118 (212) 563-9797 Flying Information American Wheelchair Pilots Association c/o Dave Graham 1621 East Second Ave Mesa. CA 94568 (415) 829-9576 (415) 971-2661 International Senior Amputee Golf Society c/o Dale Bourisseau 14039 Ellesmere Dr Tampa.org/alp/chap24-02.S. Inc. NY 11710 (516) 826-8340 Easy Kneeler Gardener's Supply Co 133 Elm St Winooski. Courage Center 3915 Golden Valley Rd Golden Valley.24B: Adaptations for Sports and Recreation | O&P Virtual Library 20840 Pacific Highway S Seattle. Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon. IL 60302 (312) 284-2206 Eastern Amputee Athletic Association Jack Graff.asp[21/03/2013 21:56:47] . MN 55422 (612) 588-0811 Cycl-one Access Designs. 11705 Mercy Blvd Savannah. WA 98198-5999 (206) 878-7457 FAX (206) 824-3038 Two-wheeled tandem bikes. NY 10022 Golf Information Amputee Sports Assoc c/o George C. OR 97351 Hand-operated device attached to the wheelchair. CA 90066 (213) 390-4448 Girl Scouts U. OR 97215 (503) 238-0049 or PO Box 216 Independence. 53rd Ave Portland. FL 33624 (813) 961-3275 National Amputee Golf Association PO Box 1228 Amherst. Disabled Outdoors Foundation 320 Lake St Oak Park. The 52 Association 350 5th Ave. Jr. PO Box 66071 Los Angeles. VT 05404 (802) 655-9006 Kneeling stool for gardening. 627 S.A. Inc. Beckmann. Hicks 7595 Carlow Way Dublin. CA 92025 (619) 746-5018 The Soaring Society of America.E. Room 1829 New York. NH 03031 (800) 633-NAGA Project Fore. Ice Sledding Breckenridge Outdoor Education Center Mike Mobly. Executive Director PO Box 697 Breckenridge. CA 90807 (213) 5955738 Permanent hand controls.asp[21/03/2013 21:56:47] . ext. CO 80424 (303) 453-6422 International Council on Therapeutic Ice Skating PO Box 13 State College. MN 56701 Skating boot. President Bill Blackwood. Hand Controls for Flying Aircraft Inspection and Maintenance 2680 E Wardlow Rd Long Beach. Grosse Physical Education Specialist Milwaukee Public Schools 7252 West Wabash Ave Milwaukee. CA 94304 (415) 493-5000. Schwandt can also be contacted for information on the Counterpoint or Sunburst bikes. Mr. Suite 104 San Clemente. PO Box 207 Sturgis. Handbike Rehabilitation R and D Center Doug Schwandt VA Medical Center 3801 Miranda Ave Palo Alto. Inc 102 Fosse Ct Thief River Falls. TX 77380 (713) 363-4707 International Games for the Disabled c/o Tony Giustino Eisenhower Park East Meadow. KY 42459 (502) 333-5918 FAA-approved portable hand controls for certain Cessna and Grumman aircraft. Handicapped Scuba Association Jim Gatacre 116 West El Portal.oandplibrary. 4473 Two-wheeled cycle. WI 53223 (414) 354-8717 Groundgrabbers K and R Specialties 2809 Charles Court NW Rochester.org/alp/chap24-02. MN 55901 (507) 281-1351 Snow chains for wheelchairs. Union Aviation. NY 11554 (516) 542-4420 International Senior Amputee Golf Society. CA 92672 (714) 498-6128 Hein-A-Ken Skate Aid Hein-A-Ken. Inc. Secretary 1117 http://www. PA 16801 (814) 865-2563 International Foundation of Wheelchair Tennis Peter Burwash 2203 Timberloch Place.24B: Adaptations for Sports and Recreation | O&P Virtual Library Susan J. Suite 126 The Woodlands. Inc c/o Dale Bourisseau 14039 Ellesmere Dr Tampa. FL 33624 (813) 961-3275 International Sports Organization for the Disabled International Stoke Mandeville Games Federation Stoke-Mandeville Spinal Injury Center Aylesbury England International Sports Organization for the Disabled S-12387 RARSTA Sweden International Wheelchair Aviators Mindy Desens. org/alp/chap24-02. VT 05053 Mission Bay Aquatic Center 1001 Santa Clara Point San Diego. Atlanta. New Hampshire 03031 (800) 633-NAGA National Association of Handicapped Outdoor Sportsmen. Inc c/o Rick Riley 398 14th St N. Inc 2411 N. Executive Director 451 Hungerford Drive. Inc RR 6. Suite 103 Gaithersburg. CA 94954-2380 (707) 769-9417 A modified ice pick is attached to the forearm portion of the crutch. MI 49684 (616) 941-4626 Motorcycling Information The Wheelchair Motorcycle Association. Dowling.W. Suite 100 Rockville. CT 06902 (203) 967-2231 International Wheelchair Tennis Federation Brad Parks. MD 20850 (301) 217-0960 (301) 217-0968 FAX National Ocean Access Project 410 Severn Ave. WA 98032 (800) 342-1579 (206) 872-072 Mobility Systems 861 Robinwood Ct Traverse City. MA 02401 (617)583-8614 Mountain Climbing Hittenbergers 106 Lynch Creek Way.oandplibrary. Inc North Pomfret. President 30 Myano Lane Stamford. CO 80211 (303) 455-3578 Innovative Recreation. OR 97759 (503) 549-7022 Magic in Motion 20604 84th Ave South Kent. President 35-34 84th St #F8 Jackson Heights. GA 30318 (404) 873-3725 National Amputee Golf Association PO Box 1228 Amherst. Inc 101 Torrey St Brockton.24B: Adaptations for Sports and Recreation | O&P Virtual Library Rising Hill Escondido. Inc Joseph M. MD 21403 (301) 2800464 National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs. IL 62801 (618)532-4565 National Association of Swimming Clubs for the Handicapped 63 Dunnegan Rd Eltham. CA 95060 (408) 429-8447 Enabling Technologies. Suite 107 Annapolis. Georgia Prosthetic. Suite 8 Petaluma. CA 92672 (714) 361-6811 A Man and His Mountains by Norman Croucher Available from David and Charles. Inc 5858 Empire Grade Rd Santa Cruz. Federal Blvd Denver. CO http://www. CA 92109 (610) 488-1036 Monoskis Beneficial Designs. MD 20877 (301) 948-3010 National Handicap Motorcyclist Association (NHMA) Bob Nevola. London SE9 England National Council for Therapy and Rehabilitation Through Horticulture c/o Charles Richman. Executive Director 9041 Comprint. President 940 Calle Amanacer. NY 11372 (718)565-1243 National Handicapped Sports Kirk Bauer. Box 25 Centralia. Inc PO Box 159 Sisters. Suite B San Clemente.asp[21/03/2013 21:56:47] . CA 92025 (619) 746-5018 International Wheelchair Road Racers Club. British Columbia V5X 3L7 Canada (604) 324-4011 A swim-scuba prosthesis has also been developed. MN 55033 (612) 437-1792 The Netherlands Sport Association for the Disabled PO Box 622 3800 AP Amersfoort The Netherlands NOAP Universal Adaptive Seat National Ocean Access Project 410 Severn Ave. CO 80233 (303) 452-1212 North American Wheelchair Athletic Association PO Box 26 Riverdale. CO 80211 (303) 455-3578 Physically Challenged Swimmers of America Joan Karpuk 22 William St.24B: Adaptations for Sports and Recreation | O&P Virtual Library 80909 (719) 635-9300 National Wheelchair Basketball Association Stan Labanowich 110 Seaton Bldg University of Kentucky Lexington. CO 80903 National Wheelchair Shooting Federation Deanna Greene.G. Pentland Limited 82239 Main St Vancouver. 87401 Japan Outriggers Enabling Technologies 2411 North Federal Blvd Denver. Commissioner 1616 Todd Ct Hastings. PA 15644 (412) 744-3320 or 815 North Weber. Nordic Director U. CA 90254 (213) 372-5063 Scuba hand fins.oandplibrary. Disabled Ski Team PO Box 186 Hanover. Suite 101 Colorado Springs. CA 92021 (619) 442-3425 Racquetball United States Wheelchair Racquet-Sports Association (NWRA) Gary Baker 1 Desavage St http://www. Water Sports 530 Sixth St Hermosa Beach. John Barber. Director 3200 Mustang Dr Grapevine. TX 76051 (817) 481-0119 Power Gloves B. Suite 107 Annapolis. FCBC. KY 40506 (606) 257-1623 National Wheelchair Racquetball Association (NWRA) Gary Baker 1 Desavage St Jeannette. Chief Prosthetist J. CP(C). NH 03755 (802) 295-3625 North American Riding for the Handicapped Association PO Box 33150 Denver. Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon. Project FORE. TX 78218-0251 National Wheelchair Softball Association Jon Speake. MD 21403 (301)280-0464 Nordic Skiing Ted Fay. NY 10471 (212) 7965084 Oita Sports Association for the Disabled c/o Japan Sun Industries Kamegawa Beppu Oita. CT 06073 (203) 548-4500 POINT (Paraplegics on Independent Nature Trips) Shorty Powers. #225 South Glastonbury.A.asp[21/03/2013 21:56:47] .S.org/alp/chap24-02. President PO Box 18251 San Antonio. org/alp/chap24-02. Robinson. #107 Fresno. PA 15644 (412) 744-3320 Rampro. Rowing Ankle Unit Prosthetics Research Study 720 Broadway Seattle. CP(C) Prosthetics and Orthotics Division 6300 Darlington Ave Montreal. Recreation and Athletic Rehabilitation-Education Center c/o Brad Hedrick University of Illinois 1207 South Oak St Champaign. a multiposition sports ankle. VA 22011 Outback Ranch Outfitters Attn: Ken Wick Box 384 Joseph. "Freedom in Depth. Colme St Edinburgh EH36 AA Scotland Scuba Diving Information Diving for Disabled People British Sub-Aqua Club 16 Upper Woburn Place London WC1QW England Handicapped Scuba Assoc c/o Jim Gatacre 116 West El Portal. and Fox. IL 61820 (217) 333-4606 Recreation Center for the Handicapped c/o Janet Pomeroy. Quebec H3S 2J4 Canada Rowcycle 3188 North Marks. NY 10990 (914) 986-6686 Rock Climbing Transfemoral Prosthesis Montreal Rehabilitation Institute Claude Levesque. Suite 104 San Clemente. IL 60639 (312) 2922900 Scottish Sports Association of the Disabled c/o Scottish Sports Council 1 St. Director 207 Skyline Blvd San Francisco.oandplibrary.asp[21/03/2013 21:56:47] . President 3408 S Rte 94 Warwick. OR 97346 (503) 432-1721 Winslow Therapeutic Riding Unlimited Virginia G. Alberta T6G 2H9 Canada Riding Information North American Riding for the Handicapped Assn PO Box 100 Ashburn. IL 61820 (217) 351-5076 http://www. CA 94132 (415) 665-4100 Research and Training Center for the Physically Disabled Dr Robert Steadward Department of Physical Education and Sport Studies The University of Alberta Edmonton. NY 10128 (212) 967-9300 Amputee running club. CA 92672 (714) 439-6128 A videotape. J. Schwinn Air-Dyne Schwinn Bicycle Co 1856 N Kostner Ave Chicago. Inc PO Box 3256 Santa Monica. WA 98122 (206) 328-3116 Running Club Achilles Track Club 9 East 89th St New York. D: Scuba Diving with Disabilities Leisure Press PO Box 5076 Champaign. CA 93722 (800) 227-6607 Hand-operated device (combination of bicycle and rowing machine). Mazza.24B: Adaptations for Sports and Recreation | O&P Virtual Library Jeannette. CA 90403 (213) 828-6781 Activankle." is also available. by Hal O'Leary (1987) Winter Park Handicap Program PO Box 36 Winter Park. MT 59715 (406) 587-0310 Skating Association for the Blind and Handicapped (SABAH) c/o Sibleys.oandplibrary.asp[21/03/2013 21:56:47] . Boulevard Mall Store Niagara Falls Blvd Amherst. Inc 4401 Devonshire Lansing. FL 33133 Sit-Skis Mountain Man 720 Front St Bozeman. VA 22314 (703) 8363495 Ski-Eze Ski-Eze USA. Inc PO Box 1002 Newport. Inc 350 5th Ave. MI 48910 (517) 487-0924 http://www. DC 20036 (301) 652-7505 Winter Park Handicapped Skier Program Winter Park Sports and Learning Center PO Box 36 Winter Park. RI 02840 (401) 849-8898 Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami. 1988 Canadian Association for Disabled Skiing Box 307 Kimberly. CO 80482 Ski Instruction Organizations Canadian Association for Disabled Skiing (CADS) Box 307 Kimberly. ext 179 These are some organizations that help the disabled individual get started or restarted in skiing. Room 1829 New York. NY 14226 (716) 833-2994 Ski Instruction Manuals Alpine Manual by Jerry Johnston and Susan Clift. British Columbia VIA 2Y9 Canada (604) 427-7712 52 Association. NY 10118 (212) 563-9797 National Handicapped Sports 1145 Nineteenth St Suite 717 Washington. Skidiving Information United States Parachute Assn Mike Johnston 1440 Duke St Alexandria.24B: Adaptations for Sports and Recreation | O&P Virtual Library Shake-a-Leg.org/alp/chap24-02. British Columbia V1A2Y9 Canada Bold Tracks: Skiing for the Disabled. CO 80482 (303) 726-4101. asp[21/03/2013 21:56:47] . Swivel Golf Shoe The War Amputations of Canada Armand Viau or Cliff Chadderton 2277 Riverside Dr. Ski-Tur War Amputations of Canada 2277 Riverside Dr. CO 80909 United States Wheelchair Racquet-Sports Association (NWRA) Gary Baker 1 Desavage St Jeannette. Trimaran Cheeseman Biffins Boat Yard Staines Bridge Staines.oandplibrary. President Box 890 Ketchum.org/alp/chap24-02. PA 15644 (412) 744-3320 United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown. Suite 210 Ottawa. (Shared Outdoor Adventure Recreation) c/o Linda Besant PO Box 14583 Portland. PA 19057 (215) 945-1964 US Amputee Athletic Association Jan Wilson. VA 23111 (804) 746-4088 Fred Davis. Middlesex England TW1830N Turfking Aquatic Chairs Beach Wheels. http://www. Suite 210 Ottawa. ID 83340 (208) 788-9666 United States Swimming Handbook for Adapted Competitive Swimming (1989) United States Swimming 1750 East Boulder St Colorado Springs. S. Executive Director 255 East 400 South. Baumgartner Orthopadische Universitatsklinik Balgrist Forchstrasse 340 CH-8008 Zurich Switzerland Tel: 01/532200 Professor Baumgartner is developing a transfemoral prosthesis designed and aligned specifically for skiing. CA 95669 (916) 989-0402 Transfemoral Prosthesis for Skiing Professor Dr Rene F. TX 77254-0022 Three Tracker's Ski Tote NHS of California c/o Betty Lessard 5946 Illinois Ave Orangevale.A. OR 97214 (503) 238-1613 South Africa Sports Association for the Physically Disabled 1 Stellenberg Rd Somerset West 7130 South Africa S'PLORE (Special Populations Learning Outdoor Recreation and Education) c/o Patti Mulvihill. Inc 1555 Shadowlawn Dr Naples.R. UT 84111 (801) 363-7130 The Steed Jerry Selness 4724 Point Loma Ave San Diego. Ltd PO Box 540022 Houston. FL 33942 (813) 777-1078 Forward Motion Sand-rik PO Box 782 Mechanicsville. Ontario K1H7X6 Canada TES Belt Syncor. Ontario K1H7X6 Ski stabilizer device.24B: Adaptations for Sports and Recreation | O&P Virtual Library (517) 882-4608 A device to facilitate ski turning ability and the ski stabilizer.O. CA 92107 (619) 224-2619 A 30-ft sloop for disabled sailors. Suite 107 Salt Lake City. Executive Director PO Box 560686 Charlotte. Kent. TX 77019 (713) 522-9769 Wheelchair Bankshot Basketball Rabcan Associates 485 5th Ave New York. Chairman 681 Bailey Woods Rd Dacula. TN 37203 (615) 327-1546 Welsh Sports Association for the Disabled c/o E. Mid-Glamorgan. CA 92109 (619) 488-1038 Ski Seat Water Sports Industries 10230 Freeman Ave Santa Fe Springs. Wales Western Australia Disabled Sport Association PO Box 1162 East Victoria Park 6101 Western Australia Wheelchair Athletics of the USA Judy Einbinder 1475 West Gray.asp[21/03/2013 21:56:47] . WI 53051 (414) 781-6876 Wheelchair Motorcycle Association Dr. Chairman N54 W 15858 Larkspur Lane Menomonee Falls. Suite 210 Ottawa. KY 40506 (606) 257-1623 Wheelchair Bowling Wheelchair Bowling Association. #161 Houston. Ontario K1H7X6 Canada Water Ski Devices Magic in Motion c/o Jim Martinson 20604 84th Aves. Box 111 Newport Beach.24B: Adaptations for Sports and Recreation | O&P Virtual Library NC 28256 (704) 598-0407 US Association of Disabled Sailors Southern California Chapter Mike Watson PO Box 15245 Newport Beach. CPO 1904 Hayes St Nashville. Roberts Crosswinds 14 CAE GAM HEOL-YCYW Bridgend. GA 30211 (916) 868-5733 Christian Family Ski School c/o Fred and Wanda Horrell PO Box 7425 Winter Haven. CA 90670 (213) 946-1323 Water Ski Information American Waterski Association Disabled Ski Committee Phil Martin. WA 98032 (800) 342-1579 Mission Bay Aquatic Center c/o Tod Bitner 1001 Santa Clara Point San Diego. FL 33880 (813) 299-4044 Northwest Adaptive Water Skiers PO Box 1478 Granite Falls. Inc c/o Daryl Pfister. MN 55356 The War Amputations of Canada c/o Cliff Chadderton 2277 Riverside Dr. Eli Factor 101 Torrey St Brockton. WA 98252 Weight lifting Prosthesis Nashville Orthotic and Prosthetic Services. NY 10017 National Wheelchair Basketball Association 110 Seaton Bldg University of Kentucky Lexington.org/alp/chap24-02. Director 3857 Birch St.oandplibrary. NH 03833 (603) 778-0315 Voyageur Outward Bound School c/o Ted Mooras PO Box 250 Long Lake. CA 92660 (714) 851-1707 http://www. Inc c/o Jim McElhiney. MA 02401 (508) 583-8614 Wheelchair Tennis International Foundation of Wheelchair Tennis c/o Brad Parks. CA 92659 (714) 534-5717 US Rowing Association Adaptive Rowing Committee Richard Tobin 11 Hall Place Exeter. HI 96815 (808) 9461236 Wilderness Inquiry 11 c/o Greg Lais. Suite 1507 Honolulu. Contact Us | Contribute http://www. ext 179 Chapter 24B . CO 80482 (303) 726-5514. Suite O Minneapolis. Ltd 1909 Ala Wai.org/alp/chap24-02. MN 55408 (612) 827-4001 Winter Park Sports and Learning Center c/o Hal O'Leary PO Box 36 Winter Park. Director 2929 Fourth Ave S. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 24B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .Atlas of Limb Prosthetics: Surgical.oandplibrary. Prosthetic.24B: Adaptations for Sports and Recreation | O&P Virtual Library Peter Burwash International.asp[21/03/2013 21:56:47] . dissemination. and feedback.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 24C Chapter 24C . and Rehabilitation Principles Special Considerations: Emerging Trends in Lower-Limb Prosthetics: Research and Development Charles H. IL. competition among the suppliers ensures a continuous process of innovation to allow not only growth but economic survival. With the creation of a market and the revenue that it generated. It took many years to learn the requisite skills. it became attractive for prosthetic suppliers to engage in research and development efforts of their own. Many disparate groups with widely varying interests were brought together in a common purpose through the intercession of this outside agent with its independent base. What reshaped the practice of prosthetics was the dissemination of this now rationally ordered and internally logical body of knowledge. The new techniques and devices that appeared during that time were not necessarily invented but rather synthesized from the ofttimes conflicting body of contemporary practice and theory as reiterated in the light of fundamental studies of human gait. a limb fitter would often custom-fabricate every element of a prosthesis and use a minimum of purchased items. Pritham. In the period beginning shortly after World War II. and the results varied widely. and created a market.P. Click for more information about this text. Prosthetic. and Rehabilitation Principles. and others have continued. and the feedback loop has been disrupted. Prepared in clinical practice and inspired with the example of past efforts. Instructional courses were held. the federal government has fundamentally abandoned its leadership. Financial support of the schools of prosthetics and orthotics is gradually being withdrawn. As stated. manufacturers. manufacturers http://www. 3. thereby creating a new profession in the place of a craft. a few major points will provide perspective about present circumstances and speculation regarding future developments. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. coordination. Their willingness to accept standardized manufactured components freed them from bench work. 1. promise to produce continuing results in a number of different areas. 1992. 4. and funding. The result was an integrated process of innovation. Today. C. it is a tribute to the excellence of the work done in the post-World War II period that developmental efforts by clinicians. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). edition 2. many of the concepts now identified with the new practice of prosthetics were readily available to all.oandplibrary. American Academy of Orthopedic Surgeons. long-term courses of study in prosthetics were developed. Radcliffe and others showed that applying engineering concepts of rational analysis and development to clinical problems would bear fruit many times over. 2.org/alp/chap24-03. All of the above happened because the federal government provided leadership. and from these. Prosthetic. STRUCTURAL COMPONENTS As prosthetists grow ever more willing to accept standardized components. Prosthetic. While the loss of central coordination and leadership is regretted. ©American Academy or Orthopedic Surgeons. it was labor-intensive. Previously. this new cadre of better-educated prosthetists embarked on research and development efforts of their own.O. reprinted 2002. While it is not appropriate to review this transformation in depth. Reproduced with permission from Bowker HK. as shaped by these four factors. The standardization of prosthetic practice along with the education of a new generation gave impetus to the development of a fledgling industry in the manufacture of prosthetic components. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. a revolution occurred in the provision of prosthetic care.Atlas of Limb Prosthetics: Surgical. Present and future efforts. Today. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Rosemont.asp[21/03/2013 21:56:53] . gave them time to pursue new avenues of development. development. The new generation of prosthetists was unequipped and unwilling to adopt this method of practice. MATERIALS Many of these developments and others in the area of socket design were only made possible by the availability of new materials at reasonable cost. Smaller-size units for children are also being fabricated.org/alp/chap24-03. epitomized by the Seattle Foot ( Fig 24C1. standardization has led to increased compatibility of components produced by different manufacturers and has increased the ability to readily mix and match components. Decreased weight has also come to be a design parameter to be carefully considered. the design parameters adopted by Otto Bock have become the worldwide de-facto standards for development by other companies. composite structures of carbon fiber and epoxy have been used to offset the often formidable weight of the control unit. are designed for improved compliance and range of motion at the ankle to adapt more readily to irregular terrain. This development was sparked by the introduction of the Otto Bock modular endoskeletal system some 20 years ago. With reasonable costs ensured and with a body of engineering data to work with. Newer. in transfemoral applications. termed dynamic elastic response or energy-storing feet. has led manufacturers to respond to the need with new feet. The original system has been continuously refined and updated with an increasing array of options available. New and improved methods of providing cosmetic finishing for the structural components are needed. amputees as well. Paradoxically. It seems likely that future research efforts will be focused on working within the context of the endoskeletal rather than the exoskeletal structure. which demand a considerable amount of labor. among One general other factors. Cosmetic fairings are laborious to shape and fragile and. Feet are now routinely designed with such sculpted details as toes and veins. Most such structural systems make provision for changing the alignment of the prosthesis without performing major structural changes. In the process. These two factors enable the prosthetist to readily vary the prosthesis throughout its life to meet the changing needs of the patient. Although such feet.). is designed to absorb energy from the early portion of stance phase and to release it at the end of stance phase to assist with forward propulsion. Physically active amputees have pressed for prostheses suited to a range of activities more demanding than just walking. flexibleendoskeleton (SAFE) foot. This trend has been marked by a shift from exoskeletal wood components.oandplibrary. Quantum. they found ever wider application and allowed a reduction in cost.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library strive to outdo each other in offering improved devices. including those controlled by hydraulic and pneumatic units. more sophisticated materials such as titanium and carbon composite are being used to design systems that are both more robust and lighter in weight. but rather to adapt exoskeletal designs to the endoskeletal context. The availability of newer materials at reasonable cost. at best. Component parts within the endoskeletal system have also received attention. it became possible for prosthetic manufacturers to design and produce new components with the new materials. Otto Bock has now introduced a new composite knee incorporating a Mauch S-N-S control unit. category. Today. Materials such as titanium and carbon fiber/epoxy composites found their first applications in the aerospace industry where weight was at a premium and cost was of little object. As these materials proved their worth and as confidence grew in the ability of engineers to work with them. and Multiplex. were originally envisaged as being most suitable for they have found favor with geriatric younger amputees interested in athletic activities. an endoskeletal analogue for every exoskeletal knee can be found. to endoskeletal components that can be bolted together with a minimum of labor. The development of these feet has been marked not just by a concern with performance but with appearance as well. and Flex-Foot. Components that fit into the Otto Bock system and complement it are now being designed by competitors. including the stationary-ankle. It was designed with an interchangeable series of components in such a fashion that prostheses to accommodate virtually every level of amputation could be fabricated. This attention to cosmetic effect will probably continue and be heightened in the future. In regard to knee control units. As a result. the trend has not necessarily been to develop new units. Spray-on or paint-on prosthetic skins offer.asp[21/03/2013 21:56:53] . Carbon Copy II Foot. can impede the proper function of knee control units. Significant costs in product design have been incurred by manufacturers developing such http://www. a partial solution to these problems while creating new ones of their own. The other group of feet. While these various designs have been given a variety of names such as normal shape-normal alignment (NSNA). toys. consumer appliances. as fostered by their improved educational status. including weight. thus leading to increasing reliance on such devices. they all can be classified as ischial containment Sockets. economics. It is now possible to find manufacturers from around the world who are developing ever more sophisticated products from expensive materials. contoured-adducted trochanteric. This.) system developed in the United States. and cars. and Sabolich contoured-adducted trochanteric. and polycarbonate find their most common applications in such everyday products as packaging. it was possible to discern distinctly different national styles of prosthetic fitting and construction. Thermoplastic polymers such as polyethylene. or similar ones derived from his work. in socket fabrication in order to make more functional and comfortable devices. various options and variations can be explored during the trial fitting stage. these developments. These interacting trends will doubtlessly accelerate in the future. and it has only been attractive to the manufacturers to take the risk because of the existence of a market for commercially available components. flexible socket concept and the use of silicone elastomer components to provide suction suspension for levels at which it was not previously practical. in turn. At the end of World War II. Of particular importance among the efforts of clinical prosthetists are those of the Icelandic He has been responsible for such innovations as the prosthetist Os-surr Kristinsson. The existence of a standardized context within which to design components and a body of data describing human gait and the performance of prostheses has smoothed the way.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library components. Market size has grown as a result of the globalization of the prosthetic market. and prostheses themselves. With the growth in standardization. these differences have become less clear. for transfemoral (above-knee) amputees. This has. http://www. The technology used in fabricating transparent check sockets is also being employed to fabricate socket elements of other more durable thermoplastic materials such as copolymer polypropylene. His work epitomizes a trend in the field: the growing interest in exploiting the characteristics of elastomeric polymers. all within a common context. These materials and some of the techniques used to shape them have been borrowed to produce flexible sockets.org/alp/chap24-03. A variety of concerns motivate this switch in technique. Most of these latter applications have been made by clinical prosthetists working singly or in small groups. including new fitting methods. are variously known as the Scandinavian flexible socket (SFS) or Icelandic-Swedish-New York (ISNY) in the case of flexible sockets and Icelandic Roll-On Suction Socket (ICEROSS) or silicone suction socket (3-S) in the case of suction suspension sockets. The net result is a much greater level of patient involvement in the fitting process and presumably a higher level of satisfaction. SOCKET DESIGN/FITTING METHODS These various factors have interacted with growing expectations among amputees and a concern with meeting the needs for extra-ambulatory activities to create an entirely new style of interaction between prosthetists and amputees. controlled alignment method (CAT-CAM). Thermoplastic techniques are particularly suitable for use with endoskeletal structural components. most notably Transparent check sockets have also given rise to innovative socket designs. these new methods emphasize the use of multiple transparent check socket fittings along with such aids as alginate and radiographic examination of the fit. function. Another group of materials primarily used in socket construction has considerably more mundane origins. Regardless of amputation level. controlled alignment method (SCAT-CAM). transparent check sockets.oandplibrary. When these tools are used. primarily silicone or urethane. has stimulated manufacturers to develop new endoskeletal components such as the Endolite system developed in England and the Carbon Copy III ( Fig 24C-2. illuminated signs.asp[21/03/2013 21:56:53] . and fabrication safety. In the United States. ionomer. They also rely on the use of structural components that can be readily adjusted in alignment and that can be set up with different feet and knee control units. They have been abetted in these efforts by their growing sophistication about design principles and the biomechanical basis for prosthetic fitting. spurred the pressure to develop an internationally agreed-upon standard for physical strength and performance. polypropylene. in turn. older. Coping with the implications of this quandary and answering the questions it raises are likely to play a prominent role in future prosthetic research.org/alp/chap24-03. knees. to be attached to endoskeletal components to produce a prosthesis. If they are not. As a result. promises even more far-sweeping impact on the field. Likewise. a number of installations have been made in the past few years. ADVANCED TECHNOLOGY The foregoing sections have reviewed the developments that have had the most immediate impact on current practice. The feedback from prosthetists using the systems should prove to be invaluable in the efforts of their designers to improve them and develop new applications. and we have been able to provide them with new measures of comfort and function as a result of the application of new materials. The first is acquisition of dimensional information from the involved body segment. our ability to fit patients comfortably has increased. Their availability to prosthetics and orthotics only occurred with the widespread availability of personal computers. Many of the new materials are expensive to purchase and to fabricate into finished components. human error is not eliminated. more sedentary patients have benefited and will continue to do so from the emphasis on light weight and comfort. These last two elements correspond exactly to the CAD-CAM process. This is the application of the computer-aided design-computer-aided manufacturing (CAD-CAM) concept to prosthetics. The second is manipulation of this information to generate the specifications for a socket model to be produced by the third element. The units needed to automatically record information from all segments of a patient's body are not yet available and do not take into account tissue density. In the most basic Automated production of prostheses has been sought for some 20 years. more active patients. while still in its early stages. These limitations. As noted. CAD-CAM software to be run on such personal computers. The impact that this will have on the nature of prosthetic practice remains to be seen. have limited their commercial appeal. the capital expense of the equipment will have to be borne as well. but the capital expenses at all levels of the delivery system necessary to support this advance will have to be recognized and met. This demands more sophistication about materials and performance upon the part of prosthetists and other clinicians and creates more opportunities for manufacturers. however. Productivity in the field has increased since the end of World War II as a result of the introduction of more efficient means of fitting and the standardization of components. the outcome of the CAD-CAM system is a socket model. the incentives to develop even newer techniques will cease to exist. The prosthetist of the future will doubtlessly be able to produce more and better prostheses. and shins will culminate with relinquishment of any direct hands-on role in producing the socket. This model is generally utilized in producing a thermoplastic vacuum-formed socket. by either automated or nonautomated means. The capital investments needed to work such new materials are high. an automated carver.oandplibrary. COST CONTAINMENT As in so many areas of medicine. If CAD-CAM comes to be an integral part of clinical prosthetic practice.asp[21/03/2013 21:56:53] . One other emerging trend. have not been without their price. Commercial units depend on information generated by the prosthetist and entered indirectly into the system. Nonetheless. It is costly to adequately educate and train a prosthetist. and the costs of research and product development must be reckoned with.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library It seems likely that the future will see continued efforts to exploit newly available materials in creative ways to meet the expressed needs of amputees for prostheses that do more than just walk. and the possibility of directing numerically controlled carving machines with them. the trend that began with the prosthetist ceasing to craft elements such as feet. manner. the introduction of new technology to prosthetics has troublesome and contradictory implications for cost containment. http://www. In effect. it can be described as consisting of three elements ( Fig 24C-3.). This means that it is not yet possible to generate true productivity gains. These advances. While many of these efforts have been and will be directed to the needs of younger. and it is still necessary to use check socket procedures in order to ensure a socket fit that equals the best that is currently available by conventional means. coupled with the fact that currently available CAD-CAM systems are only capable of dealing in a limited fashion with just transtibial and trans-femoral sockets. There is also likely to be a concurrent increase in the number of geriatric amputees. both will work in the context of the endoskeletal structural system.E. The former will seek to gain competitive advantage by exploiting the possibilities of newly available materials and methods to produce components that are stronger. and more functional. the needs of these amputees will change. Research efforts could well be shifted from developing newer means of providing prosthetic care to justifying and defending the expense of present methods. Faulkner V.F. Gottschalk F. Ever more CAD-CAM production systems will be purchased for use in clinical practice. 2:94. 40:63. et al: A computerized ultrasound shape sensing mechanism. 1:92. 37:58. The growing self-assurance and assertiveness of younger. Dietzen C. Orthot Prosthet 1980. Clin Prosthet Orthot 1985. Staats T: The Slipper Type Partial Foot Prosthesis. et al: Suction sock suspension for above-knee prostheses.org/alp/chap24-03. and improved methods of providing cosme-sis. http://www. Alaranta H. 37:25. most likely produced by CAD-CAM methods and available to the beneficiaries of funding systems stressing a fixed fee for service structure and to amputees in the Third World. J Prosthet Orthot 1991.asp[21/03/2013 21:56:53] . with more elaborate attention being paid to such factors as fit and function. et al: Does socket configuration influence the position of the femur in above-knee amputation? J Prosthet Orthot 1989. Hanak R. 9. De facto acceptance of Otto Bock's design parameters and the globalization of the market will aid and abet this trend. 10. 13. 34:3. but the ultimate realization of their fullest potential must await the introduction of devices that will automatically acquire information about the shape and physical characteristics of the involved body segment. UCLA Prosthetics-Orthotics Education Program. References: 1. Childs C: The S. In all likelihood. et al: The Carbon Copy II-From concept to application. Orthot Prosthet 1983. 40:38. These factors will shift priorities and developmental efforts. et al: Specifications and fabrication details for the ISNY above-knee socket system. 8. This will accelerate the rate of development of such systems. The other level of care would be provided to patients for whom price is of little concern. Campbell J. et al: Evolution and development of the silicone suction socket (3S) for below-knee prostheses.oandplibrary. 1:32. 6. Orthot Prosthet 1986. Orthot Prosthet 1987. lighter. 3. prostheses that can be more readily adapted to the varying needs of amputees. One would provide a tolerably comfortable. 2.A. Orthot Prosthet 1988. The latter will explore the possibilities of new materials for the same advantages in constructing prostheses and in producing sockets with novel shapes and characteristics. this development will first occur in some field peripheral to prosthetics and will only become available in the field of prosthetics when the price is reduced to manageable levels. et al: Practical benefits of Flex-Foot in be-low-knee amputees. By common consent. Hayes R: A below-knee weight-bearing pressure-formed socket technique. it must be recognized that as the population ages. 3:179. However. 7. This and other factors are likely to lead to more functional feet and knees. J Prosthet Orthot 1991. Black L: Orthosil silicone gel for pads and soft insert liners. Abrahamson M. et al: The Seattle prosthetic foot-A design for active sports: Preliminary studies. J Prosthet Orthot 1988. 9:13. foot. Los Angeles. et al: Improved techniques in alginated check sockets. Orthot Prosthet 1983. minimally functional lightweight prosthesis. 3:90. Burgess E.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library CONCLUSION The federal government has withdrawn from its active role in shaping prosthetic research and development and has left it to manufacturers and prosthetists to take the lead. Childs C. Arbogast R. J Prosthet Orthot 1989. 12. 4. Cost containment efforts might extinguish the marketplace incentives spurring research and development and could formalize the present trend of two distinctly different levels of prosthetic care. 11. 41:57. 1983. All these factors may interact in unexpected ways with the desire of society to curtail the growth of medical expenses. The need for marketplace incentives and well-educated prosthetists will become even more important. more active amputees will probably also shape developments. 5. Fillauer C. J Prosthet Orthot 1988. et al: Perception of walking difficulty by below-knee amputees using a conventional foot versus the Flex-Foot. Issue devoted to CAD-CAM.) 19. Orthot Prosthet 1986. Clin Prosthet Orthot 1985. Journal of Prosthetics and Orthotics 1990. 14:9. 48. Kristinsson O: Flexible above knee socket made from low density polyethylene. 36. 37:45. 5:129. Oberg K: Swedish attempts in using CAD-CAM principles in prosthetics and orthotics. 21. et al: Experience with the use of aliginate in transparent diagnostic belowknee sockets. 9:3-47. International Society for Prosthetics and Orthotics. Pritham C. 11:154. 10:101. Kay H: Three-Dimensional Shape-Sensing and Reproduction of Limbs and http://www. 1978. 34. Oberg K. (Issue devoted to thermoplastic materials in lower limb prosthetics. 39:44. 1:24. Prosthet Orthot Int 1989. Michael J: Energy storing feet: A clinical comparison. et al: The UCLA total surface bearing suction below-knee prosthesis. Staats T. Orthot Prosthet 1983. 47. Clin Prosthet Orthot 1986. 24.asp[21/03/2013 21:56:53] . 18. 49. Imler C: Imler partial foot prosthesis: IPFP-"The Chicago Boot. Sabolich J: Contoured adducted trochanteric controlled alignment method (CAT-CAM): Introduction and basic principles. 3:1-54. 40. J Prosthet Orthot 1988. 3:106. Koike K. 1:116-190. Clin Prosthet Orthot 1985. 39. et al: Comparison of CAD-CAM and hand made sockets for PTB patients.) 20. 46. et al: Recreational activities of lower extremity amputees: A study.oandplibrary. 12:136. suspended by a weight transmitting frame. (Issue devoted to CAD-CAM. 11:118. 11:109. Schuch M. Menard M. Journal of Prosthetics and Orthotics 1989. 39:17. Prosthetics and Orthotics International 1985. Orthot Prosthet 1985. Prosthet Orthot Int 1988. 23. 22. Riley R: The amputee athlete. 29." Orthot Prosthet 1985. 44. Orthot Prosthet 1985. Pritham C: Biomechanics and shape of the above-knee socket considered in light of the ischial containment concept. et al: The CAPOD system-A Scandinavian CAD/CAM system for prosthetic sockets. 43. 25. Roberts R: Suction socket suspension for below-knee amputees. McFarlane P. Schuch M. 32. Hittenberger D: The Seattle foot. 1959. 15. 41. 1:139.org/alp/chap24-03. 39:53. 16. 45. 28. 41:46. 12:77. 9:19. Arch Phys Med Rehabil 1986. Foort J. et al: The TC double socket above-knee prosthesis. Prosthet Orthot Int 1988. Prosthet Orthot Int 1990. Clin Prosthet Orthot 1987. Clin Prosthet Orthot 1987. Orthot Prosthet 1987. Clin Prosthet Orthot 1987. 33. Orthot Prosthet 1972. Clin Prosthet Orthot 1985. McFarlane P. 26:1. 31. 1:50. 3:150. 13:19. 30. 26. Philadelphia. 10:105. 35.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library 14. Hittenberger D: A thermoplastic endoskeletal prosthesis. Krouskop T. Klopsteg P. 1:220. 9:27. et al: Comparison of energy cost and gait efficiency during ambulation in below-knee amputees using different prosthetic feet-A preliminary report. Nielsen D. 27. J Prosthet Orthot 1989. 67:196. Wilson P: Human Limbs and Their Substitutes. Kegel B. Clin Prosthet Orthot 1986. 40:17. J Prosthet Orthot 1991. Jendrzejxzyk D: Flexible socket systems. et al: Subjective and objective analysis of energy-storing prosthetic foot. 37:25. New York. 17. et al: Gait comparisons for below-knee amputees using a Flex-Foot versus a conventional prosthetic foot. J Prosthet Orthot 1991. Orthot Prosthet 1983. Schuch M: Modern above-knee fitting practice. 9:9. J Prosthet Orthot 1989. 61:258. 9:15. Madden M: The flexible socket system as applied to the hip disarticulation amputee. et al: The use of surlyn and polypropylene in flexible brim socket designs for below-knee prostheses. Arch Phys Med Rehabil 1980. Staats T: Advanced prosthetic techniques for below-knee amputations. et al: Fabrication and application of transparent polycarbonate sockets. et al: Measuring the shape and volume of an above-knee stump. 42. Prosthet Orthot Int 1981. et al: Experience with the Scandinavian flexible socket. Long I: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet Orthot 1985. Wilson AB Jr: Standards for Lower-Limb Prosthetics. Kohler P. 37.. Pritham C: Workshop on teaching materials for above-knee socket varients. Mooney V. 38. Hafner Publishing Co. 54. Varnau D. 39:14. Chapter 24C . 28:13. 24:369. J Rehabil Res Dev 1991. 51. 52. et al: Motion analysis of SACH vs. Wirta R. Torreros-Moreno R: A reference shape library for computer aided socket design in above-knee prostheses. 13:130. J Rehabil Res Dev 1990. National Academy of Sciences. 55.oandplibrary. Prosthet Orthot Int 1989. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 24C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . et al: Effect on gait using various prosthetic ankle-foot devices. 1975. 14:136. Washington. 50.asp[21/03/2013 21:56:53] . Torburn L. Clin Prosthet Orthot 1987. Prosthet Orthot Int 1990. et al: Below-knee amputee gait with dynamic response prosthetic feet: A pilot study.Atlas of Limb Prosthetics: Surgical. Contact Us | Contribute http://www. Flex-Foot in moderately active belowknee amputees. et al: The enhancement of prosthetics through xeroradiography. 11:55. Prosthetic.24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library Limb Remnants. Topper A. Fernie G: An evaluation of computer aided design of below-knee prosthetic sockets. 53. DC. Wagner J. Orthot Prosthet 1985.org/alp/chap24-03. Handling dysvascular skin with forceps. Keagy. to a large extent.Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles. Prosthetic.A).. A casual or defeatist attitude toward amputation surgery engenders many of the problems to be discussed. the patient should be thoroughly reevaluated to determine the reason for wound failure. mapping can yield valuable information Delayed healing can also be due to suboptimal operative technique. is the prevention of complications due to that procedure. Robert D. it should be done at this point. attempting to close the skin under tension.) One of the primary aims of any surgical procedure. These include inappropriate amputation-level selection. apart from obtaining primary healing at the operative site. If the patient's wound healing potential was not evaluated preoperatively.S. PREPROSTHETIC COMPLICATIONS Delayed Healing Delayed healing may be related to several factors that can be operative singly or in combination. Bovvker. Pradip D. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. M. American Academy of Orthopedic Surgeons. If these are deficient. The preoperative vascular studies should be reassessed to be sure that the level previously selected was correct. This would include a determination of serum albumin level to ascertain nutritional status and a total lymphocyte count to assess immunocompetency.. and infection. http://www. or placing excessive closure tension on muscle of questionable vascularity can result in ischemic changes leading to dehiscence. In general. M. A common cause of delayed healing is inappropriate amputation-level selection. inadequate postoperative management. 1992.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 25 Chapter 25 . Prosthetic. ©American Academy or Orthopedic Surgeons. the frequency and degree of complications decrease remarkably when the surgeon is keenly interested in the challenge presented by properly designed and executed amputation procedures and keeps abreast of innovations. especially in the immunocompromised or dysvascular patient. (Gen. M. Reproduced with permission from Bowker HK. Noninvasive techniques such as segmental Doppler studies and transcutaneous oximetry (see Chapter 2C). Poonekar. further surgery should be delayed until nutrition is normalized.D.B).B. edition 2.asp[21/03/2013 21:56:58] .D. it is common to find them smoking within a day or Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. It is better to place a few widely spaced sutures and reinforce the wound with adhesive paper strips ( Fig 25-1. Removal of skin sutures prior to firm initial healing of the amputation wound may also lead to dehiscence. There is also little need for subcutaneous sutures in most amputations if good myofascial and fascial closures are done. In chronic renal failure.. and one may be forced to proceed without this assurance. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. IL.org/alp/chap25-01. B. and Rehabilitation Principles Musculoskeletal Complications in Amputees: Their Prevention and Management John H. M. Even with minimal closure tension. reprinted 2002. This can. Amputee management has the added dimension of complications related to the amputation-prosthesis interface.oandplibrary. especially mattress sutures ( Fig 25-1. Rosemont. sub-optimal operative technique. The complications of amputation surgery can therefore be divided into preprosthetic and post-prosthetic problems. be obviated by proper use of the vascular laboratory as an aid in level selection. Surg. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Click for more information about this text.S.. Prior to any definitive treatment of dehiscence other than debridement. this may not be possible. skin edges may be made ischemic by the placing of too many sutures. Although it is good practice for patients to permanently discontinue the use of nicotine or at least delay resumption until the wound is well healed. Prosthetic. . repeated attempts at healing a trans-femoral amputation in cases of severe dysvascularity result in wound dehiscence due to necrosis at a higher level. the choice is limited to a revision amputation. the residual limb may be allowed to heal by secondary intention following conservative debridement under adequate antibiotic coverage. debridement. Evaluation should begin with baseline transcutaneous oxygen pressure (Tcp0 2 ) determinations on room air at the site of proposed revision.A and B).. This may be followed by split-thickness skin grafting once adequate granulation tissue forms. This will also allow wound inspection at weekly intervals and afford an opportunity for a full range of motion of the knee prior to application of each cast. Gauze dressings applied moist and removed dry three times daily will encourage the formation of granulation tissue. followed by HBO therapy if Tcp02 readings are borderline at that level. If vascular studies and nutritional parameters are normal and the patient stops the use of nicotine. If peripheral vascular parameters are poor. Cleansing. which will lead to either healing by secondary intention or the production of a suitable bed for a split-skin graft. If Tcp02 levels are still borderline. the patient is at great risk of death due to the difficulty of controlling a wound at that level without involving the pelvic structures. treatment should proceed with the most appropriate technique. transcutaneous oximetry can be utilized to determine the potential for skin healing slightly more proximally in the same limb segment. Often a temporary fiberglass or plaster of paris cast helps in the healing of such cases. the marginally viable skin beyond the necrosis is not traumatized by the scalpel. In older dysvascular patients. coordination. and weakness during crutch or walker ambulation. The next proximal level is a hip disarticulation.org/alp/chap25-01. and closure should be done on an emergency basis to prevent infection. postoperative hyperbaric oxygen (HBO) therapy may In selected cases. the measurements may be repeated after the patient has been breathing 100% 0 2 at 1 atm for 20 minutes.oandplibrary. If wound edge separation due to necrosis is confined to the skin. the decision can be made to allow healing by secondary intention. flap shrinkage. so long as life is not threatened.4 atm.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library two of surgery. with delayed split-skin grafting coverage of granulating areas. pretreatment test results are favorable. If infection is the sole cause of dehiscence. This is. This complication is usually prevented by application of a cast to the midthigh with the knee in full extension each week for 3 weeks. local debridement that avoids trauma to skin of marginal viability is called for. Once the wound is clean and granulating well. readings can be taken in the hyperbaric chamber while be considered.asp[21/03/2013 21:56:58] . the wound should be widely opened for drainage and appropriate antibiotics given. This small rim of necrotic tissue should separate spontaneously. On occasion. This will often stop the inexorable spread of necrosis attendant upon repeated aggressive debridement. Dehiscence with moderate wound separation can be managed by adequate debridement and secondary closure without tension by utilizing a minor wedge excision with minimal bone shortening ( Fig 25-2. or to revise proximally and maintain the same anatomic level if an adequate soft-tissue envelope for the bone can be constructed. Direct falls on a partially healed amputation wound can result in massive dehiscence and leave the bone exposed. Skin Adherence to Bone of the Residual Limb The ideal closure of an amputation includes the construction of an adequate soft-tissue http://www. Treatment is determined by the length and depth of the dehiscence. combined with improvement of nutrition HBO treatments are again a useful adjunct in management if and cessation of smoking. If skin separation is minor. falls in the early postoperative period are common due to problems with balance. and prolonged delay in prosthetic fitting ( Fig 25-3. This is done by leaving a residual rim of necrotic tissue approximately 2 to 3 mm in width.A and B). In this way. consideration should be given to amputation at the next higher anatomic level. from transtibial to transfemoral. If necrosis then recurs. with no assurance that this level will heal. In the presence of gross necrosis or failure of the wound to produce adequate granulation tissue. of course. If Tcp02 values then meet or exceed 40 mm Hg. Rather than have another immediate failure due to smoking. It is sometimes best to merely debride high transfemoral wounds in a manner so as to avoid trauma to wound edges of marginal viability. If less than 40 mm Hg. before proceeding to a higher anatomic level. for instance. the surgeon has the option to refuse surgical treatment beyond debridement on these patients if they fail to comply with this request. the patient is breathing 100% 0 2 at 2. however. will assist in early prosthetic fitting. tapering of the muscle mass avoids excessive distal bulk ( Fig 25-6. possibly leading to difficulties in fitting.). it can be held in the proper weight-bearing position by a carefully fabricated prosthesis. the additional advantages of myodesis are stabilization of the femur in adduction by the adductor magnus. This presents two possible problems for the transfemoral amputee.oandplibrary. Control of this edema will greatly reduce the tendency for wound complications and thus facilitate early healing. opposing muscle groups are simply joined to each other by sutures through the myofascia and investing fascia over the end of the bone. As postoperative swelling decreases. which are not weight bearing. If passively correctable. and enhanced hip extension by the biceps femoris. Here the role of myodesis/myoplasty cannot be overemphasized. it is equally true that redundant skin and muscle can lead to slow stump shrinkage with persistent distal edema despite adequate attempts at shrinkage ( Fig 25-4. proper shaping of the bone end and adequate softtissue coverage are important. who do surprisingly well with splitskin grafts once they have matured.). If the heel pad is secure and well centered. opposite the original contracture. it will not be able to comfortably tolerate shear forces applied by the prosthesis at the interface with the residual limb. The overall conformation of the residual limb will then be altered. or a scar.A-C). it should be surgically repositioned by division of the contracted tendons or scar and removal of an ellipse of excess skin.). Problems in Shaping of the Residual Limb Much can be done at the time of surgery to create an amputation stump that. including the incisional scar. on the other hand. this should be applied only over deeper soft tissues such as muscle and not directly on bone because the graft is very likely to ulcerate as soon as use of a prosthesis is begun.. and soft-tissue retraction occurs if absorbable sutures are used. One is scar irritation by the socket brim. While it is axiomatic that wound closure tension should be minimized by designing ample myofasciocutaneous flaps. If the skin cannot slide over the underlying bone. Whenever removal of a limb for malignancy is to be followed by chemotherapy. In a severely dysvascular residual limb with marginal muscle viability. The most structurally stable residual limbs are achieved with myodesis in which the surrounding muscles and their fasciae are sutured directly to the bone through drill holes ( Fig 25-5. On the other hand. enhanced hip flexion by the rectus femoris. Exceptions occur in upper-limb amputations. myoplasty is probably the preferable method but should be done with little closure tension. Fascia and other soft tissues tend to heal poorly in the presence of chemotherapeu-tic agents. This is a major benefit of rigid circumferential dressings of plaster of paris or fiberglass. On the other hand. In either case. by its configuration. If the cast is changed promptly on loosening. Myodesis or myoplasty are the two best techniques available to provide both distal padding and to prevent adherence of the incisional scar to the underlying bone. there is a tendency for terminal swelling to occur.). if the heel pad becomes fixed off center by contracture of the triceps surae. it may migrate posteriorly or to one side in the socket ( Fig 25-7. In the case of transfemoral amputation. it is recommended that nonabsorbable sutures be used to oppose the fascia and other deep structures. and in children. the patient will be able to tolerate a great deal of end bearing. The plantar fascia of the heel pad may then be firmly sutured to the distal-anterior portions of the tibia and fibula through drill holes. this problem will not occur. Prior vascular surgery may have resulted in a longitudinal scar beginning on the lower portion of the abdomen and crossing the inguinal crease into the thigh ( Fig 25-8. It may also be necessary to remove a wafer of distal tibia and fibula to allow reduction of the heel pad. The http://www. many problems that lead to delayed application of a definitive prosthesis are a direct result of suboptimal operative technique.org/alp/chap25-01. the rigid dressing may slip distally and produce a circumferential constriction with distal choking and aggravation of distal swelling. If it is not properly anchored to the end of the tibia. other muscle groups.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library envelope for the enclosed bone or bones. all three being muscles that cross the hip joint. If wound closure is to involve split-thickness skin grafting.asp[21/03/2013 21:56:58] . The Syme ankle disarticulation presents a special case. Following amputation surgery. In myoplasty. In order to ensure optimal configuration. the sock may need to be fitted with a waist belt to keep it in place. Very muscular or obese amputees may show virtually no shrinkage of their residual limbs by wrapping or shrinker sock usage. The sock is briefly removed daily for skin care. Shrinkage may be further enhanced by applying a snug elastic shrinker sock when the preparatory socket is removed each night. If. especially those with a short tibial segment. many surgeons and prosthetists now recommend the use of an elastic shrinker sock. This shrinkage includes the removal of edema as well as atrophy of all the soft tissues of the residual limb. ). a variety of contractures may occur. Repeated application of an elastic bandage has been the time-honored method of shrinking and shaping a residual limb. ). a temporary prosthesis or weight-bearing rigid dressing fitted as soon as the wound is sound will cause both the bulky calf and the obese thigh to shrink most rapidly. Two socks should be supplied so that a clean one can be worn each day to assist in hygienic care of the residual limb. Shrinkage is the greatest during the first 6 weeks of compression by prosthesis use but continues for approximately 1 year after amputation. a circumferential rigid dressing of plaster of paris or fiberglass with the knee in full extension is advised until the wound heals sufficiently to allow the removal of sutures. These are serious complications that will interfere with proper prosthetic gait and increase the energy requirements of ambulation. less-than-expert application of the bandage will produce a poorly shaped residual limb. ). Contractures The joint immediately proximal to an amputation site tends to develop contractures if full range of motion is not initiated early in the postoperative phase. it should be snug. The dysvascular amputee with a short contracted residual limb may be fitted with a bent-knee prosthesis. As a result. This technique may also be applied to the standard residual limb as well. This sock not only is easy to don and doff but also results in the proper pressure gradient. parallel and just distal to the inguinal crease. In amputations not done for vascular insufficiency. The patella should be well padded to prevent pressure necrosis of the prepatellar skin. Another incisional approach that results in a scar that will not cross the socket brim begins in the proximomedial portion of the thigh and extends laterally. a contracture later develops. In these cases. When first fitted. frequent rewrapping is necessary to avoid circumferential constriction and distal edema formation. Transtibial amputees. Depending on limb configuration and activity level. generally with distal edema ( Fig 25-9. a definitive prosthesis may be fitted. are prone to develop knee flexion contractures in the first or second week postoperatively ( Fig 25-11. or a hip flexion contracture may be encouraged.asp[21/03/2013 21:56:58] .oandplibrary. hamstring lengthening and release of the posterior knee joint capsule should be considered. Unfortunately. moderate knee contracture in a proximal-third amputation may be improved by http://www. The bandages are meant to be applied on the bias with gradually decreasing pressure as the wrapping proceeds proximally. a second percutaneous Achilles tendon lengthening or revision to the Syme ankle disarticulation level may be required.org/alp/chap25-01. at which time a new socket will probably be required. especially if the scar is depressed. A plastic ankle-foot orthosis fitted with an anterior ankle strap can be similarly used. In lower-limb amputees. This is replaced weekly for 3 weeks with a full range of knee motion at each change. This may be prevented during tarsometatarsal (Lisfranc) and midtarsal (Chopart) amputations by reattaching the extrinsic muscle-tendon units of the foot to more proximal bony structures in a balanced fashion and by lengthening the Achilles tendon percutaneously. A postoperative cast applied with the partial foot in a plantigrade position will prevent contractures until a definitive prosthesis is made. Since layers of bandage tend to shift with movement. despite these precautions.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library other is maintaining suction suspension. Even with a cast in place. A tuck may be sewn in the sides of the sock every 7 to 14 days to keep it snug as the residual limb decreases in volume ( Fig 25-10. Patients with partial-foot amputations between the transmetatarsal and Syme ankle disarticulation levels are likely to develop an equinus deformity due to the relatively unopposed action of the triceps surae. pillows should not be placed under the residual limb. which is functionally no better and cosmetically inferior to that for a knee disarticulation ( Fig 25-12. When a definite plateau in shrinkage has been reached. as determined by no further need for shrinker sock tightening or by stable weekly circumferential measurements of the residual limb.). Occasionally. Severe knee flexion contractures are virtually impossible to reduce by exercise once they become fixed. Contractures most often occur as a result of the patient keeping the residual limb in a comfortable flexed position. For this reason. they may be very dissatisfied with the prosthesis and reject it. When prescribing a prosthesis in cases with significant flexion contracture of the hip or knee. Postoperatively. the patient and family must be forewarned of the relatively grotesque appearance of the prosthesis. localized osteomyelitis. including reattachment of the adductor magnus tendon to the lateral aspect of the femur as it is held in adduction and extension (see Chapter 20A). Otherwise. the resulting cosmesis of the prosthesis will leave something to be desired. Since a sinus is likely to become inflamed or infected. a pylon and foot may be added to convert it to a preparatory prosthesis. and the wound is protected from shear and direct pressure. A good way to determine this is to probe the opening with a malleable metal probe or a flexible polyethylene intravenous catheter after antiseptic skin preparation. pillows under the thigh are forbidden. it is useful to know that it is present. Active extension of the residual limb while flexing the opposite thigh to the chest is also effective. flexion-abduction contracture can be discouraged by a balanced myodesis. it is increasingly difficult to compensate prosthetically for a hip flexion contracture. thereby reducing pain. Either can be easily prevented by instituting rangeof-motion exercises as soon as postoperative pain has subsided at 5 to 7 days. Within a few days of surgery.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library fitting a prosthesis with the foot in slight equinus to provide a knee extension moment on foot contact. POSTPROSTHETIC COMPLICATIONS Painful Residual Limb http://www. More than 15 degrees of hip flexion contracture will require a marked compensatory increase in lumbar lordosis that. The hip is aligned to discourage contractures.oandplibrary. nonacute interval. At the transfemoral level of amputation. if the patient and family do not understand the rationale for this initial fitting in the hope that prosthesis usage will tend to decrease the contracture. is discouraged by early walking with crutches or a walker. At the first cast change.asp[21/03/2013 21:56:58] . even if available. A unilateral hip spica is applied in the operating room immediately following wound closure.org/alp/chap25-01. Again. Excessive wheelchair use. prevention is the key. Limitation of glenohumeral abduction and forward flexion is common in short transhumeral amputations. may lead to low back pain. If contractures become fixed. Application is easily done by lifting the patient by the opposite leg. Elbow flexion contracture occurs readily in a short transradial case. or it may be a sinus related to a bone spur or low-grade. During transfemoral amputations. An alternative approach may be used in anticipation of prosthetic use by vigorous transfemoral amputees. As one progresses distally to the midthigh level. needed for good prosthetic knee stability. a hip flexion-abduction contracture can be devastating because the already high energy requirement for ambulation at this level is further increased by contracture. Radiographs will help to determine bone involvement. Chronic Wound Sinus The patient who appears with a small adhesive bandage on his wound with minimal drainage has a problem that may or may not be related to one of the many conditions mentioned above. This small opening may only lead to a superficial suture abscess. the patient should be taught to lie prone for 15 minutes three times a day to stretch out any early flexion contracture and to actively adduct the residual limb to prevent abduction contracture. flexion contracture of up to 25 degrees may be accommodated by prosthetic alignment. Spontaneous use will usually stretch the contractures without other special treatment. distal constriction edema from bandaging is avoided. Contractures also occur in upper-limb amputations. which encourages contractures. In children. knee and hip flexion contractures can be stretched out by ignoring their presence and fitting the patient with conventional alignment techniques. The benefits are analogous to those achieved by postoperative casting of transtibial amputees. A sinogram followed by excisional surgery can be curative. Gentle muscle-strengthening exercises begun at 2 to 3 weeks postoperatively are also helpful. even an extensive program of stretching may be ineffective and require selective release of contracted muscles to allow fitting of a prosthesis. A sinus is best managed surgically during a benign. Even then. but hip extensor power. is compromised. At the short transfemoral level. if a dynamically balanced myodesis has not been performed. with inspection. surgical revision may be required. This complication is prevented by routine primary excision of the fibular remnant if amputation is close to the tibial tubercle. Widespread ectopic bone formation also occurs when the trauma leading to amputation has resulted in wide stripping of periosteum from the bone that is to be retained. One is by surgical extension of periosteal stripping onto bone that is to be retained ( Fig 25-13.org/alp/chap25-01. Neuroma formation is a natural consequence of nerve section. ). Pain in a residual limb can have as many causes as pain in an intact limb. In addition. the fibular remnant may require complete secondary resection ( Fig 25-14. if the fibular head and shaft are unduly prominent or hypermobile. Socket modification should be attempted. If the fibula is inadvertently left longer than the tibia. palpation. with or without injection of the local bursa with steroids. the femur may drift anterolaterally through the soft tissue to present its distal end subcutaneously ( Fig 25-15. may be necessary. the residual limb should be carefully examined at each visit for areas of local inflammation secondary to excessive pressure. ). they will http://www. In the transtibial amputee. the surgeon should determine exactly those portions that are contributing to discomfort and not disturb all ectopic bone just because it is present. Transfemoral amputees may complain of a burning sensation in the ischial weight-bearing area. there is a tendency for patients. performance tests. Following any bone transection. This is commonly due to inadequate contouring (beveling) of the tibia at the time of amputation. radiography. Before proceeding to revision. chronic phantom pain is very rare and presents a specific syndrome of a totally preoccupying pain in a stocking-glove distribution. it may be controlled by using a supracondylar-suprapatellar or supracondylar prosthesis or a PTB prosthesis with a thigh corset. Depending on the degree of instability. This will produce local tenderness and even ulceration with or without use of a prosthesis. In fact. with resultant hypermobility of the fibula. Symptomatic spurs from ectopic bone formation of the transected bone may be generated in one of two ways. and physicians not familiar with amputees to consider all pain in the residual limb to be phantom pain. In the absence of ulceration.asp[21/03/2013 21:56:58] . This can be quite massive and may lead to considerable discomfort in the residual limb. With the increasing utilization of ischial containment sockets and the advent of flexible socket materials. torn knee ligaments may result in painful instability while wearing the standard patellar tendonbearing (PTB) prosthesis. families. Nonetheless. If simple socket adjustments do not produce relief.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library In this section we will be dealing with causes of residual-limb pain other than phantom pain. Ertl has recommended distal tibiofibular synostosis to prevent or treat this Fusion of the proximal tibiofibular joint is a much simpler procedure that hypermobility. prosthetic modifications including socket relief over the bony prominence or anterior filling-in of the socket just above the prominence may be effective. In very short transtibial residual limbs. Preamputation traumatic disruption of the interos-seus membrane and proximal tibiofibular joint. surgical revision. including myodesis. Although this can often be corrected by local socket relief. the soft tissues should be copiously washed to remove minute bone fragments. Another equally poor presumption is that all pain problems are related to a poorly fitting prosthesis. ).oandplibrary. Since all persons with acquired amputations have phantom-limb sensation. can be a cause of pain in the transtibial amputee. the approach to the fibula should be extraperiosteal to avoid fibular regeneration. particularly in the early phases of using a quadrilateral socket. and other imaging studies used as necessary. If nerves are divided at a level that avoids both inclusion in the wound scar and weight-bearing or other significant pressure from the prosthesis. In transfemoral amputations. but surgical revision is often necessary. A common site of discomfort and skin breakdown in a transtibial amputation is over the distalanterior part of the tibia. the resulting distal bony prominence may be weight bearing and tender. pressure discomfort over the ischium is less common. does not require shortening of the residual limb or disturbance of the otherwise satisfactory distal tissues. and this results in the making of many unnecessary new limbs. The periosteum should therefore be disturbed as little as possible on any bone that one anticipates keeping. Adventitious bursae develop over bony prominences and occasionally need treatment beyond socket relief. and all amputees will therefore have several neuromas. Taking an adequate history and performing a physical examination continue to be appropriate. ). Pain-producing bone spurs may develop at the cut end of the femur and require similar socket relief or excision ( Fig 25-16. the amputee should be reassured that it is a normal finding and does not require corrective surgery. Partial unloading of the transtibial level by the addition of knee joints and a long thigh corset or the use of ischial weight bearing may be necessary to allow continued ambulation. Adherence of Skin to Bone In any residual limb. The proper course of action depends upon the type of tumor and may range from radiation or chemotherapy to amputation at a higher level. If a transtibial amputation stump continues to show skin breakdown despite competent socket adjustments. the amputee can be taught to mobilize tissue by gentle persistent fingertip massage on a daily basis over several weeks as a routine part of self-care. Consultation with an oncologist is essential before proceeding. In the case of adherent split-thickness skin grafts. In the case of a very short transtibial limb with a symptomatic peroneal neuroma. but especially at the transtibial level.oandplibrary. Insensitive Skin Amputees with diminished sensation in the residual limb are seen quite commonly. The treatment of neuromas should usually begin with socket accommodation. Ertl advocated a distal tibial fibular fusion to correct this problem and provide an "end-bearing" bone. tibial. If a neuroma is incidentally found by palpation in an asymptomatic residual limb. Surgical revision is done as a last resort and will usually require only a local wedge excision.asp[21/03/2013 21:56:58] . In some transtibial amputees who have had traumatic disruption of the interosseus membrane and subluxation of the proximal tibiofibular joint. either by traction or by tissue expanders. The addition of a rotator unit will decrease rotational shear forces. Other sites where split-thickness skin grafts may not stand up to prosthetic use is over the adductor longus tendon in the groin. at socket brims over the biceps tendon in the antecubital fossa. is probably the best way to develop enough normal skin to eliminate large areas of split-skin grafts. it is usually sufficient to swing a small flap distally from the abdomen downward or proximally from the thigh. often a relatively small area of adherent split graft can be excised. Medication may be prescribed. there may be ill-defined pain related to fibular hypermobility producing pressure on the peroneal. other methods may be helpful. .25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library rarely be symptomatic. Skin stretching. direct manipulation should produce a Tinel's sign with a tingling discomfort in the peripheral nerve patterns of the missing portion of the limb.A and B). The http://www. and in the anterior axillary fold in relation to transhumeral sockets. there will be no signs of inordinate prosthetic pressures. the neuroma can be easily deafferented by removal of peroneal nerve proximal to the knee through an incision posterior to the distal portion of the biceps femoris muscle. however. local recurrence is a possibility. It is easier to simply fuse the proximal tibiofibular joint and not shorten the residual limb or disturb its distal soft tissues. the neuroma should be moved to a deeper site. Firm fibrous nodules that are only locally sensitive are probably not neuromas. If this approach is unsuccessful after several attempts. Whenever late pain occurs in a limb amputated because of tumor. the adherence of skin to bone or the application of split-thickness skin grafts directly to bone may rapidly lead to pain and ulceration when a prosthesis is used. In these cases. and the pain will occur regularly when the patient walks a specific distance. Amputation to a higher anatomic level is rarely indicated. To cover the adductor tendon region in the groin. including a small length of bone. and sural neuromas. In dysvascular patients. In an attempt to avoid revision. but the amputee should be assured that refabricating the prosthesis will not help. A nylon sheath should be provided to reduce shear forces. A gel socket may be useful. either by proximal division under moderate tension or by placing the nerve end in bone. with primary closure effected by advancement of surrounding skin and subcutaneous tissue once muscle atrophy has resulted in relative skin redundancy at 10 to 12 months ( Fig 25-17. If a symptomatic mass is suspected of being a neuroma. This occurs because skin without underlying soft tissue has little resistance to direct or shear forces imposed by the prosthesis.org/alp/chap25-01. a healed skin wound may be associated with considerable ischemia of the underlying muscles and result in intermittent claudication during walking. This is certainly the case when the neuroma is directly over bony prominences where pressure from use with or without a prosthesis is unavoidable. such as in the hand at the metacarpal heads or at the neck of the fibula. usually 10 to 15. This problem is usually related to residual-limb volume decrease by atrophy or weight loss. All team members should therefore be aware of the signs of both loose and tight socket fit. Areas of skin blanching and/or erythema should be noted by the prosthetics team for prompt corrective action. during donning or doffing of the prosthesis. It is often seen in the humerus. Lower-limb edema resulting from renal and/or cardiac disease will adversely affect socket fit. and femur in that order of relative frequency ( Fig 25-18. With an excessive number of sock plies. It does. These patients are not deterred by pain from continuing to walk on a locally ischemic or ulcerated residual limb and must be taught to remove their prostheses at regular intervals for skin inspection. tibia. This is appositional bone growth and is not related to physeal growth. such as any sudden change in their health. it may be impossible to get the socket back on. The edema can become relatively chronic. the amputee has good suspension at the socket inlet but relative freedom of motion distally so that the residual limb moves inside the socket like a clapper in a bell and strikes the anterior socket wall each time the knee is extended during swing phase. but it may be noted. the prosthesis no longer fits properly. Poor Fit After a variable period of use. Another transtibial problem of fit related to distal circumferential shrinkage is usually associated with ill-defined pain in the residual limb. In this case. In these cases. Pressure and shear forces result in inflamed and/or ulcerated areas of skin in either case. erythema in abnormal places. Evaluation of a residual limb for prosthetic pressures is exactly the same as evaluation of a foot for shoe fitting. and distal end of the patella as the residual limb enters the socket too deeply. A weight-bearing radiograph of the residual-limb/socket interface is useful to confirm the presence of a distal void. demand precise prosthetic fitting and attentive follow-up care. and local tenderness under erythematous areas. This may occur several times during childhood and is easily treated by resection of sufficient bone to allow coverage with an adequate soft-tissue envelope. http://www. chemical cautery. but other neurologic disorders such as my-elomenigocele. Relative socket looseness will commonly cause excessive direct and shear forces over the tibia and fibula. and resumption of ambulation can be very difficult as one struggles to shrink the residual limb again. callus or bursa formation. many problems are easily corrected with minor sock or socket adjustments.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library largest group are diabetics. ). even though bony overgrowth usually ceases when physeal growth ceases. Relative socket tightness will cause direct tibial tubercle pressure on the patellar tendon bar and verrucous hyperplasia of the limb end due to loss of distal contact. the socket/residual-limb interface is disturbed. costly skin breakdown is to be avoided. plugs. the same situation leads to choking. that while there is a snug fit proximally. This problem may sometimes be corrected by filling in the socket posteriorly. Proximal epiphysiodesis is con-traindicated since this has no influence on distal appositional bony overgrowth and will lead to unnecessary shortening. fibular head. One looks for areas of prolonged erythema after walking in the prosthesis. If they are admitted for treatment of their underlying condition. Often. tibial tubercle. however. especially at the transtibial level.org/alp/chap25-01. as manifested by a reduction in rotational control and an increased tendency to piston. Multiple short periods of daily ambulation will usually allow gradual skin adaptation. and a new socket is needed promptly if dangerous.oandplibrary. There is no sign of inordinate prosthetic pressure. Hansen's disease. most amputees find that prosthetic fit can no longer be effectively adjusted by further socket padding and additional stump socks. and alcoholic neuropathy are also seen. especially during the early phases of prosthetic use. On the other hand. Caps. Bony Overgrowth in Children The traumatic transosseous child amputee may experience rapid growth in length of the residual limb to the point where the bone grows through the skin. there is room distally for an examining finger or that a soft insert feels loose. fibula. The presence of insensate but otherwise normal skin on the residual limb should not be considered an indication for more proximal amputation. It is extremely important that they have appropriate shrinker socks to wear in bed. If these amputees are unable to use their prosthesis for any reason. compression of the residual limb should be started promptly while in the hospital rather than being neglected for a period of several days. or electrocautery have not proved to be consistently useful in controlling overgrowth.asp[21/03/2013 21:56:58] . This problem is often related to wearing excessive sock plies or due to weight gain. org/alp/chap25-01. In transtibial amputees. if possible. If pain is not relieved. Patients with stable supracondylar femoral fractures can be mobilized rapidly by the use of the cast-brace technique ( Fig 25-19. some will have arthritis of the joints proximal to the site of amputation. the lightest-possible prosthesis should be fabricated to require less forceful contractions of the muscles crossing the hip joint.asp[21/03/2013 21:56:58] . certain goals in the treatment of late residual-limb fracture become clear. In displaced intraarticu-lar fractures of the knee. Also. and all of these were transtibial amputees. fracture in a residual limb following amputation does occur sufficiently often to warrant a careful design of treatment methods to allow an early. http://www. Superimposed ambulation with a prosthesis may put more strain on the proximal joints. are paramount. joint congruity should be restored as accurately as possible. preservation of knee motion and restoration of limb alignment. remain the same as in any other individual. with a fall while wearing the prosthesis as the usual cause of injury. The average age at injury was 50 years. arthroscopic evaluation and surgery should be considered. Unstable supracondylar fractures should be fixed primarily. nor did a hip joint with a pelvic belt prevent fractures about the hip in transfem-oral amputees.A and B).oandplibrary. Likewise. Moderate malunion or loss of length at the transtibial level is easily compensated by prosthetic adjustment. Weightbearing pain in the knee secondary to femo-rotibial joint arthritis may be partially relieved by the addition of knee joints and a thigh corset to allow shared weight bearing between the residual limb and the thigh. Displaced femoral neck fractures in both groups may be managed either by reduction and internal fixation or by endoprosthetic replacement. but a different approach is allowed due to the reduction in distal limb segment mass and lever arm length. Because of the small residual-limb mass and lever arm length in transfemoral amputees. transtibial amputees were more likely to resume the use of their prosthesis than were trans-femoral amputees due to lesser energy demands. femoral endoprosthetic replacement or total-hip arthroplasty may be undertaken based on the same criteria as in any patient with otherwise intact limbs. . thus reducing joint compression forces. ).25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library Degenerative Arthritis Since most people who sustain amputations are middle-aged to elderly. Only 25% required a prosthesis modification following fracture. A combined American and Canadian study produced 90 cases with sufficient information to provide both epidemiologic data and some specific recommendations for management. By applying current knowledge of the gait cycle and energy expenditure in lower-limb amputees. Operative scars did not interfere with the fitting or use of prostheses. thereby contributing to arthritis pain. ). In this study. however. Excision of the femoral head alone will lead to an unstable gait. The general principles of fracture management. Instead. Patellofemoral arthritis has not proved to be a major concern. In cases of internal derangement of the knee joint. a total-hip arthroplasty should be considered to maintain function in a prosthesis user. Although manipulation and casting often suffice in two-part intertrochanteric fractures. Proximal revision of amputations through the fracture site was not found to be necessary or desirable. but an effort should be made to avoid flexion contracture of the knee. effective return to prosthesis use. especially in more proximal femoral fractures. It was notable that knee joints and a thigh corset did not prevent supracondylar fractures in transtibial amputees. transtibial amputees with significant symptomatic hip joint arthritis should not be denied the benefits of hip joint arthroplasty if it is otherwise indicated. most nondis-placed peritrochanteric fractures and shaft fractures can be successfully managed by non-weight bearing alone or minispica casts after appropriate manipulation of malaligned fractures. those amputees with unstable fractures are best served by open reduction and internal fixation. to preserve knee motion. which is much less compensable ( Fig 25-21. Severely comminuted supracondylar fractures unsuitable for fixation may be managed by casting with or without preliminary skeletal traction and/or manipulation ( Fig 25-20. One important goal in the treatment of intertrochanteric fractures that applies to both transtibial and trans-femoral amputees is the restoration of a normal neck-shaft angle to restore hip abductor function. Fracture Although uncommon. Arthritis of the hip joint in the transfemoral amputee may be alleviated to some degree since the trans-femoral socket bypasses the hip joint by utilizing a portion of the pelvis for weight bearing. Watts HG: Special considerations in amputations for malignancies.25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library Fractures of residual upper limbs are very rare. Arch Surg 1987. 9.oandplibrary. The primary goal of complication prevention and management is the successful prosthetic restoration of the amputee. 4. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 25 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . internal fixation. in Mader JT (chairman): Hyperbaric Oxygen Therapy. Chirurgie 1949. pp 93-117. Bowker JH. 20:218. Chapter 25 . 111:1128-1130.org/alp/chap25-01. Kazim M: Biomechanics of ambulation. Hauser CJ: Tissue salvage by mapping of skin surface transcutaneous oxygen tension index. Mosby-Year Book. 6. Prosthetic. The amputation surgeon. 1989. 10. 2. Rills BM. 267:211-217. 66:71-75. J Bone Joint Surg [Am] 1981. Philadelphia. in Moore WS. 3. 1989. Matos LA: Enhancement of healing in selected problem wounds. Dickhaut SC. Lind J. WB Saunders Co. SUMMARY Knowledge of the common complications of amputation surgery should lead to their prevention in most cases and their speedy resolution when they occur. In summary. open reduction. 1989. Clin Orthop 1991. Ertl J: Uber amputationsstumpfe. DeLee JC. Fractures about the elbow may be managed by open or closed methods so long as treatment is designed to maintain elbow range of motion. Philadelphia. A Committee Report. 5. WB Saunders Co. will be able to use these proposed solutions as a creative starting point to upgrade the care of amputees in the local community.asp[21/03/2013 21:56:58] . J Bone Joint Surg [Am] 1984. Malone JM (eds): Lower Extremity Amputation. Wagner FW Jr: Amputations of the foot and ankle. et al: Fractures in lower limbs with prior amputation. pp 459-463. Bodtker S: The influence of smoking on complications after primary amputations of the lower extremity. in Moore WS. 1981. Undersea and Hyperbaric Medical Society. This chapter provides numerous examples of preprosthetic and postprosthetic problems and their possible solutions. pp 37-44. Malone JM (eds): Lower Extremity Amputation. A study of ninety cases. 63:915-920. in Atlas of Limb Prosthetics. Kramhoft M. References: 1. It is recommended that humeral fractures be treated by splinting. working with a dedicated prosthetic team.Atlas of Limb Prosthetics: Surgical. especially in transradial amputees. pp 261-273. Ledbetter CA. Matos LA: Personal communication. and bone grafting should be considered. good results in the management of fractures of residual limbs may be expected if they are treated with the same care and expertise accorded fractures occurring in intact limbs. Page CR: Nutritional studies: Importance in predicting woundhealing after amputation. Bethesda. St Louis. 7. If delayed union or nonunion ensues. Contact Us | Contribute http://www. 8. Bowker JH. and it is of vital concern to the physician and prosthetist to prevent any disorder that may return the amputee to crutches or bed rest. These will be mentioned subsequently. specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Many new designs are now reported to store energy during stance and release energy as the body weight progresses forward.org/alp/chap26-01. dermatologist. for he is familiar with the problems of the skin that can result from the wearing of an artificial limb. Lower-limb amputees are frequently involved with skin problems since many have been subjected to anatomic loss of the lower limbs at widely varying levels. to a larger degree. In others. reprinted 2002. prosthetic fitting and alignment problems. It is best to view any minor irritation as a potentially dangerous symptom and to deal with it as early as possible. edition 2. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. and medical problems such as skin disorders that are secondary to the use of the artificial limb. Early recognition and treatment of these conditions can avert much mental anguish and avoid loss of social or economic activity. Amputees require the continued care of a prosthetist who constructs the artificial limb on which the amputee must depend for locomotion and. a specific hygienic program for care of the stump and socket has been developed. Skin lesions. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). IL. Amputation at any level is accompanied by distinct problems of functional loss. http://www.asp[21/03/2013 21:57:03] . and Rehabilitation Principles. stronger prostheses with more dynamic action than was available in previous years. Click for more information about this text. This is especially true in diabetics. thus helping to passively propel the limb. socially. 1992. and other medical personnel concerned with amputees should be aware of certain conditions and danger signals that are frequently the forerunners of seriously incapacitating cutaneous disorders. Prosthetic. Prosthetic. Numerous means to suspend prostheses have been developed. This chapter is devoted to the common skin problems and danger signals associated with the wearing of a lower-limb prosthesis.D. and diversity has resulted from attempts to fit individuals of differing physical characteristics and life-styles. prosthetist. Stump and socket hygiene is important in relation to several clinical disorders of the skin. with each level subjected and reacting to different pressures. American Academy of Orthopedic Surgeons. it should not be ignored in the hope that it will heal of its own accord. Most leg Reproduced with permission from Bowker HK. and accordingly. are nevertheless of great importance since they can be the beginning of an extensive skin disorder that may be mentally. In working with numerous amputees over the years. In the past decade there have been numerous advances in the development of prostheses for transtibial (below-knee) and transfemoral (above-knee) amputees. Nothing can be more frustrating to the lower-limb amputee than to be told to remain off his prosthesis or to go onto crutches because he has neglected a minor skin eruption. William Levy. The skin of an amputee who wears a prosthesis is subject to numerous abuses. Amputation is just the beginning and not the end of a treatment! The amputation surgeon and prosthetist have joined together to become the lifelong advisors to the amputee who will wear an artificial limb for the rest of his life. M. Prosthetic. Rosemont. and economically disastrous to a given amputee. It should be remembered that once in a prosthesis. however minute they may appear. and frequent difficulties do arise. Once the skin problem has begun.oandplibrary. ©American Academy or Orthopedic Surgeons. the amputee desires to continue. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.Atlas of Limb Prosthetics: Surgical. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and Rehabilitation Principles Skin Problems of the Amputee S. A dermatologist is capable of rendering valuable aid to not only the amputee but also other members of the rehabilitation team. for social and economic rehabilitation. the skin is a weaker tissue for them. Some amputees will go for months or years without any skin complaint or irritation. The orthopaedic surgeon. Partial or total loss of an upper limb can also be associated with similar complaints. The strongly expressed desire of amputees to participate in sports with high physical demands has resulted in the development of lighter-weight.26: Skin Problems of the Amputee | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 26 Chapter 26 . the groin. In addition to the effects of pressure and friction. Additional pressures also occur from mechanical rub over the prepatellar and infrapatellar areas. an amputee's skin is vulnerable to the possible irritant or allergic action of the material used in the manufacture of his prosthesis or topical agents applied by the patient himself. who usually has at least the upper third of the tibia remaining. his skin must adapt to an entirely new environment. Examples of such stress are intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. thereby trapping perspiration. http://www. stick to the socket. it should be changed daily and should be washed as soon as it is taken off before perspiration is allowed to dry in it. the prosthesis cannot be worn. uneven loading may cause stress on localized areas of the stump skin. constriction of soft tissues of the thigh by the thigh corset may cause significant obstruction to venous and lymphatic drainage of the leg. In the transfemoral amputee. The cleansing routine should be followed nightly or every other night. nonspecific eczematization. the sides. rub. The amputee can expect mild edema and a reactive hyperemia or redness when first becoming accustomed to the prosthesis. In the majority of instances. and this has often had a preventive or therapeutic effect on a cutaneous disorder. the stump is subjected to negative pressure as well. depending on the rate of perspiration. or hexachlorophene. such a simple regimen has been curative for some persistent eczematoid eruptions of the stump skin. For example. and perspiration generated within the socket. If a routine cleansing program is not employed. stump socks are worn for reduction of the friction. Poor hygiene may be an important factor in producing some pathologic conditions of the stump skin. Some amputees prefer to use a cake or bar soap containing similar agents or triclocarban and should be fully informed as to their use for cleansing both the stump skin and/or the wall of the socket. These are relatively inexpensive and available in drugstores throughout the world with and without a prescription. the best time to cleanse the socket is also at night.26: Skin Problems of the Amputee | O&P Virtual Library prostheses have a snugly fitting socket in which air cannot circulate freely. and be irritated by friction during walking. no matter how accurate the fit of the socket may be. do not usually require therapy." a plastic or rubber ball can be inserted into the base of the sock to give it the correct shape. pressure may be exerted on the adductor region of the thigh. If the sock does dry with a "dog-ear. all points of contact with the socket rim. intertrigo. If the normal skin condition cannot be maintained despite daily wear and tear. SKIN HYGIENE Some amputees fail to adequately wash either the stump or the socket. In the older conventional transtibial prosthesis. the degree of malodor. and persistence of infected epidermoid cysts can eventuate. and hence maceration and mal-odor can result. If suction is used for suspension. STUMP EDEMA SYNDROME When an amputee first starts to wear a prosthesis with suction suspension. If a stump sock is worn.oandplibrary. The season of the year may also dictate the frequency of cleansing. For the same reason. Some amputees prefer to use witch hazel or rubbing alcohol compound for the wall of the socket. Amputees should be advised in a program and asked to purchase a plastic squeeze container of a liquid detergent containing chlorhexidine gluconate. There has been no unanimity of opinion as to exactly what measures should be used routinely. With certain prostheses. An incorrectly fitted socket may predispose the leg amputee to these problems by imposing a pressure distribution that can disturb local circulation. We have suggested a simple hygienic program with the use of a bland soap or sudsing detergent. and the bathing habits of the person. they are relatively innocuous. Soaps or detergents that contain bacteriostatic or bactericidal agents in addition to their cleansing action help to reduce the possibility of infection.asp[21/03/2013 21:57:03] .org/alp/chap26-01. and can be minimized by gradual compression of the stump tissues postoperatively with an elastic bandage or "shrinker" sock prior to use of the prosthesis. The socket provides for weight bearing. These changes are the inevitable result of the altered conditions that are now forced on the skin and subcutaneous tissues of the stump. Similarly. and some amputees have come to us with varied and often strange ideas about their own hygiene. and the ischial tuberosity. and sometimes. In the transtibial amputee. The stump should not be washed in the morning unless a stump sock is worn because the damp skin may swell. a transtibial amputee wearing a total-contact socket must adapt to the heat. bacterial and fungal infections. pressures occur over the anterior portion of the tibia. triclosan. the end of the stump. The state of the stump skin is of utmost importance in the amputees' ability to use a prosthesis. months. Varnishes. or more often chronic. and in rare instances deep ulcers can result from continued mechanical injury and poor skin nutrition. One also has to analyze the different conditions of heat. Areas of eczema appearing at the site of contact with an irritant or allergen may be acute. humidity. certain cutaneous problems associated with the wearing of a prosthesis continue to occur quite commonly. edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket. This includes elimination of all mechanical factors contributing to the edema.oandplibrary.org/alp/chap26-01.). One has to learn about the materials used in the manufacture of prostheses in order to understand and treat the problem adequately. if incompletely cured in their manufacture. Much of the skin involving the interface is not designed physiologically to withstand the environment and the variety of pressures that are inherent in prosthetic wearing. others a plastic-covered pad on the bottom of the socket. Here. they can develop allergic contact dermatitis from a variety of contactants and complain of intense itching or burning of the skin when using their prosthesis. with small blisters and swelling or oozing of the skin. which can also produce allergic sensitization over a period of time. topical antibiotics such as neomycin. It is thought that this disorder is vascular in origin. Out of the studies. such as choking by the socket or lack of total contact distally. Common sensitizers include nickel. The irritant form of contact dermatitis is the most common and can result from contact of the skin with strong chemicals or other known irritants. Many cements and volatile substances used to repair prostheses are also capable of producing either an irritant reaction or allergic sensitization. and this may cause ulceration or gangrene as a result of the impaired blood supply. chromates (used in leathers). Allergic contact dermatitis may arise from the application of medicaments by the patient or the physician or possibly from agents used in the manufacture of the prosthetic socket by the prosthetist. and resins are frequently used in finishing the inner lining of the socket of leg prostheses. and friction within the socket since these are interrelated with the intensity of the reaction. and topical anesthetics such as ben-zocaine or lidocaine. CONTACT DERMATITIS An amputee can have an acute or chronic skin inflammatory reaction caused by contact with an irritant or allergenic substance. lacquers.. Every amputee who wears a prosthesis experiences the skin adaptations and problems incident to this intimate interface. The man-machine interface is critical to wearing an inert prosthetic substitute for the limb loss. The disorders that follow are not only seen in lower-limb amputees but are also seen in upperlimb amputees as well. Occasional use of an oral diuretic and a shrinker sock will be advantageous. Superficial erosion of the distal stump skin is not uncommon.. rubber additives. chronic irritant dermatitis is nonetheless frequently seen in older amputees. a venous and lymphatic congestion producing edema and hemorrhage. the disorder was usually caused by contact of the skin with chemical substances that acted either as a primary irritant or drying agent or as a specific allergic sensitizer to the skin ( Plate 11. or even years of http://www. with scaling and mild redness or erythema. ). Any of these agents are capable of producing a contact dermatitis of the stump skin after weeks. perhaps by making a pad in the bottom of the socket. Plate 9. Although older patients are less readily sensitized to experimental allergens. Amputees may develop delayed hypersensitivity to a variety of substances that come into contact with the skin. Excessive negative pressure in a socket can also contribute to circulatory congestion and edema. In these. The pigmentary changes so often seen on the distal portion of the stump of amputees is due to hemosiderin or blood pigment deposited within the distal stump skin ( Plate 7. Newer plastics and metals developed through the United States Space Program are now utilized in the manufacture of prostheses. improved methods of treatment are continuing to evolve. plastics.asp[21/03/2013 21:57:03] . Although improvements in technology continue. Although some elderly amputees have a less pronounced inflammatory response to standard applied irritants than do younger patients. therapy by the dermatologist requires teamwork with the orthopaedic surgeon and prosthe-tist. and Plate 10 ).26: Skin Problems of the Amputee | O&P Virtual Library If the amputee continues to wear a malfitting prosthesis. Continued uneven mechanical rub can produce thickened. lichenified areas on the skin or weeping superficial erosions ( Plate 8. may produce a primary irritant reaction or even cause a specific allergic sensitization. Plastic resins. Treatment should be directed toward better support of the distal soft tissues by restoring distal tissue contact. A number of patients with contact dermatitis of the skin of the stump have been observed. Cutaneous disorders common to lower-limb amputees have been classified as well as evaluated and treated in numerous individual cases. The socket wall in itself can also produce such allergic contact dermatitis. wool fats and especially lanolin found in many moisturizers and skin creams. Some amputees will use a foam rubber cushion. subcutaneous intercommunicating sinuses may develop. Patch tests are most informative in pinpointing specific substances as the cause of a dermatitis. Characteristically.org/alp/chap26-01. the eczema has been secondary to poor fit or alignment of the prosthesis or to edema and congestion of the terminal portion of the stump so that only with the improvement of these fitting problems has the condition cleared. Usually the cysts do not appear until the patient has worn a prosthesis for months or years ( Plate 13. and even adhesive tape. lotion. only a carefully taken history will reveal that the use of a new cream. Plate 14.26: Skin Problems of the Amputee | O&P Virtual Library continued use. In other patients. frequently called posttraumatic epidermoid cysts. temporary symptomatic topical therapy with hydrocortisone or other topical corticosteroid preparations is effective. it should be avoided as much as possible. small follicular keratin plugs develop in the skin of the inguinal fold and/or the skin of the adductor region of the thigh along the brim of the prosthesis. solutions of such substances are first diluted according to published lists in order to prevent a false-positive reaction and possible continued injury to the skin. the nodular swelling may suddenly break and discharge a purulent or serosanguineous fluid. When contact dermatitis is suspected or diagnosed. scars can remain after the cysts have eventually healed. some of these plugs may become deeply implanted and develop into small or large cysts.oandplibrary.asp[21/03/2013 21:57:03] . The skin may break down and erode or ulcerate. Cool or cold compresses. ). . Naughahyde. weeping. All documented skin allergies should be carefully noted on a patient's record since systemic exposure to chemically related compounds may result in systemic allergic reactions. They are seen as round or oval swellings deep within the skin. lubricant. In other patients we found that over-the-counter topical antibiotics or skin-"toughening" agents will produce a dermatitis. covered by the upper medial margins of the prosthesis. in the skin of amputees' stumps in association with the wearing These occur most frequently in transfemoral amputees in the areas of an artificial limb. but they have also been seen in other areas and in transtibial amputees. Some lesions may become as large as 5 cm in diameter. they become sensitive to touch or pressure. waxes and polishes. We have investigated a number of contact dermatitis cases. The condition often fluctuates over a period of months or years and may be the source of much anxiety to the amputee. physical examination. Through the process outlined below. It appears in some patients to be seasonal and in others to be related to continued standing or unusually active episodes. while at other times they become moist without apparent reason. epoxy resins. Frequently. Once an agent causing a given reaction has been identified. and the topical application of corticosteroids or similar preparations have been beneficial in controlling the process and allowing for improvement. In some we have noted the use of a new drug taken orally or some unusual dietary changes. . ). and subsequent patch testing has identified the offending agent after the acute process subsided. but the condition frequently recurs unless its cause can be eliminated. bland anti-itch lotions. Similar plugs may appear over the inferior portion of the buttock where the posterior brim or ischial seat of the prosthesis rubs. In those instances of contact dermatitis where the irritant has not been obvious and where patch test results have been inconclusive. or cleansing agent coincided with the onset of the dermatitis. http://www. Here again. itching area of dermatitis over the distal portion of the stump. every attempt should be made to determine the contactant in order to avoid future complaints. EPIDERMOID CYSTS A number of authors have described the appearance of multiple cysts. NONSPECIFIC ECZEMATIZATION Nonspecific eczematization of the stump has been seen in a variety of instances as an acute or chronic persistent. If irritation by the prosthesis is allowed to continue. The lesions at times can be dry and scaly ( Plate 12. If the break takes place within the deeper portion of the skin. Removal of a suspected contactant has resulted in a cure. laboratory tests. Since patch testing with strong concentrations of known primary irritants will result in reactions on almost any skin. temporary symptomatic therapy has always alleviated these symptoms. We have been able at times to elicit a significant history of recurrent. In some patients. and Plate 15. in the transfemoral amputee. and some have been due to neomycin. allergic eczema and in others to demonstrate active eczematous lesions on other portions of the body to account for the eruption on the stump skin. The sinus discharge may become chronic and thus make it impossible for the patient to use his prosthesis effectively. and subsequent observation of the clinical course of the condition. and with gradual and continued enlargement. various cements. In almost every instance we have tried to find the cause of this recurrent dermatitis through a complete study of the patient: history. http://www. in some patients. In the acutely infected phase. that superficial fungus infections of the stump skin may be difficult to eradicate completely because of continued moisture. At the present state of knowledge. which in turn favors invasion of the hair follicle by bacteria. Once the diagnosis has been made. become abscessed and produce the characteristic clinical picture. and each and every patient is a therapeutic challenge. superficial. the skin bacterial flora of the residual limb was compared with the flora of the opposite normal limb. We are currently applying various topical preparations in an effort to prevent or retard the inflammation that follows formation of the keratin plug.oandplibrary. applied once nightly. or an eczematous weeping. impetiginized pyoderma ( Plate 16. It should be noted. followed by proper fit and alignment of the prosthesis. the majority of patients respond to topical medications. It is usually worse in the late spring and summer when increased warmth and moisture from perspiration promote maceration of the skin within the socket. the keratin plug and its underlying epidermis are displaced into the corium. however. but sometimes. which may be the precursor of the epidermoid cyst. Although this reduces inflammation. but there is no completely satisfactory method of treatment.). cellulitis. warmth. with secondary bacterial invasion by Staphylococcus or Streptococcus. isolated. Superficial fungal infections such as tinea corporis and tinea cruris can appear on any part of the residual limb enclosed by the socket. Ordinarily this process is not serious. bacterial and fungal infections are usually short-lived if the diagnosis is made early and correct therapy is administered. or fluconazole given orally for several weeks can be curative in these resistant patients. incision and drainage may be temporarily beneficial. These cysts can remain quiet for a long period or can. In those patients where topical antifungal agents are not effective. The chronic problem can. We have attempted to develop a stump sock or adductor rim sock for use with the suction suspension prosthesis to prevent cyst formation. In some of our amputees. Poly-tetrafluoroethylene film (Teflon) has been found satisfactory for this purpose.). The stump skin was found to harbor bacterial flora more abundant than that of the skin of the intact leg. and Fig 26-1. All subjects wore prostheses and followed a satisfactory routine of skin hygiene. can be curative. Chronic recurrent folliculitis can be cured by having an amputee adhere to the routine hygienic program previously described. Folliculitis and furuncles can also be the result of poor hygiene of the stump and/or the socket. ketoconazole.26: Skin Problems of the Amputee | O&P Virtual Library From our studies it appears that the condition is one in which the surface keratin and the epidermis become invaginated and act as a "foreign body. especially over the brim of the socket. therapy may require a wet compress. Cortisone or its derivatives have been injected into the cysts and their channels to reduce the inflammatory reaction. especially in diabetics. it can progress to furuncles. erythematous eruption can be confirmed through culture and/or microscopic demonstration of the fungus filaments in scales or tiny vesicles removed from a given lesion ( Fig 26-2. Topical application of corticosteroids in areas of maximum friction have also been tried. incision and drainage of boils after localization and oral or parenteral use of antibiotics.asp[21/03/2013 21:57:03] . Chronic recurrent fungal infections are especially common on the stumps of individuals who perspire freely and easily. BACTERIAL AND FUNGAL INFECTIONS Bacterial folliculitis and furuncles or boils are often encountered in amputees with hairy. In still other patients.org/alp/chap26-01." Under the continued influence of friction and pressure from the prosthesis. Fortunately. As the cyst localizes. and local application of bacteriostatic or bactericidal agents. be improved or successfully eliminated through evaluation by the prosthetist. it provides only temporary symptomatic relief. oily skin. The diagnosis of a nonspecific scaling. Griseoful-vin. In our own experience. hot compresses and topical or oral antibiotics selected through bacterial studies and sensitivity tests of the cystic fluid are indicated. The newer antifungal agents. Various substances have been tried as socket liners for reduction of friction over the pressure areas. oral antifungal antibiotics can be helpful and curative. Either incision and drainage or excision of the chronic. therapy consists of the application of fungistatic creams and powders for an extended period of time. and maceration within the prosthetic socket. The result is a production of nonspecific inflammation and implanted epidermoid cysts. noninfected nodule may give temporary relief. there is still no completely satisfactory method of treatment. crusted. with the condition aggravated by sweating and rub from the socket wall. org/alp/chap26-01.oandplibrary. Malignant ulcers can develop within old. The painful deep ulcers and edematous processes can be chronic and disabling.26: Skin Problems of the Amputee | O&P Virtual Library INTERTRIGO Intertriginous dermatitis is an irritation of skin surfaces that are in constant apposition. Continued edema of the distal stump skin must be corrected early in order to avoid ulceration. and between which there is hypersecretion and retention of sweat.asp[21/03/2013 21:57:03] . therefore. http://www. TUMORS Tumors of the stump skin can be benign or malignant. The condition usually occurs in the inguinal or crural areas. Bacterial and fungal infections are common in those amputees where the diabetic metabolic process is uncontrolled. All of these are treatable by using a local anesthetic and superficially removing the lesion. but on occasion it occurs in the folds at the end of the stump where two surfaces of skin rub against each other and where the protective layer of keratin is removed by friction. A chronic disorder may develop with deep. Continued friction and pressure from the socket may result in lichenified or pigmented skin. and eczema. Ulcerations or erosions of the skin in diabetics must be diagnosed and treated early to prevent serious infection. an accurate diagnosis is of utmost importance. and healing has been successful. ). OTHER SKIN DISORDERS Over many years numerous chronic dermatoses have been observed.) are easily removed. Seldom does this require a large surgical excision. The thickened skin may subsequently itch or burn depending upon the rub. Here again. Diabetic skin is especially prone to chronic disorders that can be serious and disabling. Localization on the stump skin following a generalizing eruption is not unusual. Basal and squamous cell carcinomas have been removed without incident when they were small. CHRONIC ULCERS Chronic ulcers of the stump may result from bacterial infection or from poor cutaneous nutrition secondary to edema or to an underlying vascular disorder. ) as well as lichen planus developing on the stump skin. painful fissures and secondary infection along with eczematization. The continued wear and tear from the use of a prosthesis may then necessitate surgical revision in order to free the scar in the bound area and allow for effective use of a prosthesis. and there are recorded instances of psoriasis ( Plate 17. We have seen similar localization in patients with seborrheic dermatitis. ). the amputation scar may become adherent to the underlying subcutaneous tissues. a process that invites further erosion and ulceration ( Plate 19. Diabetic dermopathy can be seen as bullae or blisters from prosthetic rub against the skin and require several weeks for healing ( Plate 18. Simple cutaneous papillomas ( Fig 26-3. Frequently the problem can be corrected by proper prosthetic fit and alignment. persistent stump ulcerations. and cauterization on the skin following removal of a lesion usually will heal within 2 weeks. and these resulted in recurrence with subsequent lymphangiosarcoma and death. In some instances localized pressure from a poorly fitting prosthesis can produce erosion followed by ulceration ( Fig 26-4. Hygienic measures to cleanse the apposing folds and the use of drying powders or mild drying lotions can be beneficial. An accurate diagnosis is of utmost importance. With repeated infection and ulceration of the skin. However. Viral verrucae or warts have been seen frequently on the stump skin and are treated by cauterization. we have had several patients where amputation was necessary for lymphangioma. Here it is important to diagnose and treat the generalized cutaneous disorder in order to improve the local process. with few lesions being present elsewhere on the body. and some have localized on the stump skin. Candidal or yeast infections are not uncommon in the groin and on the stumps of diabetic amputees following a course of antibiotics for some other disorder. and we have seen numerous cutaneous horns on stump skin. folliculitis. We have seen.). every effort should be made to treat the process before it becomes chronic. We have seen patients with acne vulgaris of the face and back develop acne lesions on the stump. A high blood sugar content may be reflected as a folliculitis on the stump skin or even elsewhere on the body of the diabetic. it is clear from our studies that the poor pressure gradient. but their skills must be combined with the contributions of the dermatologist in the solution of the many skin problems of the amputee. and engineers are applied scientists from whom great technical assistance is expected. Barnes GH. the edema will be increased. a 40-year-old physician had extensive ulceration and infection of the stump skin with verrucose hyperplasia of long standing ( Plate 20. In the transtibial amputees we have reviewed who had this process. et al: The bacterial flora of the skin of amputation stumps. SUMMARY Amputation surgeons. Lea & Fe-biger. we have made great strides in our knowledge and technical ability to produce the finest of prostheses. orthopaedists. there is likely to be edema before prosthetic treatment because of the lack of support and pressure for the terminal tissues and the absence of any pumping action by the muscles. 43:56-67. Although these factors may be present in combination. cannot be overemphasized. VERRUCOSE HYPERPLASIA A warty or verrucose condition of the skin of the distal portion of the stump has been seen in many instances. Barnes GH: Epidermoid cysts in amputees. dermatologists. The successful treatment of this disorder again serves as another example of the need for cooperation by various professionals to provide the maximum benefit to the individual amputee. the warty condition was slowly reduced. It was only through trial and error that we found external compression in combination with adequate control of bacterial infection and edema to be the best method of treatment. J Invest Dermatol 1961.26: Skin Problems of the Amputee | O&P Virtual Library In every instance one must ascertain the cause of the stump ulceration and discuss corrective therapy with the amputation surgeon and prosthetist. After several weeks' use of the modified prosthesis.oandplibrary. bacterial infection. However. The patient subsequently died in a matter of months from metastases to the lungs. the verrucose condition disappeared and did not recur as long as the compression was continued. treatments had been of only temporary benefit. A shrinker sock used continuously until prosthetic fitting and thereafter whenever a prosthesis is not employed is distinctly advantageous. This hyperplastic condition appears to be secondary to an underlying vascular disorder related to poor prosthetic fit and alignment and. unsupported tissues. in all other cases the process has been entirely reversible. In our experience. At the best. plays an especially important role. possibly. A squamous cell carcinoma ultimately developed in the distal skin and extended into the bone. It occurs whenever there is an increase of proximal over distal pressure on the tissues. The importance of early recognition and treatment of the common skin disorders of residual limbs. If the amputee is then fitted with a prosthesis that distributes pressure properly.36:165-166. http://www. the more immediate and lasting was the improvement. Through their efforts. we have found only one such instance among numerous patients with verrucose hyperplasia. ). the engineers and prosthetists then modified a prosthetic design to provide backpressure for the tissues at the end of the stump. When support of the end was provided in the socket by means of a temporary platform built up with cushions or compression. In our malignant instance. The disorder has been described by some as the common wart virus invading the skin. Verrucose hyperplasia of the stump skin can be present for months or years and can be associated with ulceration in addition to edema ( Plate 21. Allende MF. the distal part of the stump was edematous and dangled without distal support in the socket.asp[21/03/2013 21:57:03] . In an amputation stump with redundant. Patients with this condition have made the rounds of general practitioners. if his prosthesis produces greater proximal than distal pressures. Many have been treated with topical preparations and by other forms of therapy without effect. References: 1. Philadelphia. therapists. and Plate 22. prosthetists. the edema will subside. 1986.org/alp/chap26-01. Acta Derm Venereol (Stockh) 1963. Levy SW. ). Levy SW. Allende MF. 3. as described in this chapter. The greater the compression on the distal skin. As a result of our investigation. prosthetists. Fisher AA: Contact Dermatitis. while others have thought that the condition was associated with malignancy. and others dealing with amputees. 2. which tends to drive fluids into the distal tissues. Strand D: Immediate post surgical fitting and early ambulation: A new concept in amputee rehabilitation. Wirta RW. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 26 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Clin Orthop 1968. Asbelle C.Atlas of Limb Prosthetics: Surgical. 27:385-396. 5. Philadelphia. 1954. Warren H. Golbranson FL.oandplibrary. et al: Analysis of below-knee suspension systems: Effect on gait. Heinemann. 1986. Prosthetic. 8. Jelinek JE: The Skin in Diabetes. J Rehabil Res Dev 1990. Gillis L: Amputations. Green Inc.org/alp/chap26-01. 1983. Golbranson FL. 6.asp[21/03/2013 21:57:03] . 7.26: Skin Problems of the Amputee | O&P Virtual Library 4. London. 56:119-131. Contact Us | Contribute http://www. Lea & Fe-biger. Levy SW: Skin Problems of the Amputee. Chapter 26 . St Louis. mechanisms affecting the sensitivity of peripheral nerve receptors. The survey of phantom pain treatment methods used by Veterans Administration hospitals. Merkel spots. thermoreceptors. tendon.oandplibrary. personal attention. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. the importance of a specific Although there is no evidence of control situation.Atlas of Limb Prosthetics: Surgical. corresponds with the incidence of phantom pain in the immediate postamputation period but does not correspond to chronic phantom pain. and Iggo corpuscles). reprinted 2002. functional state. Obvious pathomechanical sources of pain such as degenerative arthritis of the knee in a transtibial amputation. edition 2. Ph. Mechanoreceptors and thermoreceptors consist of either free nerve endings or specialized capsulated receptors (Pacini and Ruffini endings. Rosemont. Schnell. The goal of amputation surgery is to remove an often painful. or pain receptors. M. and pain clinics showed that at least 50 different modalities are Only a few of these treatment methods currently utilized for the treatment of amputee pain. of preamputation pain. The thermoreceptors and mechanoreceptors are characterized by a low threshold for certain stimuli. but rather a reaction that involves interpretative processes within the central nervous system. pain is not simply a transmission of a neural message. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). However. An appropriate treatment regimen is dependent on a knowledge of the basic mechanisms involved in both central and peripheral pain. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists INTRINSIC CAUSES OF PAIN Pain Mechanisms Pain is a phenomenon that consists of complex circuits of cellular communication and integration elicited by stimulation of peripheral tissues such as skin. yet personality disorders do not absolutely correlate with the incidence of phantom pain syndromes. Psychiatric factors may amplify amputee pain syndromes.. Prosthetic. For example. functionless limb and to rehabilitate the amputee to a painless.D. Bunch. and Rehabilitation Principles. medical schools. were even moderately successful at long-term follow-up.D. and nociceptors. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. A large variety of surgical and nonsurgical methods exists for the treatment of postamputation pain. American Academy of Orthopedic Surgeons. Prosthetic. ©American Academy or Orthopedic Surgeons. The treatment of chronic pain following an amputation is determined by the etiology of the pain. this pain will gradually resolve. ischemia in the residual limb in a dysvascular amputee. ligaments. which occurs in approximately 80% of patients at some point following a major extremity amputation. The The presence physiologic mechanism for intrinsic stump pain and phantom pain is similar. http://www. differing somewhat from one individual to another as influenced by cultural experiences. You can help expand the O&P Virtual Library with a tax-deductible contribution. or a painful neuroma can be readily treated. For the majority of these patients. a significant number of amputees will have persistent limb pain that interferes with prosthetic usage. Postamputation pain can be isolated to the residual limb or can occur as phantom pain. IL. M. and other cognitive activities. Click for more information about this text. 1992. It is a personal experience.org/alp/chap27-01. joints. Prosthetic. Wilton H. and viscera. especially in dysvascular amputees.D. Several types of peripheral nervous receptors have been identified: mechanoreceptors.27: Management of Pain in the Amputee | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 27 Chapter 27 . The most common factor precluding successful outcome following lower-limb amputation is residual pain.asp[21/03/2013 21:57:09] . Impulses from these lowintensity receptors are carried by large myelinated fibers. Reproduced with permission from Bowker HK. and Rehabilitation Principles Management of Pain in the Amputee Maurice D. oandplibrary. The majority of these axons ascend in the contralateral spinothalamic tract. where they divide into ascending and descending divisions extending over one and two segments and establish synapses with marginal neurons and gelatinosa cells ( Fig 27-2. During the past 20 years investigators have attempted to unravel the complexities of the poorly understood. This system provides rapid transmission of somatosensory information regarding the location of peripheral stimulation in space.asp[21/03/2013 21:57:09] . assessment. IV. it is involved with supra-segmental reflex responses that play a role in respiratory. The neothalamic system is characterized by long fibers that make direct connections to the ventrolateral and posterior parts of the thalamus. Finally. fast-conducting fibers of this system carry information concerning touch. vibration. the dorsal intra-cornu tract.). The long ascending afferent pathways are formed by axons of neurons from laminae I. there is abundant evidence from experimental work that extracellular chemical substances (such as bradykinin. and localization of sensory messages and then modulates. histamine. third-relay neurons project through the internal capsule and corona radiata to the sensory cortex.27: Management of Pain in the Amputee | O&P Virtual Library thermoreceptors have a distinct sensitivity to high and low skin temperatures but can be excited by firm pressure. The large myelinated fibers give off a collateral. the pons. V. Dorsal horn cells are modulated by http://www. This older system has frequent synapses and slow transmission. and proprioception. There is considerable controversy regarding the existence of specific chemoreceptors. The axons of the ganglion cells enter the apex of the dorsal horn of the spinal cord and terminate in a complex array of synaptic arrangements ( Fig 27-1. time. Second-order neurons cross the medulla and ascend in the medial lemniscus to the ventral and medial thalamus. Another important projection system for transmission of pain is the lemniscal system. the sensory input before the action system is activated. and other propriospinal systems may play a role in the transmission of nociceptive impulses. nociceptors have a high threshold to an The two subclasses of appropriate stimulus and a relatively small field of reception. Also. the lemniscal system assists in central analysis. circulatory. The large. The third relay of fibers at the thalamic level is relayed to the postcentral gyrus. It then connects with the medial intralaminar thalamic nuclei and from there to the limbic forebrain. the system sends numerous collaterals to the paleospinothalamic system. deep unpleasant sensation that motivates the individual into action. which enters the dorsal horn and forms synaptic connections with cells and various laminae. The small myelinated sensory afferent fibers proceed into the Lissauer tract. although extremely important inhibitory and facilitory mechanisms of pain acting at all levels of the central nervous system. which represents the primary somatosensory cortex of the brain. The dorsal horn has been divided into six laminae on an anatomic and functional basis. Some fibers arising from lamina V cells enter the dorsolateral and ventrolateral white matter both ipsilaterally and contralaterally to join the spinothalamic tract ( Fig 27-3. Moreover. Although it has only three neurons involved in its transmission. and the midbrain. Sensory input from the periphery is roughly distributed according to fiber size. The spinothalamic system is composed of two divisions: the neospinothalamic tract and the paleo-spinothalamic tract. the spinocervicothalamic system (SCT). and intensity. hypothalamus. nociceptors are thermal nociceptors and mechanical nociceptors. where cell bodies of the afferent neurons are located. It consists of large alpha fibers that enter the dorsal root and pass cephalad through the dorsal columns to synapse with the nucleus gracilis and cuneatus in the medulla. which ascends medially to it. The spinoreticular multisynaptic ascending system. Once depolarization is initiated. it provokes a non-discrete. through corticifugal impulses. On the other hand. and other diffuse areas of the brain. especially laminae II and III. More recently other ascending pathways have been recognized as being important in the study of pain.).org/alp/chap27-01. and prostaglandins) released into extracellular fluid following tissue damage secondary to injury or disease act in some way to produce pain. The paleospinothalamic system is associated with short fibers that project to the reticular formation. the generated action potential flows along sensory nerve fibers to superficial and deep cutaneous complexes and ultimately to the dorsal root ganglion. and endocrine functions of the organism. Information regarding these alternate systems is sketchy. and their precise function in pain has not been described. Although past studies have failed to substantiate unique chemoreceptors. These receptors are terminal endings of small myelinated and nonmyelinated fibers and are activated by intense mechanical stimulation and low (less than 15°C) or high (above 50°C) temperatures.). Functionally. and VI. pressure. Since the phantom sensation is a painless image. supraspinal descending neural systems strongly influence synaptic transmission in the dorsal horn and along the course of the ascending The pyramidal tract. lamina V cells strongly excited by high-intensity thermal and mechanical stimuli. and reticulospinal tract have somatosensory tracts. To summarize. subcutaneous tissue. rubrospinal tract.asp[21/03/2013 21:57:09] . Most amputees are aware of the phantom limb immediately after surgery. Phantom Sensation In 1551. namely.27: Management of Pain in the Amputee | O&P Virtual Library peripheral sensory input. Ambroise Pare first described the phenomenon of phantom limb sensation. The extent to which the more proximal segments of the ablated limb are present varies widely among individual amputees. position. or needles and pins. Lamina I cells are inhibited by stimulation of the sensitive mechanoreceptors and high-threshold afferents near the excitatory receptive field but are In contrast. The presence of this phenomenon is usually described in terms of numbness. pressure. The phantom limb may change in its position and character in response to an external stimulus such as wrapping the stump. the majority of amputees describe their phantom sensations as painless. lamina V cells is produced by stimulation of low-threshold afferents at the periphery of the receptive field. The somatic input is modulated by the gate mechanism before it promotes pain perception and response. Amputees should be warned that in instances of altered consciousness after the use of certain medications or arousal from a deep sleep there may be a momentary tendency to use the phantom limb for weight bearing or external support with the possibility of an associated injurious fall. However. In addition to local and segmental factors that participate in modulation of sensory information from the periphery to the brain. Scientific data Psychological factors play an important role in the total pain experience. viscera. and the type of sensation described differs with each. and other deep Inhibition of structures and are quite responsive to noxious stimuli in their respective field. suggest that various emotional. psychological factors can enhance the transmission of noxious impulses to the brain under certain conditions and consequently increase the severity of the pain problem. In some patients the limb http://www.) is one of the basic pain theories used to explain the complex anatomic and physiologic mechanisms that perform this integration process. Silas Weir Mitchell phantom sensation. in fact. His observations resulted from management of 90 amputees from the 15. Other fibers from each of these structures descend to lower relay stations and influence their transmission. cognitive. the situation is one of convergence. the hand or foot.org/alp/chap27-01. have a wide range of inputs from skin. and control. The neural areas that are responsible for pain perception and responses are only activated when the flow of neural impulses through the gate exceeds a critical level. no treatment is necessary. These sensations seem to vary in intensity in individual patients. His work pointed out that phantom sensation.000 individuals who were estimated to have lost limbs during the conflict. temperature.oandplibrary. and dorsal-column relay station. with its remarkably constant subjective pattern. The descending fibers from the cortex of the brain affect transmission in the thalamus. and affective factors can stimulate areas of the brain that have the ability to inhibit transmission of painful impulses at the spinal cord and various other levels of the neuraxis. The term "phantom sensation" is usually reserved for those individuals who have an awareness of the missing portion of their limb in which the only subjective sensation is mild tingling. consultation with the patient both in advance of amputation and postoperatively is imperative for acceptance of phantom limb sensation as an expected sequela to this type of surgery. reticular formation. It is rarely unpleasant. After wrote a classic essay on his experience with the Civil War (1871). Paradoxically. The degree of modulation by the gate is determined by the relative activity in the large (A ß) and small (A d and C) fibers and the descending influences from the brain. The pattern of the phantom sensation is usually the most distal portion of the limb. use of a postoperative rigid dressing. The gate-control theory proposed by Melzack and Wall in 1965 ( Fig 27-4. or wearing a prosthetic device. muscle. impulses from afferent fibers are not simply transmitted to the brain by a group of spinal cord cells that are specific for each type of afferent receptor. This concept of pain suggests that the substantia gelatinosa in the dorsal horn of the spinal cord functions as a gate-control mechanism that increases or decreases the transmission of neural impulses from peripheral fibers to the central nervous system. been shown to inhibit firing of the cells in the dorsal horn and other parts of the spinal cord. motivational. Rather. interaction. is almost universally a sequela of a major amputation. defecation. A consistent inverse relationship has been demonstrated between stump temperature in a painful stump in comparison to the contralateral asymptomatic limb. sleeplessness.oandplibrary. tendinitis. abnormal sympathetic function. and application of heat with hot packs. tumors. The causal mechanism of phantom pain remains controversial." If phantom pain persists for long periods of time. (2) a burning pain. (2) trigger zones may spread to healthy areas. the trigger zones may spread to other unrelated healthy areas of the body. or pathologic conditions of underlying bone. cramping. Peripheral nerve irritation. yet none of these mechanisms satisfactorily explains the phenomenon of phantom limb pain. a vascular evaluation should be performed. but often the major sensation falls into one of these categories. In addition. In some patients pain can be stimulated by touch or pressing over sensitive areas of the stump called "trigger points. sympathectomy. painful sensations may occur in the phantom limb from immediately after surgery to years later. Certainly one of the more effective adjuncts to the treatment program is extensive use of the prosthesis. They may be episodic or continuous and are variously described as shooting. and emotional stress can elicit painful attacks but are not the primary cause. (3) phantom limb pain is more likely in patients who have suffered pain in the limb for some time. Most of these noninvasive http://www. depression. If the self-sustaining activity reaches a critical level. or crushing. the patient with phantom pain tends to fall into certain broad categories.asp[21/03/2013 21:57:09] . microwaves. joint contractures. thus suggesting some correlation with blood flow. baths. pain results." Melzack has listed four major characteristics of phantom limb pain: (1) the pain endures long after healing of the injured tissues and may last for years. may also decrease the burning sensation of phantom pain. Although the management of phantom pain is exceedingly frustrating. or ultrasound. with telescoping of the segments proximal to the hand or foot. burning. to suggest "that the painful state may be an accentuation or exaggeration of the type of feeling ordinarily experienced in the painless phantom. a burning pain. the task can be made less onerous by a systematic approach to evaluation and subsequent treatment. Thus tingling or pins and needles may become a stabbing type of pain. soft-tissue infection. Emotional disturbances such as anxiety. Especially in dysvascular amputees with chronic stump pain. bursitis. neuromas. Initially. Yawning. vasomotor and sudomotor disturbances. or coughing may suddenly precipitate more severe pain. shooting type of pain. stump wrapping. Recently it has been proposed that there is a central biasing mechanism in which the reticular formation exerts a tonic inhibitory influence (bias) on transmission at all synaptic levels of the somatic projection system. or dependent positioning of the stump. local heat. The pain is usually localized to anatomic regions of the foot or hand because of their greater cortical representation. Exacerbations of phantom pain may be triggered by seemingly innocuous stimuli such as cooling.27: Management of Pain in the Amputee | O&P Virtual Library progressively shortens. and postural or positional abnormalities. temperature variations. and stimulation of these zones will produce pain. short-term treatment of phantom pain may be successful with the usage of certain drugs that increase peripheral blood flow such as (ß-blockers (propranolol).org/alp/chap27-01. Occasionally. the inhibitory influence is diminished. Simple treatment measures that create increased peripheral central input may provide at least temporary partial relief of the phantom pain. When amputation surgery destroys a large number of sensory fibers to the reticular formation. and (4) phantom pain may be abolished by changes in somatic input. micturition. and (3) a sharp. Other treatment modalities include gentle manipulation of the stump by massage or a vibrator. A vascular etiology for certain patterns of phantom pain has long been recognized. The duration of the sensation is a matter of years. The three most commonly described painful sensations are (1) a postural type of cramping or squeezing sensation. Phantom Pain In contrast to phantom limb sensation. Many patients may complain of a mixed type of pain. This results in self-sustaining neural activity at all levels that can be initiated by the remaining fibers. a thorough examination of the stump is mandatory to eliminate other causes of stump pain such as adherent scars. with only rare instances of complete disappearance of the phantom limb. a cramping pain. In 5% to 10% of amputees. and psychological factors all contribute to the pain in some manner. which increases blood flow to a limb. Variation in the degree of discomfort of the phantom sensation led Feinstein et al. vascular insufficiency. including transcutaneous Po2 determinations or Doppler flow studies. In general. The combined use of TENS and appropriate psychotherapy may represent one of the most realistic approaches to the management of phantom pain. they appear to be no more effective than TENS. hypnosis. and lo-botomies. However.asp[21/03/2013 21:57:09] . Although the sympathetic nervous system seems to contribute to phantom pain in some way. all too frequently pain recurs at a later date. The greatest success with sympathetic blockade seems to occur when this type of therapy is instituted soon after the onset of pain. or hypersensitivity to light touch may be relieved for prolonged periods by anesthetic block of the sympathetic ganglia. Since sympathetic activity is not a major cause of phantom limb pain. a recent randomized study of TENS showed no difference in the relief of phantom pain with sham TENS units in comparison to active TENS units during their early postamputee period. but repeat injections of the trigger point can be performed at will with little risk or morbidity to the patient.27: Management of Pain in the Amputee | O&P Virtual Library techniques are easily learned and can be carried out as a home treatment program without expensive equipment. decreased skin temperature. it may reduce the patient's requirement for more potent analgesic drugs. rhizotomies. particularly in view of the associated complaints and risks. surgical removal of a segment of the sympathetic ganglia rarely produces lasting relief of this frustrating pain. However. tractotomies to thalamotomies. Even if this technique is only partially successful. the phantom pain may not be affected. vasoconstriction. Since the equipment is portable. The ultimate treatment program should consist of carefully selected treatment techniques combined with ongoing psychotherapy and counseling. During the repair phase of the nerve the axons lose their architectural http://www. Specific "trigger points" on or near the stump may be injected with local anesthetic agents in combination with aqueous steroid preparations. The Minnesota Multiphasic Personality Inventory is a useful means of evaluating the presence of depression. When considering the multiple treatment modalities suggested for control of phantom pain. it is quite apparent that none of these methods is highly efficacious. prolonged relief of phantom pain is obtained. Surgical procedures for sensory interference range from neurectomies at the periphery. cordotomies. Phantom pain may be controlled or abolished by distraction conditioning. Further exploitation of the inhibitory action of large myelinated afferent fibers in peripheral nerves and the dorsal columns of the spinal cord has been attempted by implantable Although both of peripheral nerve stimulators and dorsal-column stimulators. the success of sympathetic blockade in relief of agonizing phantom pain is unpredictable. the long-term results of these surgical procedures have been disappointing.org/alp/chap27-01. these techniques have proved partially effective in the relief of chronic pain. The intensity of stimulation and the length of each treatment session are individualized. and other personality disorders that may be influencing the degree of phantom limb pain. Therefore the treatment of every amputee afflicted with this difficult problem must be approached on an individual basis. This safe and simple technique of neuromodula-tion is designed to diminish chronic pain through lowlevel stimulation of large myelinated afferent fibers. Transcutaneous electrical nerve stimulation (TENS) has been reported as being successful in reducing phantom limb pain on a temporary basis. Therefore. The use of other than mild analgesic drugs may lead to a serious drug addiction. hypochondriasis. patients are able to treat themselves at home. Neuromas The development of a neuroma is a natural repair phenomenon that occurs in any transection of a peripheral nerve. which does not have the attendant potential surgical hazards. surgical intervention has a well-defined yet limited role in the treatment of chronic amputee pain.oandplibrary. Occasionally. abnormal sympathetic manifestations such as excessive sweating. Interruption of the anatomic pathways of somatosensory input has led to a wide range of ineffective surgical intervention at all neuroanatomic levels. No singular drug has been proved effective in long-term control of phantom pain. respectively. Dorsal root entry zone procedures have shown good results in treating isolated phantom pain but poor results in combined stump pain and phantom pain. Amputees with generalized tender areas in the distal portion of the stump that aggravate phantom pain sometimes obtain excellent and prolonged relief with repeated injections of local anesthetic and steroid preparations. cortical ablation. At times. and other forms of psychotherapy. Unfortunately. Virtually no one now advocates injection of a nerve with noxious substances such as alcohol. Surgeons have varied in their recommendations regarding the handling of peripheral nerves during the performance of an amputation. Radiographs of the distal bones will show patchy osteopenia. By 6 to 9 months after the injury. hyperhidrosis. Some of these neuromas may be more easily handled by a proximal neurectomy rather than an extensive exploration of the stump. Other surgeons add a single ligature placed slightly proximal to the transection of the nerve to control bleeding from the nutrient vessels. These symptoms make wrapping and wound care extremely difficult. Reflex Sympathetic Dystrophy Amputations as a result of trauma. particularly partial-hand and foot amputations. One can only hope that this stage of the process is prevented by prior treatment. relief of the socket will generally alleviate the pain. If a technetium 99m etidronate sodium (ethane-1-hydroxy-l. Similar results have been achieved by producing slow atrophy of the intact nerve above the level of transection. The joints are fixed. and its variants may be considered together as reflex sympathetic dystrophy. relief of pain is quite transient due to the eventual development of a new neuroma. and extreme sensitivity to cold. Moreover. the skin is pale. and erythema. 1-diphosphate [EHOP]) scan is performed. In the early stages the remaining dorsal portion of the limb is swollen.asp[21/03/2013 21:57:09] . and erythematous.27: Management of Pain in the Amputee | O&P Virtual Library parallelism and tend to turn back on themselves and combine with the fibrous repair tissue to form a small enlargement at the distal end of the nerve. followed by its division with a sharp scalpel. Injection of the neuroma site with local analgesics and steroids may alleviate the pain. phenol. warm. Millipore) occluded by a Silastic rod has been recommended. originally called causalgia. http://www.org/alp/chap27-01. Not only has this technique been effective in preventing some cases of recurrent symptomatic neuromas. Since pain relief may be only temporary. cool. Encasement of the nerve stump in a microporous filter sheath (H. This produces vasospasm. and dry. If pain is still a predominant feature. This burning pain. There is a loss of bone substance.A. it is quite likely that it will be persistent indefinitely. and this causes intense discomfort. particularly to light touch. several injections may be necessary before a lasting remission is obtained. Palmar nodules and fasciitis become evident. If the neuroma is located well above the distal end of the stump and is buried in adequate soft tissue. The pressure of the socket wall can be so well distributed over a large surface area of the stump that no symptoms are elicited at the neuroma site. resection of neuromas has failed to yield uniform results. Although surgical excision is the treatment of choice. but it has also decreased phantom limb pain in some patients as well. Prolonged nerve compression is obtained by turning a Silastic rod around the nerve trunk 20 to 40 times. They believe that the ligature per se adds little to the degree of neuroma formation. it will be positive before the bone resorption is visible on plane films. The importance of neuroma formation lies in its size and location. After about 3 months. large neuromas located superficially may not be symptomatic when covered by a carefully fitted prosthetic socket. There is hyperesthesia. Commonly. allowing the nerve to retract several inches above the distal end of the stump. Some adhere strictly to gentle traction on the nerve. The pain impulses to the cortex are amplified. Large neuromas buried in a scar or located in an exposed position may be so symptomatic that the amputee is severely impaired. The cause is thought to be an abnormal prolongation of the normal sympathetic response to injury. the swelling in the remaining digits becomes fusiform. If the prosthesis does trigger discomfort by stimulation of the neuroma. pressure and traction will not be sufficient to produce any local symptoms. may be followed by severe unremitting pain that is entirely out of proportion to the injury or the apparent state of the limb. particularly in periarticular areas.oandplibrary. with up to one third of the inner aspect of the cortex being resorbed. or radioactive isotopes. Fixed contractures are present because of the lack of active motion. increased localized skin temperature. have shown an increase in cutaneous blood flow with a 1.27: Management of Pain in the Amputee | O&P Virtual Library The early treatment is interruption of the abnormal sympathetic reflex. This may be due to cervical disk disease or osteoarthritis and foraminal narrowing. (6) application of heat modalities to involved structures. Passive stretching of the suspected involved tendon should increase the pain significantly if tendinitis is present. Thus any pain in the limb may be immediately associated in the patient's mind with the amputation and the prosthesis.asp[21/03/2013 21:57:09] . and (9) modification of the prosthetic socket to alleviate local pressure to the stump. Pain on the basis of a neurotic syndrome or unresolved anxiety may persist long after the wound is healed and the physician has assumed that the patient has completed the acceptance of amputation. bursitis and tendinitis must be considered in the differential diagnosis of aggravating limb pain. Transcutaneous electrical nerve stimulation has afforded pain relief for patients who have not responded to nerve block. Usually the patient is relatively comfortable in the upright position but has significant discomfort when sitting with the prosthetic foot resting squarely on the floor. Radiographs of the affected limb segment may demonstrate a calcific deposit in some cases of tendinitis. (4) possible rigid dressing immobilization for 14 to 21 days.5°C rise in skin temperature with this technique.org/alp/chap27-01. (8) appropriate analgesic drugs. not all pain has an organic basis. EXTRINSIC CAUSES OF PAIN Lower Limbs Syme Ankle Disarticulation Two common problems that arise in the management of the Syme ankle disarticulate are (1) hamstring pressure when the patient is seated and (2) pain with or without associated skin breakdown over the anterodistal portion of the stump. These need to be remembered and eliminated as the cause. With faulty socket design patients may complain of soreness and pressure over the posterior aspect of the knee. Referred pain from the neck may masquerade as limb pain. This is done by sympathetic blocks such as a stellate ganglion block for the upper limb. These may be repeated daily until the pain subsides. Bursitis and Tendinitis Although uncommon as sources of pain in the amputee. (3) temporary discontinuance of the prosthesis. A large number of upper-limb referred-pain syndromes are entirely independent of the amputation or the prosthesis.5 to 2. slight swelling with mild erythema of the overlying skin. The various vascular and nerve compression syndromes in the neck and axilla are occasionally the cause of pain in an amputee. (7) injection of bursae or tendon sheaths with local anesthetic agents combined with steroid preparations. Cardiac pain may be referred to the limb after an amputation as well as before. Localized tenderness. http://www. Similarly.oandplibrary. and occasional soft-tissue crepitation are signs of possible bursitis or tendinitis. Stilz et al. Finally. Nerve stimulation should be strongly considered for those patients whose pain persists after a stellate ganglion block. The stumps of some Syme ankle disarticulates cannot tolerate full end bearing in the prosthesis. Treatment may consist of any combination of several of the following modalities: (1) elimination of any activity that has produced overstress to the involved tendons or localized trauma to affected bursae. lumbar disk disease may produce referred pain to an amputated lower limb. This is not always the case. In such cases the proximal portion of the socket can be modified similar to a patellar tendon-bearing (PTB) socket with resultant distribution of partial weight bearing proximally. Pain Not Associated With an Amputation The prosthesis draws the amputee's attention to the involved limb. (5) compression of swollen bursae by elastic wraps. (2) rest through reduced use of the involved limb. Lowering the posterior brim of the socket to a point just distal to the center of the patellar bar and increasing the flare of the brim are ordinarily ample to alleviate the hamstring pressure. and there is a color change from light yellow to various hues of green to deep blue. The use of this stocking locates any area of pressure quite precisely. the stump descends too deeply into the socket.If end bearing is a source of limb discomfort. Other careful tests include radiographs of the stump through the socket. superficial skin ulceration may occur. with or without dye contrast medium injected around the stump. When the prosthesis is applied. A clear check socket can be made from a plaster positive mold of the existing socket. If the pressure gradient increases. Also. the prosthesis is applied. there may be palpable bursae over the distal end of the tibia or fibula as further evidence of end bearing. A stump sock is constructed from the basic material and then placed carefully over the stump. If a physical examination is inconclusive and the possibility of end bearing warrants further evaluation. Next. and these forces must be dispersed over a large enough area of the anterior portion of the stump to prevent pain and possible skin breakdown. This system is A more informative test is the use of a Brand micro-capsular stocking. Transtibial (Below-Knee) Amputation Common causes of prosthetic pain in the transtibial amputee are (1) excessive end bearing. a new cast should be taken of the stump from which a new transtibial prosthesis is fabricated. the microcapsules of dye are ruptured. but under conditions of both static and dynamic loading. (5) hammocking phenomenon. The simplest method is to put a small ball of clay in the bottom of the socket and ask the patient to walk. This can be preceded by the use of a second clear check socket to confirm total contact in the new socket. The use of a clear check socket gives similar information. The anterior trim line of the socket must be placed at the level of the inferior pole of the patella to provide an adequate area of interface between the anterior portion of the stump and the front of the prosthesis. and the use of a transparent check socket. The addition of an appropriate number of stump socks to raise the stump from the distal portion of the socket should provide prompt symptomatic relief. High floor reaction forces are generated between heel-off and toe-off. Positive thermograms will demonstrate an increased skin temperature in the area of end bearing. . Repeat thermograms after appropriate prosthetic adjustment should show a reversal of the temperature gradient toward normal at the end of the stump. Evaluating the complaint of pain is simply a systematic process of ruling out each of these causes and then applying the appropriate solution for its correction.asp[21/03/2013 21:57:09] . Although this problem may be temporarily alleviated by adding more socks. but the amount of pressure is only grossly quantified. Excessive End Bearing. (2) uneven skin pressure. Often a callus is located over the distal end of the tibia and/or fibula. and the patient is asked to walk. With increasing gradients of pressure. and then the degree of end bearing can be analyzed by direct visualization and probing the stump surface through multiple holes drilled in the socket distally. Although radiographs provide information solely in a static loading condition. (3) frictional skin loss.27: Management of Pain in the Amputee | O&P Virtual Library Pressure on the biceps femoris and semitendinosus produces hyperemia of the skin in the area of the distal portion of these tendons. The most frequent reason for end bearing is a reduction in stump volume. they are helpful in determining the adequacy of total contact of the socket. thermography. and (6) inlet impingement. Such evidence corroborates the resolution of excessive end bearing as a source of stump pain. (4) loss of total contact. composed of cotton fabric with a polyurethane lining into which encapsulated blue dye has been sprinkled. thermistor studies.oandplibrary. If evidence exists of excessive loading of the distal end of the stump. commonly specific physical signs are present on examination of the stump. other techniques will aid in the diagnosis. This is particularly true if a contrast medium is injected between the interface of the stump and the socket wall. there is a limit to which this http://www. Clay that is severely compressed is a crude indicator of excessive load bearing at the distal end of the stump. The involved skin and tendons are tender to palpation.org/alp/chap27-01. When the patient dons the prosthesis. If the patient is comfortable in standing and walking after adjustment of the socket. and vivid stocking marks will be present. in the long run it is preferable to fit the patient with a new socket. More precise information regarding areas of specific skin loading can be determined by use of a transparent check socket. the intimate contact between the surface of the stump and the socket is altered. Uneven Skin Pressure. If all conservative measures of socket readjustment fail. -A common problem produced by an ill-fitting socket is uneven distribution of skin pressure over bony prominences. The first step in evaluating this problem is checking the relative lower-limb lengths by comparing the level of the iliac crests in the standing position. the patient is usually very specific about areas of tenderness and can point directly to the involved area. distal pole of the patella. the problem is both identified and resolved. superficial skin ulceration or blistering may occur. This phenomenon is predominantly seen in new amputees. Even with minimal skin changes. a large number of stump socks are being worn. the redness will persist for several minutes to several hours after removal of the socket. Even minor distal displacement may apply forces of a higher magnitude over various surface contours. weight gain. involved areas are the head of the fibula. this may indicate that the stump is not in the socket to the proper depth. Although this skin has good capillary refill. increased stump growth.oandplibrary. the benefit in regaining improved socket fit through this technique may be offset by problems produced by increased skin pressure at the level of the adjustment pads. the stump may be in the socket to the proper depth. If the skin has resisted breakdown. skin redness. Possible underlying pathomechanics include (1) highly localized shear forces to skin over bony prominences. The use of a microcapsular stocking will dramatically outline the areas of increased pressure. If the patient's socket is too tight as a result of increased stump volume or limb growth. With higher pressure gradients. If the patient is using a socket liner. and increased stump volume due to muscle hypertrophy.27: Management of Pain in the Amputee | O&P Virtual Library solution may be used. and distal ends of the fibula and tibia. localized tenderness. ridges or indentations in the skin from the weave of the stump sock material may be present in areas of high pressure. (3) obstruction of venous and lymphatic outflow with vertical positioning of the limb and resultant localized edema blebs in regions of secondary healing. Frictional Skin Loss. In amputees who persist in walking despite considerable discomfort. On physical examination there is significant erythema of the skin overlying involved bony prominences. A large number of stump socks will cause increased pressure on the stump at the inlet of the socket and may further complicate the existing problem by producing choking of the stump or skin pressure problems at the proximal end of the stump. Other causes of uneven skin pressure include excessive use of stump socks. or edema. With a reduction in stump size secondary to the loss of edema. The distal portion of the stump may have chronic lymphedema with associated generalized rubor. Occasionally. An easy therapeutic as well as diagnostic tool is reduction of the thickness of the socket wall in areas of skin discoloration and pain. muscle atrophy. Radiographic studies are seldom necessary in this situation. Fluctuating stump volume is a major cause of unequal skin pressure distribution. unless the examiner is concerned about the adequacy of total contact at the distal end of the stump. or excessive weight loss. Again.asp[21/03/2013 21:57:09] . fabrication of a new total-contact socket may be the only solution. or (4) the presence of an extension contracture of the knee. Frequently. http://www. tibial tuberosity. Unless the problem is easily resolved. the condyles of the tibia may show evidence of increased soft-tissue pressure. The stump socks will elevate the stump from the socket with resultant loss of distal stump contact and alteration in the interface between the contours of the socket and stump surface. both of which are secondary to choking because of the tight fit at the inlet of the socket.-Superficial frictional blisters are a deterrent to prosthetic comfort and effective gait training. Thus the stump may shift slightly distally in the socket. If the patient is long on the prosthetic side. the skin may have a deep violaceous color and be tender to palpation. but the anteroposterior or mediolateral diameters may be very snug. exterior pads may be added at various locations on the liner to compensate for the stump volume loss. (2) immature epithelium in areas of secondary healing of the surgical incision. Frequently. Removing a few of the stump socks might correct this misfit and substantially relieve the patient's discomfort during standing and walking. With the use of multiple stump socks.org/alp/chap27-01. the area of involvement may respond by formation of a callus or corn. This error can be compounded by inaccurate placement of the pivotal axis for the suspension straps on the medio-lateral aspect of the socket. choking of the stump may occur with gradual development of lymphedema in the lower portion of the stump. Hammocking Phenomenon.org/alp/chap27-01. but frustrating problem is the http://www. The skin appears thin. The first step in the remedy of this condition is removal of the ill-fitting socket and application of appropriate topical treatment combined with continuous stump wrapping. Despite extensive efforts toward excellent stump compression and judicious inspection of the limb during gait training. Range-of-motion and muscle strengthening exercises should be carried out at the knee and hip. one can determine the tightness of the anteroposterior diameter.asp[21/03/2013 21:57:09] .-Satisfactory total contact over the distal portion of a stump is difficult to maintain when stump shrinkage or loss of weight occurs. ulceration over the anterodistal surface of the stump should direct the clinicians attention to careful scrutiny of the anteroposterior diameter of the socket in the standing and sitting positions. In individuals with vascular insufficiency. Slight alteration of socket fit due to increased stump volume is a common cause of this type of skin breakdown. If the anteroposterior diameter of the socket is too large. Consequently. a new total-contact transtibial socket should be prescribed. and again. With reestablishment of proper limb volume and healing of the stasis ulcer. if the condition is not recognized and treated. the combination of increased skin compression over localized areas of the stump surface along with alteration of socket fit and possibly greater shear stress secondary to piston action of the socket resulting from inadequate suspension will produce a friction blister or ulcer. While the patient is seated. The lesion may be surprisingly devoid of significant tenderness.oandplibrary. the anterior wall of the socket can be forced backward against the front of the stump. or moving the foot forward. a firm heel wedge is used. the forces against the anterodistal stump surface are significantly increased. During this time proper stump wrapping must be done continuously. Subsequently. and immature. the skin takes on a characteristic hypertrophic Assuring called verrucous hyperplasia. shiny. during sitting the anterior wall of the socket will displace forward from the anterior surface of the stump and generate increased compression and shear forces over the anterodistal portion of the stump.27: Management of Pain in the Amputee | O&P Virtual Library Physical examination reveals a superficial blister or shallow ulcer with surrounding erythema. At the same time the location of the pivot point of the suspension system should also be checked. If the posterior trim line is too high or there is an extension contracture of the knee. Any design discrepancies of the socket should be corrected before the patient returns to walking.-A somewhat uncommon. In the early stages of gait training recent amputees have difficulty controlling the forces If a prosthetic foot with against the stump by proper coordination of knee and body action. progressive lymphatic and venous outflow obstruction may produce a stasis ulcer at the distal end of the stump. Improper socket fabrication can create skin breakdown. The use of multiple stump socks to maintain a proper fit at the inlet of the socket is insufficient to regain total contact over the lower portion of the stump. Loss of Total Contact. In some instances. The occurrence of a blister or ulcer should signal the discontinuance of the prosthesis until the lesion is healed. particularly those with diabetes mellitus. The patient may complain of excessive tightness about the knee while still feeling looseness in the distal portion of the socket. the stump will be levered upward from the distal end of the socket. Among new amputees variability in stump volume from day to day is a constant hazard. Failure to recognize this condition and to take appropriate corrective steps will only lead to gradual worsening of the soft-tissue ulceration. and it is sometimes difficult to detect. Provided that stump volume control is not a problem. prosthetic training can be initiated with skin inspection at frequent intervals and graduated periods of stump loading until skin tolerance is achieved. By placing a hand inside the posterior wall of the inlet. Chronic edema encourages the development of stasis pigmentation and hemorrhagic papules and nodules of the distal portion of the stump. With closure of the lesion and gaining control of the stump volume. However. The resultant discomfort and potentially hazardous skin pressures can be corrected by switching to a softer heel wedge. increasing plantar flexion of the foot (or extension of the socket). the lesion will increase in size and be accompanied by progressive discomfort. The transient change in socket fit is subtle. the end of the stump may be thrust forward against the anterior socket wall as the patient attempts to control the prosthesis at heel strike with active knee extension. development of a skin blister or small ulcer is likely to occur even under the supervision of an experienced prosthetic team. asp[21/03/2013 21:57:09] . even sitting may produce ischial symptoms. (7) pressure from a high anterior wall. Any decrease in stump volume that allows greater distal displacement of the stump results in increased compression and shear forces over the ischial tuberosity. The amputee complains of tenderness and chafing of the skin behind the knee and in the region of the biceps femoris or semitendinosus tendons. discomfort may result from pressure being applied against the hamstring tendons or the skin of the popliteal area with increased flexion of the knee. a new total-contact transfemoral suction socket should be prescribed.org/alp/chap27-01. The combined effect of the tight sock and stump edema is significantly increased compression and shear forces over the posterior flap that may produce a skin ulcer. Lowering the ischial seat or increasing its radius may produce effective results for some patients. (6) excessive end bearing. The definitive solution is refitting the amputee with a new total-contact socket with proper dimensions. (2) adductor roll. The skin may have a superficial ulceration where the pressure is maximal. (4) malalignment. The diagnosis is self-evident by inspection of the relationship of the posterior aspect of the socket with the back of the knee and hamstring tendons as the knee is flexed.oandplibrary. First. The discomfort is made worse by sitting or excessive bending of the knee. In the case of a suction socket the prosthetist may apply a liner pad along the interior of the posterior wall that will tighten the anteroposterior diameter and accomplish the same purpose. If the increase in pressure is gradual. because of snug anteroposterior and mediolateral diameters at the midportion of the socket. Transfemoral (Above-Knee) Amputations Prosthetic causes of pain in the transfemoral amputee include (1) excessive pressure on the ischial tuberosity. the stump sock is suspended at this level as the prosthesis is donned. Excessive Pressure on the Ischial Tuberosity. When the pressure over the tuberosity is marginal. Checkout of the socket fit reveals no obvious problems except firm contact of the ischial tuberosity against the ischial seat.27: Management of Pain in the Amputee | O&P Virtual Library development of localized skin abrasion or ulceration produced by the hammocking effect of a stump sock. As in the transtibial amputee. or unsatisfactory http://www. Further corroboration of ischial seat pressure can be demonstrated with the use of a microcapsular stocking or thermography. However. the involved skin will respond by forming a typical callus. increased stump volume. If these simpler measures fail. When the patient is asked to stand with full weight bearing on the contralateral limb and then to shift the weight gradually onto the prosthetic side. Second. Inlet Impingement. -With improper stump wrapping. and Silastic foaming of the distal aspect of the socket. The patient often finds that he can obtain transient relief of his discomfort by sitting or lying down. Physical examination reveals redness and chafing of the skin along the course of the involved tendon and associated point tenderness. The unusual location of this ulcer should be a clue to its possible cause. This peculiar problem is the result of two major factors. if the ischial seat is too wide. A temporary solution to the problem may be obtained by altering the anteroposterior and mediolateral diameters of the socket. More definite proof of the cause can be obtained by radiographs through the socket and the use of a clear check socket taken from the existing prosthetic socket. -If the posterior trim line of a transtibial socket is too high posteriorly or the channels for the biceps femoris and semitendinosus tendons are inadequate. (3) choking. the degree of compression against an examining finger between the tuberosity and the ischial seat is obviously high. -Improper design of the ischial seat may result in significant discomfort with either standing or walking. one must systematically eliminate each of these problems as the cause of the patient's complaint. Consequently. Elimination of the source of the problem can be achieved by lowering the posterior trim line or deepening the channels for the hamstring tendons. (5) inlet impingement. the posterior side of the stump sock is drawn tightly against the distoposterior aspect of the stump. Localized tenderness and skin changes ranging from hyperemia to frank skin breakdown are the hallmark of ischial seat pressure. Adductor Roll. Edema gradually develops in the lower portion of the stump with use of the prosthesis. the addition of more stump socks will elevate the stump slightly and distribute some of the load bearing to the surrounding gluteal musculature. and (8) a high medial wall. there is a lack of total contact over the distoposterior aspect of the stump. the use of a Daw nylon sheath. A combination of correct stump wrapping with modification of the prosthetic socket is quite likely to resolve the adductor roll problem. the iliac crest on the involved side is higher than on the contralateral side. The size of this roll may eventually prevent the amputee from donning the prosthesis properly. weight gain. the definitive solution is fabrication of a new socket. thus creating pelvic obliquity. Examination following removal of the prosthesis reveals a somewhat firm. The socket fit is nearly always satisfactory. the skin may show typical stasis changes that eventually lead to verrucous hyperplasia. he must incline the trunk laterally over the prosthesis to shift the weight line closer to the support line. If the roll is excessive.27: Management of Pain in the Amputee | O&P Virtual Library socket fit. If confirmation of the loss of total contact is necessary. Seldom is a clear check socket necessary. The adductor roll is easily felt on the inside of the stump above the brim of the medial wall. Often there is associated brawny edema of the distal end of the stump with early stasis changes of the skin because of the loss of total contact distally. the patient may complain of progressive pain and soreness over the distolateral aspect of the stump. If the roll is small.asp[21/03/2013 21:57:09] . and foaming the lower end of the socket to regain total contact. or a microcapsular stocking are helpful techniques. His base of support may be widened by abduction of the hip as well. may develop high on the medial aspect of a transfemoral stump. To alleviate the concentration of forces in this area during walking. the lateral wall must be precisely contoured to evenly distribute the socket pressures over the largest possible surface area during midstance. Palpation confirms the position of the ischial tuberosity well above the ischial seat. socket relief. Malalignment. If these measures are only partially effective. the ipsilateral iliac crest is elevated. use of a pull-through sock. or vaulting on the intact limb. http://www.-Constriction of the proximal portion of a transfemoral stump impedes venous and lymphatic outflow from the remainder of the stump. Or the patient may walk with the limb in abduction to reduce the medial wall pressure against the adductor roll. and a possible adductor roll. improved stump wrapping. Examination of the stump reveals no striking features except for varying degrees of skin erythema and localized tenderness in the area of increased pressure. and the patient walks with some type of gait deviation such as abduction of the hip. Despite careful socket design. a horizontal bulge of soft tissue. Almost inevitably the stump is riding partially out of the socket. it is preferable to fit the amputee with a new total-contact quadrilateral socket and anticipate the fabrication of a second socket at a later date as the proximal end of the stump changes shape. When standing. Therefore the ischial tuberosity is well above the ischial seat. Inspection of the inferior margin of the roll may reveal considerable erythema but rarely any evidence of superficial ulceration. musculoskeletal growth. Excessive use of stump socks. radiographs through the socket. If severe. a clay ball compression test. the patient may complain of pain and tenderness along the inferior border of the roll due to impingement against the upper edge of the medial wall of the socket. When adductor roll is extensive.org/alp/chap27-01. Usually careful assessment of the amputee while wearing the prosthesis will suffice in elucidating the nature of the problem.-In the short transfemoral amputee. Choking. and limb swelling are some of the causes of stump choking. drilling a hole in the distomedial aspect of the socket and using a pull-through sock to advance the proximal stump tissues into the socket will compress the roll against the medial wall. circumduction of the prosthesis. Resultant stump abnormalities include the absence of stump sock markings over the distal part of the stump.oandplibrary. tender roll of soft tissue with a horizontal orientation in the adductor region of the thigh. Subsequent atrophy of the roll provides an improved socket fit. Also. Stasis ulceration may be a late-stage sequela. the degree of adduction of the lateral wall should be as much as conditions permit. or adductor roll. An adductor roll causes a relative lengthening of the prosthetic limb and a variety of gait deviations. The resolution of choking should be approached initially by improving the socket fit through removal of unnecessary stump socks. but it is rather uncommon. Use of a microcapsular stocking or thermography are the most practical means to verify the increased local pressure to the stump. along with associated palpable edema. generalized skin redness. The patient may be forced to circumduct the prosthesis or vault on the opposite lower limb to clear the foot during swing phase. The physical findings are comparable to those of a transtibial stump. varying degrees of tenderness in the areas of pressure. the socket fits well otherwise. and (3) gait abnormalities consisting of a rapid swing phase with reduced stride length of the uninvolved limb and a shortened stance phase on the prosthetic side. -As in the transtibial amputee. an obese transfemoral amputee with a protuberant abdomen or massive pan-niculus may experience pinching of lower abdominal soft tissues with sitting or bending over. Inlet Impingement. With this modification the patient is frequently relieved of his pain. Patients with minimal end bearing may be more accurately diagnosed by a trial of additional stump socks. a clay ball compression test. Relief of the distal end of the socket and lining the socket to decrease the anteroposterior and mediolateral diameters may suffice in moderate cases.3 to 0. Customarily. the amputee will develop pain and tenderness in the region of the origin of the adductor muscles as well as along the pubic ramus. The rate and magnitude of stump volume loss determine the degree of pain and associated soft-tissue changes in the distal end of the stump. The patient compensates for these changes while walking by http://www. The stump is able to descend deeper into the socket since all total contact with the socket surfaces has been lost. or too much length of the medial wall. localized soft-tissue tenderness.27: Management of Pain in the Amputee | O&P Virtual Library Alignment adjustment through reducing the adduction of the socket and out-setting the prosthetic foot usually eliminates this problem. However.org/alp/chap27-01. In more advanced circumstances the best remedy is fabrication of a new total-contact socket. callus formation. Ordinarily. With the prosthesis removed. Any associated skin ulceration can be treated with appropriate topical care and stump wrapping. microcapsular stockings. When the patient sits or leans forward. This finding should suggest the cause of the patient's complaints. flaring the margin of the brim generously. -In a properly fitted quadrilateral socket essentially no weight should be borne by the medial wall. This is accomplished by building the anterior brim 5 to 6. it is usually 0.) higher than the ischial seat. The underlying bursitis often responds to the relief of socket pressure and stump wrapping. (2) displacement of the ischial tuberosity forward and distal to the seat. Aspiration combined with injection of a local anesthetic agent and a corticosteroid preparation administered under sterile technique will often eradicate a more persistent bursitis that has failed to respond to noninvasive treatment. namely. A diagnostic as well as treatment method consists of routing the adductor channel to increase its size. With pelvic tilt. Pressure From a High Anterior Wall. the high front does not interfere with sitting or bending over.) lower than the ischial seat. the stump may be evaluated both visually and manually. the reduction of stump volume or a significant drop in body weight will change the socket fit dramatically. In suction sockets or sockets with openings for pull-through socks. and bulging the inner wall of the brim in the area of Scarpa's triangle. Judicious lowering of the anterior wall and increasing the flare of the brim usually provide prompt relief. provided that there is no contact with bony prominences of the pelvis and a channel is provided for the rectus femoris muscle. the only localizing signs are erythema of the skin. socket radiographs. -The purpose of the anterior brim of the socket is to maintain the ischium in proper relationship to the ischial seat to prevent discomfort with ischial weight bearing. This occurs when the adductors are impinged by a narrow adductor channel of the socket. The addition of more stump socks may be the only treatment required in amputees with mild end bearing. excessive adduction of the socket. The upper third of the medial wall should be flattened and the superior brim flared to prevent skin irritation. Physical examination rarely demonstrates any evidence of change in the stump except for point tenderness over the adductor longus and gracilis.asp[21/03/2013 21:57:09] . hyperemia of the skin with possible bursitis over the distal third of the femur.oandplibrary. It is rare to have any difficulty with standing or walking. palpation demonstrates high compression against the lower abdominal tissues. and occasional superficial ulceration. -An occasional source of pain in the anteromedial aspect of the transfemoral stump is irritation of the upper portion of the adductor longus and gracilis muscles.6 cm (1/8 to 1/4 in. In the small number of amputees who are greatly disabled by chronic bursitis. and occasional small hemorrhagic lesions secondary to contusion of the skin.5 cm (2 to 2½ in. High Medial Wall. Positive physical findings include (1) relative shortening of the prosthetic limb. surgical excision may be necessary. Excessive End Bearing. Although the medial wall should be as high as tolerated. or a clear check socket. and possible restriction of proximal joint motion are only a few of the reasons for prosthetic failure. the patient with a hand amputation complains of discomfort. Careful inspection and palpation of the involved hand provide sufficient information to estimate the probable skin tolerance to compression and shear stress from a proposed prosthetic device. all partial-hand devices used in a cold environment should be constructed of material with poor thermal conductivity and lined with a synthetic substance with excellent insulation properties. the distal end of the stump tends to rotate independently of the prosthetic wall during pronation http://www. useful function must be made by the attending surgeon during initial treatment. etc.oandplibrary. thus adding another factor that enhances hand impairment. inadequate device suspension. and inlet impingement. poor skin coverage and diminished epicritical sensation further complicate functional retraining of an injured hand with or without a special device.27: Management of Pain in the Amputee | O&P Virtual Library maintaining a wide base of support by abduction of the hip during both stance and swing phase. In general. or comparable materials that will protect the damaged skin surfaces. and the difficulty of fitting the patient with an appropriate orthotic or prosthetic device is definitely magnified. functionless hand with subsequent replacement by a well-designed prosthesis is welcomed by most patients. These vasomotor and sudomotor disturbances are similar to those of sympathetic reflex dystrophy. surface friction characteristics. noncompliant scar is unyielding to shear forces that produce definite skin tenderness and discomfort with possible associated skin breakdown.org/alp/chap27-01. digits afflicted with post-traumatic vasomotor changes secondary to altered sympathetic innervation can be detrimental to patients because of episodic pain associated with increased cold sensitivity. Pelite. Massive damage to joints and their related tendons may virtually ensure extensive permanent functional loss and pain since associated vascular and neurologic recovery of the hand is marginal at best. Should reflex sympathetic dystrophy or cau-salgia develop. Upper Limbs Partial-Hand Devices Strict adherence to the surgical dogma of preserving all possible segments of an injured hand may result in chronic pain compounded by significant functional problems. reduction of sensory feedback. and excessive sweating. For example. after prosthetic fitting. Worse yet. Wrist Disarticulation Almost without exception the major reason for pain in individuals wearing a wrist disarticulation prosthesis is irritation of the soft tissue over the ulnar and radial styloid processes. If. With any reduction of total contact in the region of the distal radioulnar joint. To maximize the rehabilitation process of an injured hand. The painful hand with increased cold sensitivity often manifests coolness. A tethered. Relief is provided by lowering the medial wall and flaring the superior brim. malalignment.). Unfortunately. Summary The major prosthetic causes of pain in the lower limb are volumetric changes. partial-hand prostheses have satisfied neither the cosmetic nor the functional needs of the hand amputee. Assessment of the adequacy of skin coverage is simple but absolutely essential. Characteristic signs of Raynaud's phenomenon may be elicited by exposure of the hand to a cold environment. critical decisions regarding the preservation of those segments of the hand that have a reasonable likelihood of regaining nonpainful. If the patient fails to make satisfactory progress during the rehabilitative period. cyanosis.. polyurethrane.asp[21/03/2013 21:57:09] . every effort should be directed toward evaluation and elimination of all potential pain sources. Furthermore. edema. durability. the recovery of hand usefulness is obstructed. strength. consideration should be given to secondary reconstructive surgery that would involve a higher functional amputation. These amputees should be instructed to avoid any exposure of the hand to environmental temperatures below 10°C without an insulated glove. Faulty design. the device should be lined with Plastazote. Removal of part or all of a painful. If it is questionable whether the skin can tolerate such forces directly. thermal conductivity. insufficient venous and lymphatic drainage creates chronic swelling of the hand. poor material properties (weight. Comparison and contrast are best summarized in Table 27-1. the use of a microcapsular stocking may demonstrate increased localized pressure in the region of the ulnar and radial styloids. Detection of the source of pain and irritation is often a simple matter of careful inspection of the distal end of the amputation stump. a new total-contact socket is required. however. Amputees with acquired short transradial stumps are vulnerable to high compression and shear forces across the anterodistal aspect of the stump when lifting heavy loads with the elbow in a flexed position. Conditions are only made worse by (1) poor total contact of the socket distally as a result of stump shrinkage. increased forces over the distal end of the stump create painful pressure symptoms that reduce the functional efficiency of the amputee. Foaming of the distal end of the socket with Silastic to regain satisfactory total contact is usually adequate in relieving this problem. socket radiographs. (2) choking of the stump. and occasionally a skin ulcer. which is critical to the preservation of forearm pronation and supination. The proximal portion of the stump may have http://www. socket relief distally or foaming the end of the socket with Silastic may eliminate skin pressure. In certain patients. tenderness of the distal end of the stump. or thermography to determine the nature of the patient's complaints. In those few patients with chronic skin problems despite frequent adjustments and redesigning of the wrist disarticulation socket. Seldom is it necessary to use a microcapsular stocking. A lack of total contact may result in edema and induration of the distal portion of the stump as well. (2) inadequate soft-tissue coverage over the distal end of the radius and ulna. As a result. Careful inspection of the stump localizes the area of increased skin pressure. The torsion of the prosthesis creates a high shear force across the skin in the region of the radial and ulnar styloid processes. repetition of these forces across the involved skin produces reactive hyperemia. There may be generalized reactive hyperemia of the skin of the stump. the symptoms and signs are similar-localized stump pain.27: Management of Pain in the Amputee | O&P Virtual Library and supination of the forearm. This leads to elevation of the distal portion of the stump from the end of the socket and obstructs venous and lymphatic outflow from the stump because of constriction of the proximal portion of the stump. With increased circumference and length of the stump. Treatment should be directed initially toward healing the skin ulceration and reduction of stump edema if present.org/alp/chap27-01. If the volumetric loss of the stump is high. Transradial amputees with stump soreness will often increase the number of stump socks to relieve pressure against the end of the stump. in the detection of offending osteophytes or excessive appositional bone growth in the juvenile amputee. and (3) inlet impingement. and (3) osteophyte formation or apposi-tional bone growth of the forearm bones. Roentgenograms of the stump are valuable. localized soft-tissue tenderness. The juvenile amputee is faced with periodic loss of socket fit as a result of musculoskeletal growth. the socket is too small to accept the entire stump. In the presence of adequate skin flaps. resection of prominent ulnar or radial styloids can be accomplished without the loss of important radioulnar joint motion. Recognition of an improper socket necessitates replacement with a properly fitted one.asp[21/03/2013 21:57:09] . Transradial (Below-Elbow) Amputation Three frequent causes of pain in the transradial prosthetic wearer are (1) pressure over the anterodistal end of the stump. clear check sockets. Next. reactive hyperemia of the skin. Seldom is it necessary to resort to radiographs through the socket. possible presence of an underlying bursa. The resultant choking of the stump is painful and may produce skin changes of the distal end of the stump. Whatever the cause. relief in the area of skin pressure provides an easy solution. surgical revision of the stump may be necessary. When the problem may be the result of increased soft-tissue edema or a tight distal socket. The lower portion of the stump is swollen and tender. In addition to localized pain. or thermograms. and possible skin ulceration. With the artificial limb applied. it is preferable to fabricate a new wrist disarticulation socket. If localizing signs are scant. Inspection of the stump reveals an absence of sock markings over the distal portion of the stump. strong resistance during elbow flexion will usually produce discomfort at the distal end of the stump.oandplibrary. the magnitude of forces applied to the anterodistal aspect of the transhumeral stump is significantly increased with progressive loading of the prosthesis. it may be necessary to resort to continuous wrapping for a few days. However.oandplibrary. or fabrication of a new socket. Stump revision may be required in the presence of poor skin coverage. with further bony overgrowth. As discomfort increases. or increasing the anteroposterior diameter of the inlet will eliminate the pressure problem. Since appositional bone growth is unrelated to epiphyseal growth. confirmatory tests with a microcapsular stocking. removal of an existing socket liner and/or deepening of the end of the socket will provide temporary help. Careful physical examination is usually adequate to identify the cause of the problem. and this indicates a loss of socket fit. A Minister socket may produce impingement of the humeral condyles or the olecranon during the application of a vertical traction force with the elbow flexed to 90 degrees or with the elbow in maximum extension. its use has not been widespread. However. some amputees find that with active flexion of their elbow they feel pressure over these bony prominences. satisfactory total contact and stump protection can be obtained by foaming the socket with Silastic. total contact is poor. Removal of some of the stump socks will often achieve an improved fit of the socket. Failure to diminish elbow impingement by means of socket adjustments dictates fabrication of a new socket in greater extension. In the short transhumeral amputation. routing the socket walls will aid in opening the inlet. This leads to localized pain and skin changes that usually can be corrected by socket relief or alteration of trim lines without sacrificing good socket suspension. If necessary.org/alp/chap27-01. the symptoms and physical findings of the involved stump are identical with high soft-tissue forces over any bony prominence. Soon skin changes appear and may be accompanied by a swollen bursa over the end of the bone. Shoulder Disarticulation Achievement of proper prosthetic suspension and total-contact fit of the socket is difficult in the shoulder disarticulation amputee.27: Management of Pain in the Amputee | O&P Virtual Library stump sock indentations indicating increased skin pressures. This condition tends to recur periodically so that the child is likely to have several surgical procedures until reaching skeletal maturity when general bone growth ceases. Now the treatment of choice is surgical revision of the stump. heating and rolling the brim edges. or radiographic studies can be performed. which includes excision of the bony overgrowth and removal of any bursa. the anteroposterior walls of the socket must be extended medially over a large portion of the shoulder joint to provide rotational stability. the child periodically removes the prosthesis or refuses to wear it at all. However. Associated pain when wearing the prosthesis interferes with its optimal use. With elimination of the edema of the stump. foaming of the distal end of the socket to regain total contact. A Silastic bone plug has been recommended to prevent recurrence of appositional bone growth. or extreme softtissue redundancy. Children with acquired transhumeral amputations are plagued by troublesome appositional bone growth of the humerus. If the stump is quite short. Early in the evolution of the problem. Prosthetic solutions include relief of the distal portion of the socket. If a tight inlet is responsible for choking the stump. epiphy-siodesis is absolutely contraindicated. bony overgrowth of the humerus. excessive traction in the extended position would be expected to produce some discomfort over the humeral condyles or olecranon with high axial loads. thermography. Transhumeral (Above-Elbow) Amputation As in the transradial prosthesis wearer. Combined high compression and shear forces generated over the tip of the acromion cause localized pain and concomitant http://www. The gradual lengthening of the humerus compresses the skin over the distal end of the bone against the bottom of the socket. If edema prevents continued use of the socket. Altering the trim lines. or soft-tissue coverage of the stump is less than optimal.asp[21/03/2013 21:57:09] . the amount of stump change exceeds the improvement obtained with socket adjustments. Since this type of socket must be designed with restriction of complete extension of the elbow to maintain adequate suspension. The weight of the prosthesis tends to create a downward displacement and rotation over the acromion. With the prosthesis donned the olecranon lies above the trim line of the posterior aspect of the socket. Excessive tightness of the anteroposterior diameter of the medial portion of the inlet will produce pressure against the skin along the edges of the socket brim. Postgrad Med J 1976. in Bonica JJ (ed): Advances in Neurology. Raven Press. clinical characteristics and relationship to preamputation limb pain. 128:314-324 8. Anesth Analg 1977. periodic checking of socket contact with the thoracic wall. Langton JNK: The influence of phantom limbs. Clin Orthop 1977. and alteration of the suspension system. Arch Surg 1977. Brand PW. Bonica JJ: Neurophysiologic and pathologic aspect of acute and chronic pain. McGraw-Hill. in Tanzen R. 112:750-761 4. 34:707-710 10. in Bonica JJ. Hampton FL: Prosthetic principles in the lower extremity amputee. 151:109-116 5. Ami Sci 1973. 61:194-200 7. References: 1. Persen L. 1974 6. Orthop Clin North Am 1970. thus making the soft-tissue pressure more tolerable. Lining the involved portion of the socket wall with Plasta-zote. 1954. or musculoskeletal growth can be managed by socket relief. Neurosurgery 1987. vol 1. Adjustment or redesigning the suspension system will also reduce the rotary action of the socket. The use of the lightest possible prosthetic components minimizes the downward displacement of the device. Jensen T. 70:109 11. Linford J. socket lining. and contouring the socket wall to accommodate uneven bony prominences and bulky soft tissues is most difficult. 3:339-347 14. International Book Co. Keide WD. Pain 1985. Casey KL: Pain: A current view of neural mechanisms. pp 75-89 http://www. et al (eds): Pain. Frazier SH. et al: Psychiatric aspects of pain and the phantom limb.asp[21/03/2013 21:57:09] . New York. Ersek RA: Transcutaneous electrical neurostimulation: A new clinical modality for controlling pain. Ferguson JP. base of the neck. New York. Charles C Thomas Publishers. Iacono R. 21:267 19. Krebs B. or similar synthetic materials distributes the forces over a larger skin surface area. 1972 17. Williams & Wilkins. Springfield. Nielsen J. J Bone Joint Surg [Am] 1969. Bonica JJ: Causalgia and other reflex sympathetic dystrophies. Ebner JD: Pressure sensitive devices for denervated hands and feet. Finsein V.9:4-13 12. Albe-Fessard D (eds): Advances in Pain Research and Therapy. 11:88-112 15.27: Management of Pain in the Amputee | O&P Virtual Library skin changes. Smyth GE: Phantom limbs. 56:842-846 2. in Bonica JJ. Iggo A: The case for "pain" receptors. Wilson PD (eds): Human Limbs and Their Substitutes. Meticulous socket design usually minimizes soft-tissue pressure problems over the anteroposterior aspect of the shoulder girdle. or increased socket dimensions by routing the socket wall. Procacci P. Luce JC. Kerr FWL: Segmental circuitry and spinal cord nociceptive mechanisms. Baltimore. 1972. Lining the socket wall with compliant synthetic materials improves soft-tissue pressure distribution. 53:143-148 3. pp 60-61 18. Sandyk R: Pain management after lower extremity amputation. and opposite shoulder region. Considerable prosthetic discomfort may usually be prevented by adjustments of the trim lines. J Bone Joint Surg [Br] 1988. vol 4. New York. Raven Press. Henderson WR. J Neurol Neurosurg Psychiatry 1948. Herz A. Suspension problems with this type of prosthesis are immense.oandplibrary. Carron H. et al: Neurosurgical management of intractable pain. Pain. Forequarter Amputation Most of the discomfort associated with fitting a fore-quarter prosthesis is caused by uneven distribution of soft-tissue pressure. Lvlien M: Transcutaneous electrical nerve stimulation after major amputation. Blankenbaker WL: The care of patients with phantom limb pain in a pain clinic. Feinstein B. 20:496 16. Pugni CA (eds): Recent Advances on Pain: Pathophysiology and Clinical Aspects. Ill. Weller RM: Treatment of post traumatic sympathetic dystrophy. Iggo A: Pain receptors. et al: Immediate and long term phantom limb pain in amputees: Incidence. edema. pp 79-138 9. Subsequent alterations of tissue forces as a result of soft-tissue shrinkage.org/alp/chap27-01. 1976. in Klopsteg PE. 1:481-495 13. Foort J: The patellar-tendon-bearing prosthesis for below knee amputees: A review of technique and criteria. Orthop Clin North Am 1972. Pelite. NC Med J 1973. Artif Limbs 1965. Raven Press. Nashold B: Dorsal root entry zone lesions for post-amputation pain. Orthop Clin North Am 1972. 53:115-119 22. Springfield. Sinclair WF: Below the knee and Syme's amputation prostheses. techniques and results. 31:102-106 36. 21:278-310 43. Iacono R. 8:85 40. Pain. Parkes CM: Factors determining the persistence of phantom pain in the amputee. Carron H. Wall PD: Pain mechanism: A new theory. Artif Limbs 1955. Wilson ME: The neurological mechanisms of pain. 17:97-108 32.oandplibrary. Melzack R. Fiddler MR: Pathophysiology of pain.Atlas of Limb Prosthetics: Surgical. A review. 1961 34. Contact Us | Contribute http://www. Sherman R. Radcliffe CW. Wall PD: Physiological mechanisms involved in the production and relief of pain. in Bonica JJ. Whidden A. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 27 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . vol 9.asp[21/03/2013 21:57:09] . 35:409-419 26. Biomechanics Laboratory. 1977. Pardo EG (eds): Pharmacology of Pain. Pain 1980. Saris S. 1974. 51:188 38. Anesth Analg 56(3): 1977. Boston. Lippincott Mag 1871. Department of Engineering. Nielson KD. Long DM: External electrical stimulation. New York. Nashold B: Successful treatment of phantom pain with dorsal root entry zone coagulation. J Psychosom Res 1973. Anesthesiology 1971. Charles C Thomas Publishers. New York. 2:35-60 33. Neurol Clin 1989. Pergamon Press Inc. Mitchell SW: Phantom limbs. J Neurosurg 1975. Br Med Bull 1977. Gall N: A survey of current phantom limb pain treatment in the United States. pp 319-326 25. Sanders DB: Reflex sympathetic dystrophy in a 6-year-old: Successful treatment by transcutaneous nerve stimulation. Iacono R.org/alp/chap27-01. 96:415-496 35. Radcliffe CW: Functional considerations in the fitting of above knee prostheses. Saris S. Minn Med 1974. Stilz RJ. in Lim RKS. 33:113-120 45. Science 1965. 33:149-155 30. 29:407-421 Chapter 27 . Post Grad Med J 1973. Webster KE: Somesthetic pathways. Lim RKS: Neuropharmacology of pain and analgesia. 3:349-357 41. in Ja-cox AK (ed): Pain: A Source Book for Nurses and Other Health Professions. 1968. Melzack R: Central neural mechanisms in phantom limb pain. et al: Relief of pain by transcutaneous stimulation. Pagni CA (eds): Recent Advances on Pain: Pathophysiology and Clinical Aspects. et al: Stimulation of the posterior columns of the spinal cord for pain control: Indications. Melzack R: The Puzzle of Pain. Treatment with dorsal column stimulation.57:195-198 24. Foort J: The Patellar-Tendon Below Knee Prosthesis Manual. Loeser JD. J Neurosurg 1975. 7:249 39. Little Brown & Co Inc. Prosthetic. Procacci P. 150:971-979 28. Appl Neurophysiol 1988. Calif. et al: Phantom limb pain. Armstrong D. Rexed B: The cytoarchitecture organization of the spinal cord of the cat. Sherman R: Stump and phantom limb pain. J Comp Neurol 1952. Ill. 1973 27. Berkley. Nathan PW: Pain. Loeser JD: Neurosurgical relief of chronic pain. 8:563 29. 43:301-307 31. 1974. pp 36-63 44. Riding J: Phantom limb: Some theories. vol 4. Br Med Bull 1977.27: Management of Pain in the Amputee | O&P Virtual Library 20. Anesthesia 1976. pp 169217 21. Melzack R: Phantom limb pain: Implications for treatment of pathologic pain. University of California. 43:308-314 23. J Neurosurg 1985. Anaesthesia 1974. Basic Books Inc Publishers. Sweet WH. 62:72 37. Sherman C. New York. in Bonica JJ (ed): Advances in Neurology. pp 27-56 46. Clin Neurosurg 1974. 53:438-443 42. Prosthetic. 1992. all other considerations being equal. The experiences of many people at the University of Arizona College of Medicine and elsewhere have been incorporated into this chapter. the response to limb loss depends on its causes and the degree of disability and disfigurement. financial stringencies. thanks to their resilience and the ingenuity and dedication of those who care for them. WB Saunders. Racy. Rosemont. Reference will be made to an amputee self-help group in the Tucson area. ©American Academy or Orthopedic Surgeons. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. social isolation (especially after the death of a spouse). adapt adequately as they learn to make compensatory use of their remaining faculties. and loss of body image. Personality Style Individuals who are narcissistically invested in their physical appearance and power tend to http://www. the greatest challenges for the young amputee are in terms of identity. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. sexuality. and Rehabilitation Principles. and social confidence. For example. Children adapt well to the loss of function and manipulate prostheses and other limbs with great agility. loss of sensation. they tend to adapt well. Reproduced with permission from Bowker HK. "No boy is going to look at me.oandplibrary. in Moore WS. They do enjoy the advantages of an established identity. and occupational limitations may all conspire to complicate adjustment to the limb loss. functional capacity. These can be conveniently grouped into psychosocial variables and medical variables reflecting the premorbid health and the medical and surgical management of the amputee. More recent studies find just the opposite. In either case.28: Psychological Adaptation to Amputation | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 28 Chapter 28 . There is some controversy in the literature over the correlation of age and longterm emotional consequences of amputation. It involves loss of function. M. 1989. and social acceptance. Click for more information about this text. physical resilience. Prosthetic." Among young adults.asp[21/03/2013 21:57:16] . Amputation is a triple threat. The wonder of it is that so many adapt so well. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. American Academy of Orthopedic Surgeons. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). They are particularly sensitive to peer acceptance and rejection. and for the elderly. Used with permission.D. reprinted 2002.Atlas of Limb Prosthetics: Surgical. Hence. *Portions of this chapter appeared previously in Racy JC: Psychological aspects of amputation. and interpersonal deal-ings. Psychosocial Variables Age The degree of psychological difficulty associated with amputation generally increases with Infants born with a congenially missing limb age. Philadelphia. and quotes from its members will be inserted into the text to illustrate points under consideration. Malone SJ (eds): Lower Extremity Amputation. Several early studies suggested that elderly amputees were at greater risk for psychiatric disturbances such as depression. DETERMINANTS OF PSYCHOLOGICAL RESPONSE The observed psychological response to amputation is determined by many variables. ill health. IL. Amputation in the preadolescent or adolescent age group is a great threat to emerging sexual identity. a 13-year-old member of the Tucson self-help group interviewed for this report reacted to the news that a leg amputation was necessary to cure her osteogenic sarcoma with the statement. and Rehabilitation Principles Psychological Adaptation to Amputation John C. chap 26. edition 2.org/alp/chap28-01. Among the elderly. Prosthetic. in terms of livelihood. If disability results in improved financial or social status. sometimes expressed in self-punishing behaviors. dependent individuals may cherish the sick role and find in it welcome relief from pressure and responsibility. insomnia. constitute the vast majority of amputees-the surgery usually comes after a prolonged period of treatment for peripheral vascular disease. and many find themselves transiently or permanently in a state of isolation. Shukla and coworkers studied 72 amputees prospectively in India and found that nearly two thirds manifested postoperative psychiatric symptoms. frail individuals. Others who have a wide range of skills or whose main line of work is not particularly dependent on the function of the lost limb may experience less emotional difficulty. http://www. the prohibition of which by federal law notwithstanding.org/alp/chap28-01. Timid and self-conscious individuals who are excessively concerned about their social standing are more likely to suffer psychologically from limb loss than are self-assured individuals. indicates no relationship between such a personality and phantom pain. cuts back when the amputee is able to manage. especially. children and adolescents. Although Kolb and Brodie report that rigid personality style may predispose to a greater incidence of postoperative complications.asp[21/03/2013 21:57:16] .oandplibrary. as mentioned above. the recent literature review of Sherman et al. Unemployment is associated with a greater degree of psychological stress and may be a predictor of phantom pain. depression-with its spells. Of course. especially if those gains are not directly challenged. Economic and Vocational Variables It stands to reason that individuals who earn their living from motor skills that are lost with the amputation are especially vulnerable to adverse reactions. followed by anxiety.28: Psychological Adaptation to Amputation | O&P Virtual Library react negatively to the loss of the limb. a limit on functional restoration and the return to an active life-style. loss of appetite. but at all times maintains the amputee's self-esteem. and suicidal ideation. including phantom pain. not all are so blessed. the individual may indeed be happy that it occurred. As might be predicted. be it conscious or otherwise. Those tending toward a pessimistic or paranoid outlook are likely to find their worst expectations confirmed. crying In this regard. Single and widowed individuals suffer more psychological distress and difficulty in adapting to amputation than do those who are married and have a family. the most common of which was depression. psychological adjustment may be made easier. Unexpected reactions may arise from secondary gain. takes over functions when needed. subtle or otherwise. They see it as a major assault upon their dignity and self-worth. Mental health problems can easily enter into the picture through a complicated series of psychosomatic and somatopsychic responses to the loss. Psychosocial Support All human beings require a support system throughout life in order to maintain emotional health. The loss serves to crystallize notions of a basic defect. and their rehabilitation may be colored by much bitterness and resentment. no amputee is completely insulated from the emotional consequences of discriminatory practices. in the workplace. in fact. However. But peer acceptance beyond the family is critical in the successful adaptation of all amputees and. young individuals who lose a limb traumat-ically have many advantages over older. Should the amputation bring about the resolution of a psychological conflict. Particularly helpful in the adjustment of the adult amputee is the presence of a supportive partner who assumes a flexible approach. These disorders are likely to set often combined with at least two other medical disorders. Conversely. Among the elderly-who. parents are the major source of support for children and adolescent amputees. Medical Factors Health Healthy. Those with a premorbid history of depression are more susceptible to dysphoria following amputation. greater degrees of anxiety. the loss of a toe or a thumb -and of minimal reaction to severe loss of several limbs. in order of frequency. factors inculpated. doubt. and Adults suffering a traumatic or rehabilitation to civilian life is not often seen today. selfconsciousness. and self-consciousness are noted. Furthermore. and residual-limb revision tend to develop greater degrees of despair and withdrawal than those who do not. instances of massive psychological reaction to small physical losses. infection. As noted in an earlier communication. It is not clear whether lower-limb loss is harder to accept than upper-limb loss. the greater the loss. if the prosthetic application is absent or delayed. timidity. Such individuals seem to make an excellent adjustment. were depression. A wartime situation in which the injury to the limb might lead to evacuation. assuming of course that the malignancy has been cured. fear of further self-injury. For the elderly. The crucial elements appear to be the integration of the prosthesis into the body image and the concentration of attention on future function rather than on past loss. It is less clear whether these differences persist. as had been suggested. and secondary gain.for example. http://www. low intelligence. The current situation is quite different in that the amputation affects a much older age group and follows either trauma or chronic illness rather than combat. Above-elbow (transhumeral) amputation brings with it great anxiety and frustration. sadness. Some react indifferently or negatively and view the surgery as proof of failure. Reason for the Amputation Much of the earlier work on amputation in this century centered on wartime casualties. anger. honorable discharge from the service." Prosthetic Rehabilitation The earlier a prosthesis is applied. a delay that in turn exerts a depressing effect on the individual. resentment of the need to rely on others. Preparation for the Amputation There is little doubt that those individuals who have had adequate warning and preparation fare better in the immediate postsurgical period. Amputation necessitated by the negligent or malicious behavior of others is likely to produce persistent feelings of resentment and selfLitigation can easily complicate the process of rehabilitation and recovery. it certainly makes successful rehabilitation more possible. pessimism.org/alp/chap28-01. "A poorly performed amputation almost guarantees poor rehabilitation.oandplibrary. the greater the difficulty in adjustment. In a study of 46 amputees seen in London. The reaction is usually one of realistic acceptance and cooperation with the treatment team. amputation of one leg below the knee allows relatively good adjustment.asp[21/03/2013 21:57:16] . Contrarily. whereas those who do not receive such preparation tend to react negatively or with massive denial. with restoration of both function and body image. surgery usually occurs after a long period of suffering resulting from diabetes and peripheral vascular disease. Those who undergo an elective amputation for the cure of a malignancy benefit from the availability of time for preparation and exploration of alternatives. Most accept the surgery with relief since it often signals the end of suffering and the return to improved functioning. given that adaptation is governed ultimately by many other variables preceding and following the amputation. anger often underlies the depressive reaction described earlier. senility. accidental limb loss tend to react with varying forms of denial and bravado. While a well-performed amputation does not guarantee a successful rehabilitation outcome. Parkes found that Among the 38 amputees who were thought to have some overall limitation of function attributable to psychological origin.28: Psychological Adaptation to Amputation | O&P Virtual Library attendant loss of energy. There are. Conversely. This highlights the importance of surgical skill in the performance of the amputation. the less the psychological distress observed after amputation. and bilateral transhumeral amputation is perhaps the most difficult situation of all. Surgical Complications Those individuals who suffer pain. and psychomotor retardation-may delay rehabilitation. however. In general. pain. Dise-Lewis suggests that the death and dying paradigm may be usefully applied to the amputees impending loss of a body part. It is useful and customary to think of the process of adaptation as occurring in four stages. a hopeful attitude.oandplibrary.asp[21/03/2013 21:57:16] . The manner in which the surgery is presented by the surgeon can have much bearing on the magnitude and kind of affective response. Labeling the amputation as a reconstructive prelude to an improved life is a much different matter from implying that it is a mutilation and a failure.28: Psychological Adaptation to Amputation | O&P Virtual Library Extremes of age are by no means intrinsic contraindications for prostheses. however. the more important are such practical issues as the loss of function. loss of income. The Team Approach Because adaptation to amputation is so multifaceted and because it is an evolving process requiring different kinds of attention at each stage. and cost of ongoing treatment. Kohl notes that amputees may regard unemployment as a "denial of their 'right' to participate in the family's decision making processes. A division into four stages. Most individuals informed of the need for amputation go through the early stages of a grief reaction. and despair. allows for the highlighting of issues that arise most critically at each point in time." It is her view that "the success of rehabilitation efforts should not only be measured by return to income-producing work. they deserve a trial period of rehabilitation with a prosthesis. Furthermore. but rather the return to the person of his decision-making abilities to choose the lifestyle that would be most fulfilling to him. pre-existing illness may compound the difficulties of adjusting to such devices. Along with this acceptance. Mendelson and coworkers recommend that the surgeon paint a realistic picture of the immediate and long-term goals for the patient and his family." STAGES OF ADAPTATION The psychological reactions to amputation are clearly diverse and range from severe disability at one extreme to a determined and effective resumption of a full and active life at the other. there may be varying degrees of anxiety and concern. perhaps for most persons. and disposal of the limb. which may not be completed until well after their discharge from the hospital. Several members of the self-help group interviewed for this report eloquently described the consequences of failed communication. approximately a third to a half welcome the amputation as a signal that suffering will be relieved and a new phase of adjustment can begin. The range of skills and points of view represented in a team increases the probability that all aspects of rehabilitation will be addressed and none overlooked." She reported that her surgeon had described her as his "failure" and told her very little about http://www. most of the adjustment occurs in a gradual and often invisible continuum. Such concerns fall into two large groups. losses in sexual intimacy. First and. a loss that may threaten the amputee's core identity. Amputee self-help groups are further extensions of this approach. Second are more symbolic concerns such as changes in appearance.org/alp/chap28-01. Nonetheless. Preoperative Stage Among amputees for whom there is ample opportunity to be prepared for surgery. difficulty in adapting to a prosthesis. The team may include members of the family and successfully treated amputees. among the elderly. However. Vocational Rehabilitation Restoration of the capability for gainful employment is an integral part of the patient's recovery. the team approach has emerged as the standard approach to rehabilitation. detailed explanation of all aspects of the surgery and the rehabilitative process. and full response to all questions (especially those that seem trivial) appear to diminish anxiety. elderly amputees with chronic obstructive pulmonary disease are already compromised with respect to strength and endurance. One who regarded her impending amputation as "losing a member of my family" felt scared "out of my wits" and was repeatedly "horrified. perception by others. anger. With the exception of the clear demarcation between preoperative and postoperative stages. albeit under close supervision. For example. among other things. kinds of denial shown through bravado and competitiveness. One young man who lost the upper part of his arm as a result of an electrical injury dreamed of becoming a "bionic man." Eventually sadness sets in. (2) "pining" for what is lost. in which all hope of recovering the lost part is given up. For two women who sustained below-knee (transtibial) amputations. and introduction of a successfully rehabilitated amputee to the recovering patient. those who and pain. obtain a prosthesis looked forward to it and often fantasized about it." partly as a result of the anesthesia and partly as a way of handling the trauma of loss. Mild euphoric states may be reflected in increased motor activity. pain. One member of the group described her reaction as one of ambivalence and oscillation. the family. and indeed. A young mother who lost her hand in a paper shredder tried to put on a happy face for her family. Parkes describes the response as similar to that seen in widows." Those group members who did have the opportunity to receive adequate preparation before the surgery commented on it as having contributed materially to their peace of mind after the event. the amputation may bring much-needed relief.oandplibrary. Those who did not. is the most critical phase and presents the greatest challenges to the patient. A few resort to humor and minimization. phases: (1) "numbness. She switched repeatedly from acknowledging that the amputation was to be expected. (3) disorganization. "we have to joke so that people around us can deal with it.org/alp/chap28-01. the patient is concerned about safety. to great fear and dread. This was true for four of the eight members of the self-help group interviewed for this report. and in some instances. and even desirable. Psychological reactions noted in this phase are concerns about safety." in which outside stimuli are shut out or denied." she said. the process often lasts well beyond the period of inhospital rehabilitation. to a certain degree. Others make wisecracks such as "You see more when you walk slowly. sustain the amputation after a period of preparation react more positively than do those who sustain it after trauma or accident." she said. The degree to which individuals go through these four phases varies from individual to individual." At-Home Rehabilitation By all accounts. For those who have suffered considerable pain before the surgery.asp[21/03/2013 21:57:16] . In-Hospital Rehabilitation In-hospital rehabilitation. But the process took time and effort. Another. fear of complications In general. the emphasis shifts to social reintegration and Some individuals in this phase experience and express various vocational adjustment. Most individuals are. when informed that she would lose her leg. and disfigurement. and (4) reorganization. depending. and overtalkativeness. acceptance of the amputation and the prosthesis by family and friends. reacted with the thought. It is also during this time that some experience phantom limb sensations and phantom pain (see the discussion that follows)." Sadness. "numb.28: Psychological Adaptation to Amputation | O&P Virtual Library the details of the surgery and the process beyond. Later on. It calls for a flexible approach addressed to the rapidly evolving needs of the individual. "Like a ghost in my closet. and the kind of rehabilitation thought to be feasible. for one reason or another. The 13-year-old delighted in throwing back the bedclothes and flaunting her artificial leg to her adolescent visitors. Almost all the members of the group interviewed for this report agreed that early prosthetic introduction was of the highest importance. "They might as well take off my head. "Sometimes." Immediate Postoperative Stage The period between the surgery and the start of rehabilitation may last a matter of hours or days. Initially. awakening to find that they had two "legs" in bed was most reassuring. and the amputation team. on the reason for the amputation. racing through the corridors in wheelchairs. loss of alertness and orientation. the amputee's return home can be a particularly taxing period because of loss of the familiar surroundings of the hospital and attenuation of the guidance and support http://www. The grief response to limb loss is probably universal and time He lists four limited. Factors that are noted to facilitate adjustment and rehabilitation in this phase are early prosthetic fitting. may be concealed. the extent and condition of the residual limb. although keenly felt. "I took it out now and then to scare myself with it. in many ways. In this phase. such as a reluctance to give up the sick role. and each thought that his affliction was lighter than those of the others. It tends to abate rapidly. the attitude of the family becomes a major determinant of the amputee's adaptation. in the form of an intermittent itch that. continue to have occasional experiences of itching or locomotion. The mother of the young man who lost his arm as the result of an electrical injury spoke of the profound change that occurred in his behavior on his return home." All conceded that the adaptation would have been immensely more difficult without the active support of their families. they were intrigued by her new leg prosthesis and expressed the wish that perhaps they too could don and remove their limbs when they grew up. Others may talk. Not surprisingly." (The young mother who lost her hand in the paper shredder) was concerned that people would look at her as though she were a "freak. 10 or 15 years after amputation. Many. and sexual adjustment.asp[21/03/2013 21:57:16] . remarked that one advantage of a leg amputation over an upper-limb loss was that it could escape detection in such settings. curiously." go to the other extreme and vehemently reject any suggestion that they might be disabled or require help in any way. those amputees able to resume a full and productive life tend to fare best. is relieved by scratching the prosthesis. Phantom limb experience has not been noted in those who are born congenially missing a limb and in those who sustain the limb loss at a very early age. three areas of concern come to the fore: return to gainful employment. however. An excessive show of sympathy generally fosters the notion that one is to be pitied. Family members should be involved in all phases of the rehabilitative process. Hence. A subtle but often overlooked issue is the ease with which the disability can be concealed in social settings.oandplibrary. http://www. Later she recognized that it was "the best thing that he could have done for me" and was rather amused to learn that the scenario was contrived by her surgeon and her husband in order to encourage her independence. Some of them still do. phantom limb sensations present no particular problem. The members of the selfhelp group had all experienced them at one time or another. A middle-aged woman who sustained her amputation after a prolonged period of disability resulting from poliomyelitis found herself one day facing a sinkful of dishes and a request from her husband that she wash them. Equally helpful to her was her children's startled response on learning that their mother was receiving disability benefits. Varying degrees of regressive behavior may be evident. In fact. SPECIAL AREAS OF CONCERN Phantom Limb Sensations The feeling that the amputated limb is present and moving is so common as to be regarded as a universal occurrence after surgery. The group members were unanimous in rejecting the "handicapped" label. One of them said. more leisurely way of living and by reduced responsibility and pressure to produce. To them. for example. Of immense value in all of these matters is the availability of a relative or a significant other who can provide support without damaging self-es-teem. A number of individuals experience a "second realization. She did so with tears running down her face and thoughts running through her mind of her husband as cruel and mean. In general. so only a few individuals continue to perceive their limbs as still present and active a year after surgery.org/alp/chap28-01. and a retreat to "baby Some resent any pressure put upon them to resume normal functioning. particularly if they have other medical disorders. For elderly amputees who have limited skills. He regressed to the point that she felt she "had another baby in the house. social acceptance. sometimes after residual-limb stimulation. This can be partially or fully balanced by a more philosophical acceptance of a new." with attendant sadness and grief. It is during this phase that the full impact of the loss becomes evident. however. the probability of a full return to an active life is considerably diminished. she did not seem to be disabled at all and therefore did not need benefits. One group member. this is much easier for those with marketable skills who sustain the amputation while still in vigorous health." She found her anxiety greatly relieved when both her children and their schoolmates took her amputation in stride and asked matter-of-factly about it.28: Psychological Adaptation to Amputation | O&P Virtual Library provided by the rehabilitation team. "Most well-adjusted people prefer to accept what happened to them" and thus "would not trade with another amputee. a tendency to lean on others beyond what is justified by the disability. phantom pain was extremely rare and was noted in individuals who also showed psychopathology.. In one prospective study of 67 patients who had suffered severe hand trauma. much of the dreaming included nightmares of further injury or incapacity. However. Sherman et al. that incorporate the prosthesis or do not particularly dwell on the missing part are consistent with a more positive adaptation. So distressed was he by his pain that he had repeatedly entertained the fantasy of taking a gun and shooting his "leg" off in order to rid himself of it.org/alp/chap28-01. Early work on phantom pain led to the assumption that antecedent and concurrent medical states as well as psychological factors combined to explain its existence. in a sense. One viewed her body more positively after amputation because her prosthetic leg worked better than the leg that she had lost. of necessity. phantom pain has been reported by fewer than 2% of amputees. and with prosthesis. his only relief came from the use of oxycodone (Percodan) on a regular basis. Two mentioned aching when the weather changed and rain was approaching. Body Image Amputation. and acceptance by others. and interestingly. remains incompletely understood but approaches the model of a chronic pain syndrome with evidence of physiologic and psychological components. at times http://www.oandplibrary. acupuncture. It has been suggested that the amputee. "like putting your finger in a 220 [volt] outlet. These included nerve stimulation. the development of residual-limb complications." Parkes found that phantom pain could be predicted by certain immediate postoperative phenomena such as the presence of residual-limb pain. Individuals who are unable to accept the last two are likely to reject the prosthesis and to experience difficulty in functional and social Related to the issue of revised body image is concern with social appearances adjustment. Other members experienced fleeting episodes of pain described as an electric shock sensation or. only one member reported persistent phantom pain accompanied by residual-limb pain. In the self-help group. continued unemployment and a rigid personality). There is general agreement that phantom pain and life stresses are related. At the University of Arizona. Thus. This is reflected in dreams and in the draw-a-person test. The members of the group confirmed these observations and saw a connection between accepting one's new bodily configuration and accepting a prosthesis. irrespective of what type of external treatment was carried on. requires a revision of body image. The authors wrote that pain "tended to come and to go with psychopathological symptoms. Arena et al. as one put it.asp[21/03/2013 21:57:16] . He detailed long and complicated procedures after the initial amputation. Several members of the group spontaneously volunteered the view that the support of the family members was of great help in reducing phantom pain when it occurred. all designed to relieve his phantom pain. must contend with three body images: intact. Pinzur regards phantom pain as a variant of sympathetic dystrophy. there often remains some shyness about revealing the amputated body to others. and emotionally disturbing events. and even spinal block.g. climatic changes.284 amputees studied by Ewalt and colleagues at the end of World War II. the frequency of such nightmares decreased significantly about 1 month postoperatively. whereas those who adapt poorly draw the Similarly." A few described cramping sensations and feelings of constriction that diminished over time. which can be serious and disabling.28: Psychological Adaptation to Amputation | O&P Virtual Library Phantom Pain Pain experienced in the missing limb is a much more serious issue than phantom limb sensations. namely. It has been reported that amputees who adapt well draw a person with a foreshortened limb or without any limb at all. dreams missing limb larger than the opposite limb or with increased markings. differ from that of the general population of chronic pain sufferers. other factors not related to surgery (e. argue that the vast majority of amputees experience phantom pain to varying degrees and that it is probably a complex form of referred pain with a physiologic rather than a psychological etiology. Most had come to regard their prosthesis as part of themselves. residual-limb revision. found an isomorphic pain-stress relationship. phantom pain. Even when considerable success is achieved in functional restoration. amputated. Some amputees experience phantom pain in association with micturition. In the series of 2. a roughly contemporaneous increase in phantom pain with increased stress and vice The typical psychological profile of the amputee suffering phantom pain does not versa. prior illness of more than 1 year. In a study of 24 male amputees. At the time of the interview. is of great help. "reconstructive surgery" is preferable to "amputation" and can certainly be used along with it. one member stated that 15 years after the event. Preparation Although it is hard to prove statistically that preparation has a bearing on ultimate outcome. What perhaps is not so obvious is the need for the senior surgeon to perform the surgery or to be involved intimately in its performance. who had expressed the concern that no boy would ever look at her. Most reported success in facing it. reasons for the amputation. if any. and social impact. although the information is widely available and may be imparted by any member of the team. they tended to walk more clumsily when they felt observed by other people in public. It is an error to relegate this procedure to inexperienced http://www." As one group member put it. Sexuality This is an area of some anxiety for most amputees. it is absolutely of no use in the sexual area. mainly attributed to the supportive response of the partner. the only people who actually went into the pool were the nonampu-tees. especially those who are young and in Concern arises from the following sources: (1) fear that the body would the prime of life. and the rehabilitative process following it. It is important to present the amputation as a desirable lifesaving or life-improving option rather than as a last resort or an indication of failure. She lived for 2 years after her surgery but did not have occasion to go out on a date. and the reports of amputees all suggest that proper Such preparation must include a clear explanation of the preparation is highly desirable. several spoke of lingering difficulty in seeing themselves as adequate sexual partners rather than as repulsive sexual "freaks. all of them continued to experience self-consciousness in social situations. the exact surgical procedure. A comparison with the sexual experience of paraplegics is instructive. There is indeed some evidence in the literature that the quality of life can sometimes be improved by an amputation as compared In connection with this. Significantly. They may also entertain hope of a return of function in the affected part. Such issues include disposal of the limb. despite verbal and behavioral reassurance of the partner.28: Psychological Adaptation to Amputation | O&P Virtual Library revealed in dreams. sexuality was an important issue that had to be faced by each of them. and (3) the loss of an area of sensation. degree of functional loss and return. Yet. relationship with friends and family. not be accepted by the partner. no other person can communicate the same degree of authority and confidence that patients need as they contemplate the imminent loss." It would appear that the passage of time aids in this adjustment. despite their successful adaptation and acceptance of the new body image. sexual adjustment. even if these are not raised by the patients themselves. costs of surgery and rehabilitation. Surgical Technique It should be obvious to the readers of this book that good technique is of the essence. The amputee enjoys none of these advantages." MANAGEMENT Six principles of psychological management of the amputee are implied in the foregoing discussion. her missing limb was "a nonissue" in the sexual sense. Whereas a prosthesis can provide functional restoration and some return to normal appearance in most situations. it has been suggested that the term with limb-sparing treatments. They described a pool party to which they had invited their friends and relatives. clinical observation. Anticipating and dealing with the various issues that patients will face. Those who suffer paralysis still enjoy sensation from the affected part and continue to see their body as intact.asp[21/03/2013 21:57:16] . It should go without saying that much of the preparation should be conducted by the operating surgeon. She maintained the hope that one day she would do so and was greatly comforted by her brother-in-law. "There is still a small part that doesn't accept. This was not the case for the 13-year-old.org/alp/chap28-01. work capability. who told her that her amputation would "weed out the creeps. (2) the loss of a functioning body part such as the hand. Nonetheless. the viable alternatives. Among the members of the group. For example.oandplibrary. common sense. wrote. of 223 British amputees found that team management reduced hospital stays significantly and increased the No less important." success in the rehabilitation of amputees. and structure that it presents. capacity that can now be enjoyed. Durance and O'Shea report that amputees are least likely to use prostheses during leisure activities." http://www. Others may find that thanks to personal wealth or to disability and retirement benefits. One such modality is Schwartz's situation-transition (ST) group. Pin-zur and coworkers have suggested that psychological testing using standard personality inventories and measures of cognitive abilities may be helpful in deriving a scale of rehabilitation potential for amputees. valuable contribution of the team approach is the facilitation of a more rapid return to familiar surroundings and to independence. Kull-man found that the Barthel index of activities of daily living had a direct correlation with the general condition of the amputee and the fitness of his prosthesis and suggested its prognostic value But as Mendelson and colleagues point out. is the comfort and usefulness of the device. the senior surgical attending physician is directly involved in the performance of all amputations and supervises the entire process of amputation rehabilitation. importance to patients. role of the team in validating the amputee's right to be in control of his own rehabilitation and in providing a safe haven for emotional expression. prefer returning to employment. and livelihood. To the extent that it is possible to do so. any psychological for rehabilitation outcome. which brings with it a variety of adverse psychological phenomena. the better are the results in As Bradway and associates terms of functional capacity and psychological adaptation. and perhaps a predictor of prosthetic use. Sturup and colleagues found a higher rate of prosthetic use among below-elbow (transradial) amputees than among transhumeral amputees and a clear tendency toward nonuse among younger amputees and among those whose amputation was of the nondominant arm.28: Psychological Adaptation to Amputation | O&P Virtual Library hands. the team is in a position to address one aspect or another of the patients needs. social worker. job. The Team Approach A team approach is optimal in amputee rehabilitation and should include the surgeon. each member of counselor. rather than allowing the patient to focus only on disabilities and pain. for example." Early Prosthetic Fitting and Mobilization There is little doubt that the earlier the prosthesis is applied. It is not essential that the person resume work. surgical nurses. As these needs evolve. with all the security.asp[21/03/2013 21:57:16] . testing ought to be deferred until the patient is physically and emotionally prepared to withstand the stress of its administration. The level of the amputation also seems to be a significant determinant in the ultimate use of appliances. as Dise-Lewis points out. As Kohl wrote. the loss of earning capacity may entail a profound loss of self-esteem. Some. vocational With this variety. stimulation." Introducing the patient to a Of paramount successfully rehabilitated amputee may be of great assistance in this effort.org/alp/chap28-01. "Early prosthetic fitting and rehabilitation enable the patient to incorporate all of his physical and emotional efforts into recovery from the earliest possible moment. "In our program. and if indicated. which is different from other self-help groups for alcoholics. they are in a position to stay away from work. Even in the absence of pressing financial need. group support is part of the help being provided to amputees. flexibility and adaptation to new realities are required not only of amputees but also of those who help them. Special Approaches Increasingly. a psychiatrist or psychologist. pros-thetist. smokers. As Bradway and associates wrote. "It is important that there not be a judgmental response from the staff toward those patients who Several workers have attempted to find predictors of do not seek paid employment. and overeaters in that "members are not required to espouse Whether a trained person leads the group a particular moral or behavioral value system. Vocational Rehabilitation No approach to amputation can be considered successful without some resolution of the issue presented by the loss of skill. occupational therapist.oandplibrary. the involvement of Perhaps the most members of the family at all of these stages can be of tremendous help. is the long-term effectiveness of rehabilitation. The prospective study by Ham et al. physical therapist. but it is essential that the person accept whatever new role and This is an issue to be approached with an open mind. you become a better person because you have to work for everything. who put me in touch with the amputee selfhelp group in Tucson. It is important to recall in this connection that the various stages of grief described by Parkes and others may not be accomplished in the predictable sequence or within the expected time. D'Alli. "You become a more compassionate and less critical person towards others. for her profound observations and reflections on the lives of amputees. sophistication and sensitivity on the part of members of the team.asp[21/03/2013 21:57:16] . anxiety disorder. With respect to phantom pain. M. Furthermore. hy-pervigilance. as a third-year clinical clerk in psychiatry. Neither psychotherapy nor Psychological psychoactive medicine appear to be of efficacy in treating phantom pain. These psychiatric challenges can be addressed therapeutically on their own merit. however. leader and organizer of the self-help group. perfectly possible for psychological problems that have been avoided or disregarded in the past to surface after surgery and. Bruno GM. to Diane Atkins. psychiatric consultation and therapy are not indicated. and inspiration to all who study amputation and those who must adapt to it. who. to James Malone.. "When you become an amputee. the opportunity to ventilate feelings is probably the most effective therapeutic activity for the amputee and is a crucial phase that should not be aborted. to Joseph Leal. most individuals noted an improvement in the quality of their lives after surgery. If and when such a determination becomes desirable. et al: The relationship between situational stress http://www. For most amputees. who shared a wealth of experience with hundreds of amputees at that center. and delusions have also With the possible exception of been noted as manifestations of body image disturbances. Reclusiveness. and antisocial behavior. social worker at the Houston Center for Amputee Services. and a number of others .P. As one member put it. and anxiety must be expressed before further therapeutic work can be accomplished. to Jan Pankey and Sandy Levitt. Vivid flashbacks have been reported as among the most common early reactions to amputation. anger. References: 1. however. although unnamed. I wish in particular to acknowledge my debt of gratitude to John Bradway. such as in complicated legal situations. in longstanding marital discord.. are indispensable. the individual's previous history and former level of adjustment can be of great value in clarifying the issue. said." Another.D.28: Psychological Adaptation to Amputation | O&P Virtual Library or it is conducted entirely by its own members. M. having shelved the issue.D. for sharing his extensive knowledge and experience.oandplibrary. piqued my interest in this area by preparing a paper on psychological adaptation to amputation. In the self-help group that was interviewed for this report. Occasionally. to Sybil Kohl. chronic depression." Acknowledgement This chapter was written with the assistance of Richard E. without the necessity of determining the degree to which they are related to the amputation. It is. to be blamed on it. occupational therapist and coordinator for the Houston Center for Amputee Services. there was unanimous agreement with these principles of management. which in turn formed the basis of a report written by him. biofeedback and relaxation appear to be useful adjuncts to medical care of the stump and pain control measures. Arena JG. alcohol abuse. guidance. who had suffered greatly both before and after his amputation. the use of low-dose. drug dependence. There are those individuals who may continue to mourn the loss of their limb for a long time or who. myself. Sherman RA. It has been noted that amputee self-help groups shy away from self-pity or self-designation in terms of disability and emphasize strength and participation in a full and healthy life. C. for example.org/alp/chap28-01. Feelings of sorrow. This might be the case. third-year clinical clerks. who assisted me greatly in my meeting with the self-help group in Tucson.. of course. Psychotherapy may be indicated for individuals who suffer difficulty in any of the stages previously described and who are unable to resume a normal existence that otherwise should be possible for them. low-potency neuroleptics to extinguish flashbacks. indeed. family therapy may be indicated to assist in reaching the proper balance between the legitimate support amputees need and the independence that they must regain. return to it at a much later date (delayed grief reaction). Many individuals have assisted materially in all aspects of preparing this report. to Sharon Stites. and to the eight members of the group who. the group experience is likely to be of great value to both the participants and their families. were the source of information. et al: Early psychological aspects of severe hand injury. 2:818. SP Medical & Scientific Books. Polack EP. 29. 9:68-70. therapist and psychologist. Atkins D: Personal communication. 4. J Hand Surg [Br] 1989. 5. Bradway JK. Prosthet Orthot Int 1987. 225:1487. http://www. Br Med J 1989.oandplibrary. in Krueger DW (ed): Emotional Rehabilitation of Physical Trauma and Disability. 34:71-77. J Hand Surg [Br] 1988. 12:258. Racy J. Pritchard DJ: An amputee visitor program as an adjunct to rehabilitation of the lower limb amputee. letter. 78:181. 3. Gingras G. Br J Psychiatry 1984. Psychoso-matics 1980. 20:107. Mayo Clin Proc 1979. 1984. May CH. Gilder R Jr: Psychiatric disturbances following amputation. Br Med J 1989. Ewalt JR. 299:1287. 54:774. Kaslani SR. 23. Malone SJ: Group rehabilitation of vascular surgery patients.28: Psychological Adaptation to Amputation | O&P Virtual Library 2. 15. New York. Susset V. Devine CA. Springfield. in Atkins DJ. Randall GC. Whylie B. 9. 13. 1984. Frank RG. Dise-Lewis JE: Psychological adaptation to limb loss. 25. 7. Ill. 21. et al: Psychological response to amputation as a function of age and time since amputation. Morris H: The phantom limb. Can Med Assoc J 1956. Lippmann SB: Psychiatric consultation for acute amputees. Dalsgaard S. 28:183-189. Arch Phys Med Rehabil 1976. Psychosom Med 1947. 28:40. 33. 299:1526-1527. et al: The psychological impact of traumatic amputations-A team approach: Physician. WB Saunders Co. Smith CJ. MacBride A. Orthot Prosthet 1984. 11. Boyle M. Meier RH III (eds): Comprehensive Management of the Upper Limb Amputee. Hamilton A: Rehabilitation of the leg amputee in the community. Hand Clin 1986. 10. J Psychosom Res 1990. Kerstein MD: Group rehabilitation for the vascular disease amputee. O'Shea BJ: Upper limb amputees: A clinical profile. et al: Psychological adaptation to amputation: An overview. 10:68-72. English AWG: Psychology of limb loss. 18. New York. Burech JG. 75:819. 1984. Mendelson RL. 20. 189:798. Freierson RL. 26. Kohl S: Personal communication. 12. Med J Aust 1973. 1978. 22. Practitioner 1981. 27. J Bone Joint Surg [Am] 1987. 11:25-30. pp 17-67. Am J Psychiatry 1954. 8. 38:46. suppl. Brodie K: Modern Clinical Psychiatry. Hovgaard C. Malone JM. 1984. Practitioner 1987. 2:577-583. J Ark Med Soc 1981. 144:493-497. 14. 16. McPhee MC. Gebuhr P: The social and economic consequences of failure to replant amputated thumbs. 1989. Kashani JH. Mindell ER. 69:799-800. 17. Med Pediatr Oncol 1982. Durance JP. Kullman L: Evaluation of disability and of results of rehabilitation with use of the Barthel index and Russek's classification. Philadelphia. Goldstone J. White WL: Emotional reactions and adjustments of amputees to their injury. 13:177-180. Psychosomatics 1987. 31. Grunert BK. p 157.org/alp/chap28-01. Kessler HH: Psychological preparation of the amputee. US Naval Med Bull. Springer-Verlag NY Inc. Hansen ST: The type-Ill C tibial fracture-salvage or amputation (editorial).asp[21/03/2013 21:57:16] . Kolb L. Mongreau M. Price D. Malone JM. 34. Regan JM. Tebbi CK. J Am Geriatr Soc 1980. Kohl S: The process of psychological adaptation to traumatic limb loss. Bowker JH: Amputation rehabilitation: Critical factors in outcome. March 1946. Charles C Thomas Publishers. 9:118. ed 10. 57:180. Marks L: Lower limb amputees: Advantages of the team approach. Psychology of limb loss. pp 113-148. Caine D: Psychological considerations affecting rehabilitation after amputation. et al: Psychosocial factors in the rehabilitation of elderly amputees. 28. 24. Friedmann LW: The Psychological Rehabilitation of the Amputee. et al: Therapeutic and economic impact of a modern amputation program. and phantom limb pain: Cross-legged correlation data from six-month pain logs. 19. pp 165-172. 6. 10:301-312. Int Disabil Stud 1987. pp 574-576. Lipp M. Int Disabil Stud 1988. 14:307-308. Roberts VC: Evaluation of introducing the team approach to the care of the amputee: The Dulwich Study. Ind Med Surg 1951. et al: Adolescent adjustment to amputation. Rogers J. Ham R. Moore WS. Hughes J. et al: Psychosocial and rehabilitative aspects of upper extremity amputees. 110:609. Noble D. Datta D. 32. 30. 231:1321-1324. Ann Surg 1979. 28:285-295. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 28 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Prosthetic. 38:51-52. Tebbi CK. J Psychosoc Oncol 1987. 127:204.oandplibrary. Parkes CM: The psychological reactions to loss of a limb: The first year after amputation. J Rehabil Res Dev 1988. Brunner-Mazel. 128:645. JAMA 1945. SP Medical & Scientific Books. J Am Geriatr Soc 1990. 1981. Chapter 28 . 25:83. 38. Barja RH. Clin Orthop 1988. New York. Tripathi RP. Parkes CM: Factors determining the persistence of phantom pain in the amputee. Rosenberg SA. Surgery 1982. Arch Phys Med Rehabil 1978. 229:236-240. 45. Barofsky I. in Krueger DW (ed): Emotional Rehabilitation of Physical Trauma and Disability. 53. Ashley J. Reinstein L. 59:504. Sturup J.Atlas of Limb Prosthetics: Surgical. Osterman HM. New York. Am J Pedi-atr Hematol Oncol 1989. 25:6-10. et al: Phantom pain: A lesson in necessity for careful clinical research on chronic pain problems. 17:97. in Kostuik JP (ed): Amputation Surgery and Rehabilitation: The Toronto Experience. et al: Traumatic amputation of the upper limb: The use of body-powered prostheses and employment consequences. 47. Rr ] Psychiatry 1975. 7:249-262. 36. Pinzur MS: Phantom pain: A lesson in necessity for careful clinical research on chronic pain problems (letter). 51. Shukla ED. Mallon JC: Long-term psychosocial outcome among cancer amputees in adolescence and early adulthood. Sugarbaker PH. Pinzur MS: Amputation: Last resort or beginning? Geriatr Nurs 1987. 12:50-52. Sherman CJ. Prosthet Or-thot Int 1988. J Rehabil Res Dev 1988. J Psychosom Res 1973. Miller KH: Sexual adjustment after lower extremity amputation. Jensen JS.org/alp/chap28-01. Contact Us | Contribute http://www. Rr J Psychiatry 1982. 50. Blair H: Psychiatric reaction to amputation. Ernst JL. Sherman RA. 42. Sherman RA. Churchill Livingstone Inc. Bruno GM: Psychological factors influencing chronic phantom limb pain: An analysis of the literature. Graham G. 46. 37. pp 515-532.asp[21/03/2013 21:57:16] . Parkes CM: Psychosocial transitions: Comparison between reactions to loss of a limb and loss of a spouse. Sherman RA: Stump and phantom limb pain. Pinzur MS. Parkes CM: Determinants of disablement after loss of a limb. 39. 5:69-82. New York. Pain 1987. Osterman H: Psychological testing in amputation rehabilitation. 44. 43. Sahu SC. Ewalt JR. 41. 91:17. 48. Sioson ER: The elderly amputee with severe chronic obstructive pulmonary disease. Tebbi CK. Petrelli AS. 1984.28: Psychological Adaptation to Amputation | O&P Virtual Library 35. 1976. pp 387-393. 11:276-280. 8:246-248. Whylie B: Social and psychological problems of the adult amputee. Randall GC. Richards ME: Adjustment to amputation among adolescent oncology patients. et al: Quality of life assessment of patients in extremity sarcoma clinical trials. in Howells JG (ed): Modern Perspectives in the Psychiatric Aspects of Surgery. 40. Neurol Clin 1989. pp 105-111. 49. et al: A psychiatric study of amputees. 52. 141:50-53. Thyregod HC. oandplibrary. In areas of extreme aridity such as the desert regions of the world. http://www. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. the amputation surgeon. in lower-limb amputation. Prosthetic services should be readily available. 1992. a therapist. especially in workmen's compensation cases. The prescription of the most suitable prosthesis. taking into account the above factors. A large number of factors affect the prescription. and amputees. Local custom and knowledge are also powerful forces in determining prosthetic prescription in that they tend to limit the prescription options considered. including heat-mold-able plastics. reprinted 2002. Climate can also play an important role. the therapist who will be providing the training in its use. This multiplication of options has resulted from a revolution in prosthetic design. Bowker. both initial and ongoing. There are so many choices. and fitting due to the introduction of new concepts in socket design as well as a wider array of components and new materials. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. repair. For example. Prosthetic. Prosthetic. Prosthetic. American Academy of Orthopedic Surgeons. There is a widely held misconception that this sort of team is available only in large medical centers. a psychologist/social worker. an insurance nurse. the prosthesis should meet the needs and desires of the patient. is most effectively done by a team. the prosthetist who will be making the limb. It takes only an interested surgeon. On the contrary. both vocationally and avocationally. In areas of excessive humidity. and carbon fiber-reinforced plastics. the local prosthetist. energy requirements for ambulation increase sharply with each more proximal anatomic level (see Chapter 15). metal parts will tend to corrode and wood to rot. Before discussing factors involved in prescription. useful function decreases directly in relation to progressive loss of limb length. At the highest levels of amputation in both the upper and lower limbs. If the patient's overall health has irrevocably deteriorated to the point where he is unable to provide the strength or coordination to utilize the prosthesis. The mental status of the patient must be such that he can learn its use and limitations. it is useless to prescribe one. Geographic remoteness without ready access to a prosthe-tist for maintenance. fine sand particles will quickly wear out the joints of prostheses because of their close tolerances.asp[21/03/2013 21:57:22] . it is useful to review the reasons for not prescribing a prosthesis. similar to those prescribed for amputees in the developing world. and Rehabilitation Principles. edition 2. M. Rosemont. that prescription becomes as much of an art as a science. insofar as possible. ©American Academy or Orthopedic Surgeons. repair. some insurance companies will provide only one prosthesis for the life of the patient. the limb-fitting team should determine the tolerance of the amputee both for the various levels of prosthetic complexity available and the care with which different types of prostheses must be treated. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). manufacture. GENERAL FACTORS The prescription of a prosthesis no longer involves simply matching a particular level of residual limb with a prosthesis designed for that level. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. The cost of a given prosthesis. a psychologist and/or social worker who will help the patient through his period of adjustment. In addition. The team should consist of the patient/ family. not all of which readily come to mind until one examines all the parameters of a given patients life. in fact.Atlas of Limb Prosthetics: Surgical. Click for more information about this text. First and foremost.org/alp/chap29-01. IL. can be a limiting factor in determining the prescription. and replacement of a limb may dictate simplicity of design related to the need for self-repair of the device. lightweight metals. and Rehabilitation Principles Critical Choices: The Art of Prosthesis Prescription John H. and replacement at suitable intervals.29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 29 Chapter 29 .D. and the insurance nurse. Since prostheses vary considerably in their complexity. not only for the provision of the initial prosthesis but also for its maintenance. If the surgeon Reproduced with permission from Bowker HK. Fiscal limitations at the local and state levels may mandate only a very simple prosthesis for indigent amputees. a very effective miniteam can be assembled in most small to medium-sized cities. org/alp/chap29-01. team members can work far more effectively than by individually seeing the patient in isolation with no cross-fertilization of ideas. In borderline cases. if any. they may be given articulated limbs. the amputee still needs to be seen at 6. At the hip disarticulation or transpelvic levels. functional advantage over crutch walking without a prosthesis. This approach also helps to upgrade prescription practices and tends to move the participants into a position of leadership in this field. the amputee.29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library expresses an interest in this work. Some. during which they are able to assess the energy costs of such walking and the team evaluates their motivation. There are also cogent reasons for not fitting lower-limb prostheses. are quite uncomfortable to sit in for prolonged periods. SPECIFIC FACTORS RELATED TO LOWER-LIMB PROSTHETIC PRESCRIPTION The basic reasons for fitting a lower-limb prosthesis are to enhance ambulation by decreasing the excess energy requirements of crutch walking and improving the patients balance with restoration of bilateral proprioceptive feedback through the residual limb-prosthesis interface. Replacement may also be indicated as improved designs appear from time to time. These patients find transfers much easier without the impediment of these almost nonfunctional prostheses. most abandon these prostheses for a wheelchair because of its greater efficiency in speed and energy consumption. lightweight cosmetic prostheses can be provided. Delaying prosthetic fitting and training of the unilateral dysvascular amputee in order to http://www. including active sports. prostheses also require maintenance. however. there is little. lower-limb transtibial amputees should be fitted with inexpensive preparatory prostheses to realistically assess their potential for ambulation. however. however. Not only do residual limbs change in volume with muscle atrophy and weight gain or loss. The fitting of bilateral dysvascular transfemoral amputees with articulated prostheses. If the patient requests some form of cosmetic restoration. While it is obvious that an amputation affects the amputee for the rest of his life. After a variable period of training. Eventually. These devices. Young traumatic bilateral transfemoral amputees. These are basic nonarticulated transfemoral sockets with rocker bottoms and appropriate suspension ( Fig 291. the goal is to restore as much functional capacity to the lower-limb amputee as possible. In short. Patients should not be rejected for fitting of unilateral or bilateral lower-limb prostheses solely on the basis of age. on the other hand. may find that the decreased speed of prosthetic walking is the overriding factor in rejecting prosthesis usage for most occasions. typically a younger trauma or tumor patient. Even though there may be frequent follow-up visits immediately after the fitting is carried out. will almost always demand a trial of ambulation but should also start with stubbies. to the minimum acceptable rehabilitation goal of assisted transfer activities that aid the care-giver as much or more than the amputee. Many very elderly patients can be successfully fitted at the transtibial or Syme ankle disarticulation levels provided that they are physiologically sound and have sufficient mental capacity to comprehend the subtleties of sock adjustment for changes in residual-limb volume ( Fig 29-2.oandplibrary. This will vary widely from returning him to all activities that he had previously engaged in. in addition to being expensive and extremely difficult to walk with. If these high-level amputees require two external aids such as canes for prosthesis use. they may be given a trial on stubbies. By meeting once or twice a month at the physician's office or other designated location. the hands are freed for activities other than handling a walker or crutches. repair. other local surgeons are very likely to refer patients for this purpose.). for example. and periodic replacement. is rarely successful. Very importantly.). often becomes a long-term community ambulator. If these patients insist on some form of household ambulation and can demonstrate sufficient cardiac reserve clinically. The other benefit to any amputee is the cosmetic restoration provided by the prosthesis.asp[21/03/2013 21:57:22] . Even the unilateral dysvascular transfemoral amputee may not be able to muster the cardiopulmonary reserve to manage mere household ambulation and will prefer a wheelchair. or a pair of panty hose can be filled with properly sculpted foam to give a pleasing appearance with slacks or skirt and shoes.to 12-month intervals for the rest of his life. the need for regular lifelong prosthetic preventive maintenance is often forgotten. Patients with hemiparesis following a cerebrovascular accident can often walk with their transtibial prostheses provided that they have adequate mentation and balance and no disruptive spasticity or severe extensor or flexor patterning. as well as the limits of prosthesis function vs. therefore.asp[21/03/2013 21:57:22] . simultaneous fitting as a bilateral amputee is far less likely to produce useful walking than if the patient had been fitted as promptly as possible after each of the separate operations. the patient will then be accomplished as a unilateral prosthesis user and have a better chance of success in learning to use a prosthesis on the second side. It should also be remembered that prosthetic fitting is entirely optional at the discretion of the amputee. It is therefore necessary to give a fairly detailed explanation of what is realistically available. Because of these factors. and is low in cost and easily maintained. Although the surgeon cannot be expected to carry out the activities of other team members. operating in close conjunction rather than independently. On the other hand. The dysvascular amputee who loses one foot should therefore be made ambulatory with a prosthesis as rapidly as possible. Despite the obvious attractions of myoelectric http://www. Behaviorists should be enlisted in an early stage to assist the amputee in starting to work through the grieving process.oandplibrary. effective management is best achieved by a team as described above. This discussion should include the basic differences between body-powered and myoelectric limbs. This approach will result in months of avoidable deconditioning and tend to inure the patient to alternative modes of mobility.org/alp/chap29-01. both physically and psychologically. The fitting of blind unilateral or bilateral transfemoral amputees should be approached with caution because of the loss of proprioceptive knee function. These would include prostheses specifically made for skiing and swimming activities (see Chapter 24B). The motivation of the unilateral amputee for prosthetic fitting is usually highest immediately after amputation. especially at the transtibial level. Once properly trained. It is also important to realize that function and cosmesis of the upper limb are much less completely replaced by a prosthesis than are foot function and cosmesis by a lower-limb prosthesis. Additional factors that may enter into the fitting of lower-limb amputees. In approaching the upper-limb amputee. in other words. functions like the hand and elbow that were lost. The team should be both interdisciplinary and interactive. although most bilateral upper-limb amputees find that prostheses enhance their function. In fact. The first step in prescription is eliciting the amputee's expectations while realizing that every upper-limb amputee feels that he should receive a prosthesis with a hand and elbow that look real. prosthetic services can best be provided by a specific upper-limb prosthetic team. will wish to participate again in their previous sports activities. the amputee expects the surgeon to be fairly knowledgeable in all areas of prosthetic rehabilitation so that he can effectively coordinate the limb-fitting program by synthesizing the findings and recommendations of the team. The complexity of various prostheses must be explained. Many younger lower-limb amputees. Awareness and use of the hand for grasping occur much earlier in infancy than the use of the lower limb for walking. The hand is of greater significance than the foot. some amputees will benefit from prostheses specifically designed for given sports. Because of these complexities. If and when the second foot is lost. especially in diabetes mellitus. foot loss. If the amputee is interested in returning to any sport based on running. and the tolerance of the individual amputee for these should be ascertained. a blind unilateral or bilateral Syme ankle disarticulate or transtibial amputee should be able to walk about in familiar surroundings but may be safer with a companion for community ambulation. there is a variety of dynamic-response feet available for him to try since many of them can be easily interchanged at the ankle level. that of the intact upper limb. It is very useful.29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library prevent stress to the remaining foot is not recommended. SPECIFIC FACTORS RELATED TO UPPER-LIMB PROSTHETIC PRESCRIPTION The key to successful fitting of the upper-limb amputee is largely based on the amputees motivation. If the second foot is then amputated. successful fitting of the unilateral upper-limb amputee is unusual after the amputee has become fully functional with one hand. are blindness and hemiplegia. before one-handedness develops. it is important to note that there are significant differences in the impact of hand vs.). to fit an immediate postoperative prosthesis (IPOP) whenever possible to provide a prehensile tool to assist the intact hand and prevent the development of complete one-handedness ( Fig 29-3. Other amputees may wear the more cosmetic device at work and switch to a body-powered prosthesis for working in the garden after hours. as to what constitutes successful use of a prosthesis for the upper limb. In high bilateral cases. consideration should be given to modifying the amputee's environment as much as possible for more effective function. As in the case of lower-limb amputation. nonfunctional device so long as it is cosmetically acceptable.oandplibrary. Even part-time use of an upper-limb prosthesis for specific vocational. it has served an extremely useful purpose at the workplace. the terminal device for sports and recreational activities should be carefully matched to the patient's needs and desires (see Chapter 12C). When these modified forearms are not in use. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 29 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Follow-up with the team. to get desired information regarding the prosthesis and use training. Is it related to a certain number of hours of wear each day? Many amputees will wear a myoelectric or cosmetic device during working hours and remove it at home for reasons of comfort. Conversely. they can be covered with cosmetic prostheses. should be on a lifetime basis. after the initial intensive effort involved in fitting and training has been completed.asp[21/03/2013 21:57:22] . a manual worker such as a welder may use his body-powered prosthesis at work and switch to a cos-metic/myoelectric prosthesis for social functions. collectively or individually. Chapter 29 . Blindness presents especially difficult problems for the upper-limb amputee since the use of a terminal device is almost entirely dependent on visual control. Contact Us | Contribute http://www. Again.org/alp/chap29-01. or purely social purposes is a sign of acceptance of the prosthesis. The patient should meet as often as is necessary with team members. In this situation. They have the option of myoelectrically controlled hands or body-powered terminal devices that feature either passive or active prehension. avocational. The entire team should then meet again with the patient before actually ordering the prosthesis. A blind unilateral upper-limb amputee may find a prosthesis useful for holding a coat or carrying objects in a gross manner. consideration should be given to a Krukenberg procedure on one or both sides (see Chapter 36A). The older patient who has lost a limb from trauma or tumor at a high level may decide to forego any prosthesis or to use a very light. with at least yearly evaluations. Cosmesis is also of concern. the amputee must understand that not only are they very costly initially but they also generally weigh considerably more than the usual body-powered prosthesis designed for that same level. Prosthetic. especially by third-party payors. Not only do prostheses wear out and sometimes break. especially to women and to all who must meet the public in their daily work. but improved designs that might be a real advantage to individual amputees also appear from time to time. Questions are often raised.Atlas of Limb Prosthetics: Surgical. Nonetheless.29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library prostheses. many upper-limb amputees will want to return to the sports and recreation activities in which they previously engaged. A blind bilateral upper-limb amputee will have no use for prostheses except perhaps as cosmesis. SKILLS FOR PATIENTS WITH UPPER-LIMB AMPUTATIONS Clothing Selection and Dressing Unilateral Amputation Many garments and modifications suitable for patients with hemiplegia also serve the needs of individuals with unilateral amputation. Slippery Front rather than back or side openings simplify fabric is more manageable than knitwear. IL. The stick has a large hook at one end. and clinicians may decide not to proceed with definitive fitting. family. is to delineate means to accomplish representative activities. cannot cope with the physical demands of prostheses. Many people.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 30 Chapter 30 . Some individuals replace regular laces with elastic ones.asp[21/03/2013 21:57:26] . reprinted 2002. Edelstein. and Rehabilitation Principles. 1992. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Prosthetic. Reproduced with permission from Bowker HK. A dressing stick held in the antecubital fossa enables the user to don and remove coats and shirts rapidly. with accessories such as loops and pressure-sensitive tape the same color as the garment.Atlas of Limb Prosthetics: Surgical. the clinical responsibility is to guide each patient to achieve the highest degree of personal. pressure-sensitive tape can be sewn under buttons to preserve the appearance of a buttoned front yet facilitate dressing.A. therefore. Nevertheless. American Academy of Orthopedic Surgeons. Donning slacks is easiest if they are placed on a bed near a wall. Prosthetic technology does not serve all the needs of every person with amputation. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).oandplibrary. and Rehabilitation Principles Special Considerations. lacing without crossing the ties aids tightening the laces because the end of the lace can be readily fashioned into a slip knot. although styles with pressure-sensitive flaps are readily available. The client inserts one leg Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. vocational. ©American Academy or Orthopedic Surgeons. A few individuals do not wear prostheses simply because they are unaware of current componentry and funding sources. Rosemont.org/alp/chap30-01. particularly those with multiple disorders. Therapists can incorporate the suggestions in this discussion when training children and adults to enhance their quality of life. M.30: Special Considerations. Loosely fitting clothing is more convenient than snug apparel. edition 2. Other clients. Prosthetic. A button hook and a zipper pull may be handy. Snaps and magnetic closure are even less cumbersome than buttons. however. even if a prosthesis is not used. alternatively. Physicians and prosthetists should be familiar with the function that can be achieved by people with particular amputations who do not wear prostheses. Some individuals. Even those who wear prostheses perform some activities such as bathing and donning undergarments without the device. The intent of this chapter. Larger buttons are easier to manipulate with one hand than are small ones . and recreational independence. http://www. dressing. The nonuser challenges scientists to improve the prosthetic armamentarium so that future devices can enable the wearer to obtain greater function at less physiologic and financial cost. P. Step-in skirts and dresses are easier to don than those that must be pulled on overhead. Adaptations should be as inconspicuous as possible.Rehabilitation Without Prostheses: Functional Skills Training Joan E. particularly those with very proximal or very distal amputations.. may choose to forego prostheses altogether.T. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Click for more information about this text. have no difficulty in tying shoe laces with one hand. Prosthetic. Although a trial fitting may demonstrate some functional or cosmetic value of a prosthesis. Slip-on shoes are recommended. the patient. Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library and then leans against the wall to hold that side while putting the other leg into the garment. The family and patient may require psychological support to overcome societal aversion to seeing one accomplish ordinary tasks with the feet while sitting on the floor. The client can then hang the pants on two wall hooks installed at a height suitable for stepping into the pants. then uses the table edge to slide the watch onto the wrist. rub to the shirt with a tie clasp. Some girls and women find that underpants modified client can lower and raise the pants. then inserting the feet into the pants legs. the individual utilizes friction between the floor and trousers to work the garment into place.asp[21/03/2013 21:57:26] . The antecubital fossae and. Some adults are limber enough to be able to grasp with the feet. and then raising one's legs. A buttoned cuff should be fastened before donning the shirt. A single padded hook or wooden knob on the wall can be used to aid dressing. skirt. Once they are on. another option to augment security. one can use the back of a chair to work the fingers into place. the axillae are useful to hold items. however. Grooming and Hygiene Unilateral Amputation Although little difficulty should be encountered. A pretied. particularly if the narrow end of the tie is held To don a glove. clip-on necktie is another option. Most individuals can operate faucets with the feet. Bilateral Amputation The adult who acquires bilateral amputation should be guided to make maximum use of the remaining portions of the amputation limbs when performing daily activities such as dressing. To put the watch on the sound wrist. A necktie can be knotted one-handed. selection and modification of undergarments are especially important to foster independence. is simpler to manage. nail file. Children with a phocomelic hand can manage underpants to which a tape has been sewn from the midfront waistband to the midback waistband. Once the hand is part way into the glove. the client rises on the forefeet to release the loops. Bilateral Amputation Clients with bilateral below-elbow (transradial) amputation can use a sponge mitt over one forearm for soaping and scrubbing. They provide the individual with tactile sensation and considerable prehensile skill. the individual lays the watch on a table and cups the fingers inside the band. When they are at the buttocks.oandplibrary. Similarly. Shirts are donned by first inserting the amputated limb in its sleeve and then the sound limb into the other. particularly if the faucet has a flange rather than a knob handle. to a lesser extent. Objects may be stabilized in the teeth and between the thighs. and clipper each equipped with suction cups. A terry cloth bathrobe simplifies drying oneself. Shaking the torso and legs causes the pants to slide upward. a terry cloth mitt can hold a bar of soap. Undergarments designed for incontinence are with a split crotch facilitate toilet activity. Underpants may have two tape loops sewn to the waistband. the floor. http://www. The child with congenital bilateral limb deficiencies should be encouraged to manipulate with the feet. One section of the trousers. thus reducing reliance on adaptive equipment and help from others. For people of all ages. stabilize a nail file or emery board between the thighs. A mitten. a stick with a hook at one end. some people like the convenience of scrub One can also and denture brushes.org/alp/chap30-01. Shaving is speeded by filling the cheeks with air to make the skin taut. it against the hip in the same direction as the hand is inserted. A watch with an expandable bracelet goes on more quickly than one with a buckled strap. flanged faucet handles at the wash basin are convenient. the patient can loop one end of a strip of toweling over the shower head by maneuvering with both amputation limbs.30: Special Considerations. the tape drapes over the front and With a reacher. Alternatively. The other end of the strip adheres to the tub floor by means of suction cups. or shirt is secured to the hook while the patient maneuvers into the An alternative for donning both underpants and outer pants is placing them on garment. the continues to the back of the garment. For cleansing while in the shower. securing the cuff button with elastic thread may be needed to allow the hand to slide easily through the cuff. The holder accommodates a spoon or If the amputation limbs are long enough. Kuhn described a vaginal tampon applicator for women with bilateral amputation. The pen can be held in a forearm cuff. the toes. The client should slant the paper in the opposite direction from that used by right-handers to avoid twisting the left arm into a cramped posture.oandplibrary. A self-correcting feature helps the one-handed typist. Paper is held in the toes or Others drape paper over the rim placed over the heel. A snap-on plate guard is useful for the beginner and serves as a stable area against which one can push food. Some individuals regulate the diet in order to defecate at home in the morning or at night.asp[21/03/2013 21:57:26] . The individual can urinate independently. Dining Unilateral Amputation A commercial fork clip secures the utensil to the plate so that the sound hand can cut. he or she merely stabilizes the fork or spoon with both limbs. Communication Unilateral Amputation The person with amputation of the right hand will find that writing with the left hand is easier with a table rather than a right-armed writing desk. the diet can omit meats and other that the user can spear food morsels. For men and boys. will find that a felt-tipped pen makes writing easier. and toothbrush. foods that one would have to cut. the patient can place the receiver on the desk or use a commercial holder that eliminates the need to stabilize the receiver against the shoulder with one's head while writing a message. The client with bilateral transradial or elbow disarticulation amputations can The beginner use both limbs to stabilize a pencil. the teeth. such as a comb. the client can secure the paper in a clipboard and use the transradial amputation limb or the chin to nudge the paper into position.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library Before toileting.org/alp/chap30-01. Bilateral Amputation When writing. Other The individual with phocomelia can use a reacher stick with a padded hook or wire coil at one end to secure toilet paper. or if one is limber. Bilateral Amputation A utensil holder designed for individuals with quadri-plegia can be worn on the forearm of the client with at least one transradial amputation limb. Defecation is aided if the client wears slacks with suspenders so that he can pull the trousers down by grasping the pants leg with the toes. equipped with a water spigot and warm airflow is suitable for the home. the trouser zipper may be left partially open. as are computer keyboards designed for unimanual use. or crayon for writing and drawing. Chopsticks are another mode of one-handed dining. particularly if he does not wear undershorts. http://www. Some agile individuals can manage a commercial one-handed writing board that clamps the paper and has rubber feet to prevent the board from slipping. the patient then rocks over the foot. covered by the hem of an overshirt. pen. The rocker knife facilitates one-handed cutting. the patient does not need any device to hold fork. hairbrush. Techniques for buttering bread and opening a milk carton are easy to learn.30: Special Considerations. For telephone dialing. eating utensils. An electric floor model shoe buffer enhances one's appearance. A bidet or special toilet seat of the toilet and straddle the bowl to wipe themselves. Paper insertion is aided if the typewriter has a lever that positions the paper on the platen automatically. hygienic aids can be constructed easily. One-handed touch-typing methods devised for individuals with cerebral palsy can be used by the person with unilateral amputation. Various grooming aids may be attached to a similar stick. Special typewriters for one-handers are available. outer and undergarments must be loosened or removed. one model has prongs so Alternatively. Perineal cleansing can be accomplished by foot and trunk motion. The billiards player can use a mobile bridge to support the cue stick. Some chores such as folding laundry are aided by using the teeth as a holder. Lightweight bowls and pans can be lifted single-handed. Left-handed Embroidery and extensive sewing are less scissors are sold in most needle-craft shops. the bridge has a hole for the stick. skirt.asp[21/03/2013 21:57:26] . commercial playing Simple devices aid the golfer.30: Special Considerations. the client with unilateral amputation to accomplish most tasks efficiently. beaters.oandplibrary. or one can use an automatic needle threader. An alternative is a broad waist belt fitted with a pocket to hold the pole. Onehanded knitting is expedited by a knitting holder clamped to a table. Recreation: Games and Sports Unilateral Amputation One can shuffle cards one-handed or use a bowl or hat to hold them. sometimes aided by simple modifications or variation from customary performance practice. The camera tripod can be modified to support a bow for the archer who has unilateral amputation. Bilateral Amputation A reacher stick can help the client engage in light household tasks. or the novice can use an egg separator.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library Homemaking and Other Vocations Unilateral Amputation A full range of cooking can be achieved by the one-handed person.org/alp/chap30-01. The amputation limb makes an effective stabilizer in many carpentry and office tasks. and fishing enthusiast. or trouser leg. Bilateral Amputation Book holders are offered by many special equipment manufacturers. The technique of setting nails with one hand relies on the force one can obtain from the hammer Farm equipment and work site modifications enable head against which the nail is held. Other activities such as those involved in child care can be managed efficiently by using one hand while securing the infant against one's torso with the amputated limb or relying on the crib or other flat surface for stability. One-handed jar openers. Those with bilateral transradial amputations may make considerable use of the antecubital fossae for holding packages. Children and adults play many instruments. and an automatic focus mechanism. Sewing begins with threading the needle. which can be secured by slipping it into one's shirt sleeve. A leather mitt riveted to the side of each aluminum ski pole accommodates the skier with transradial amputations. which frees the hand to sew. which can then be opened with the teeth. mounted on two wheels. A mixing bowl can be stabilized by placing it on a rubber mat or setting it into a bowl holder or into a drawer that is closed snugly against the bowl. gardener. The reader turns pages with the bare amputation limb or a mouth stick. arduous if one uses an embroidery hoop on a floor stand. A champion tennis player has bilateral longitudinal deficiencies. a trigger to snap the shutter. Eggs can be broken one-handed. Wrist disarticulation does not preclude a career as a major league baseball pitcher. Because farming and many other vocational and avocational pursuits involve operating a vehicle. and choppers are readily available. the use of a spinner knob on the steering wheel should prove helpful. card shufflers are inexpensive alternatives. Cameras designed for one-handed operation feature a pistol grip. a one-hand fishing vest holds the rod so that the user can cast and retrieve. An apron with a semirigid plastic clip rather than fabric ties can be slipped onto the waist with one hand. Recreation: Music Among the recreational options for patients with upper-limb amputation is musical participation. mashers. http://www. A board with stainless steel holding pins secures potatoes and other firm vegetables so that one can peel with the sound hand. commercial page turners are an expensive alternative. For example. carpenter. and gong suspended from a stand. with an adapted neck strap. often without using assistive devices. Assembling the instrument is accomplished by asking a friend to assist. The piano and other keyboard instruments can be played one-handed. much http://www. Those with left amputation reverse the strings and bridge and. The musician with transradial amputation holds the mallet or stick in the intact hand and has the other mallet secured to a snugly fitting leather cuff on the forearm. the pick guard also. as does the footrest ordinarily used on the right side. chimes. resilient surfaces of the transradial limbs to stabilize the brass segments. because it has no valves. The French horn is particularly suitable for those with amputation. although balancing the horn will be cumbersome. basic skills are. an instrument with tubing coiled in reverse can be ordered from the manufacturer. particularly if the handle is covered with friction tape to increase stability in the cuff. with music chosen from the large literature ranging from elementary to virtuoso pieces. they can be depressed with either hand.asp[21/03/2013 21:57:26] .oandplibrary. One or a pair of leather cuffs worn by a percussionist with bilateral transradial amputations enables playing the triangle. Although valves are designed for the right hand. The piano and other keyboard instruments are accessible to children with phocomelia who play by sitting on a low stool so that they can extend their small limbs to reach the keys with bare fingers. Conventional performance assumes valve control with the left hand. It can be held by either intact limb or by a neck strap or floor stand.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library Unilateral Amputation The individual with transradial amputation can support the trumpet on the amputation limb. Numerous ways of striking percussion instruments such as drums and xylophones make them accessible to virtually all individuals with amputation. If the player develops a serious interest. Commercial left-hand guitars are another option. A person with left amputation can play in reverse.30: Special Considerations. The foregoing section indicates that the patient with unilateral upperlimb amputation who does not wear a prosthesis can accomplish daily and vocational activities rather easily. however. A double-headed drum stick enables the bass drummer to play while marching. for the steel-stringed guitar. valves are pushed with either or both amputation limbs. thus the musician with right transradial amputation places the bare amputation limb in the bell. Tambourines and bells are ideal for the person who can hold the instrument in the sound hand. The person with transradial amputation can strum a guitar with a pick secured in a forearm cuff. depending on the note. SKILLS FOR PATIENTS WITH LOWER-LIMB AMPUTATIONS The functional problems that attend lower-limb amputation differ from those associated with loss of the upper limb. or the player can use the broad. A snugly fitting sandal modified to hold a plastic pick enables one to play stringed instruments with the foot. A cupped cardboard or plastic fixture mounted in the bell facilitates pitch regulation. Bilateral Amputation The musician with bilateral transradial amputation can sit and support the bell of a trumpet on the leg. persons with unilateral and bilateral amputation can obtain a rigid neck support for the harmonica to facilitate playing by moving the mouth along the instrument rather than the usual method of moving the instrument along the mouth. or on a custom-made stand. The conventional strap aids in supporting the guitar. Borrowing from the one-man-band tradition. Instrumentalists with left amputation can manage the larger brasses such as the tuba by supporting the instrument on the lap or on a commercial chair-stand and working the valves with the right hand.org/alp/chap30-01. Some musicians with transcarpal amputation who retain wrist motion hold the pick in the wrist. pitch is determined by the musicians mouth. The banjo and ukulele can be played in a similar manner. Electronic keyboard instruments are another option for unimanual playing. One guitarist simply strums with the pick held in the toes. Shaken instruments such as mara-cas can be secured with the cuffs. The bugle can be held and played by anyone with unilateral or bilateral transradial or above-elbow (transhumeral) amputations without prostheses. especially locomotion. some individuals prefer to wear gloves to increase control of the crutches. The patient should move the amputation limb in the opposite direction from the sound leg rather than maintaining the residuum flexed in order to create a rhythmic. whether for vascular disease or trauma. with particular regard to the upper limbs. the individual with amputation of one or both legs who does not wear prostheses is likely to experience considerably more difficulty during certain tasks. which should be kept next to the chest. crutch walking may facilitate maneuvering in small or crowded rooms. the tip should be a large suction one to increase traction on the floor. the use of forearm crutches resulted in a freely selected speed that was 15% to 40% slower than that chosen by nondisabled persons. Young adults with hip disarticulation or transpelvic amputations are likely to opt for crutches rather than wear a relatively cumbersome prosthesis. and lungs.oandplibrary. A rubber cover increases the friction of the axillary piece. Good posture requires that the crutches be kept parallel to the trunk to minimize pressure on the chest.30: Special Considerations. When the same subjects were tested with their prostheses. at a metabolic cost 30% to 40% greater than normal.asp[21/03/2013 21:57:26] . Locomotion Unilateral Amputation The patient who does not wear a prosthesis may be able to manage with a pair of axillary or forearm crutches. swinging gait. Some models of chair have an extension that fits over the edges of the tub to aid transfer. A rubber hand cover reduces the risk of the patients hand slipping. such as the formation of contractures and pressure sores. For both styles of crutch. Crutches must be the proper length. than those who are able to use prostheses. comparable to the stress that jogging imposes on nondisabled persons. Strategically placed wall-mounted bars increase safety during transfers. Alternatively. walking speed was 12% to 33% slower than control subjects.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library more daunting for the client with bilateral upper-limb amputation. crutches should be considered only for traveling short distances. Among subjects with above-knee (transfemoral) amputation. In contrast. The top of the axillary crutch should be two finger widths from the axilla to avoid compression of the superficially located radial nerve. Dressing and Clothing Selection Unilateral Amputation The individual who intends to ambulate with a pair of crutches should select a low-heeled shoe for the sound foot. for most individuals. A survey of 500 patients indicated that 80% sat on the shower floor to bathe. For those who rely on a wheelchair.org/alp/chap30-01. Occasional use of crutches counteracts the negative consequences of prolonged sitting. The hand piece should be set at a point that permits the user's elbow to be slightly flexed. energy cost per unit distance ranged from 48% to 70% greater. Bathing Unilateral and Bilateral Amputation A bath chair with a plastic seat and rubber-tipped legs contributes to safety in the shower or bath. The body should progress forward in a continuous manner. Some individuals in good physical condition. Waters and colleagues found that heart rates were elevated to an average of 130 beats per minute among crutch users. Walking with crutches without a prosthesis is stressful and associated with markedly elevated heart rates for those with amputations. especially if the hand is wet with perspiration. Forearm crutches are safer on stairs and uneven ground than are axillary crutches. heart. The shoe should also have a laced or strap fastening high on the dorsum of the foot to prevent the shoe from slipping off the foot when the patient swings the leg while walking. http://www. predominantly those with bilateral amputations. Consequently. relied on grab bars to assist balance. those who stood or used a stool. walk smoothly and efficiently for long distances with crutches. While swing-out footrests are appropriate for those who wear cosmetic or functional prostheses.oandplibrary. and left foot accelerator pedal. Using a single axillary crutch often promotes a significant shift of body weight toward the crutch and subjects the patient to the risk of impinging vessels and nerves in the axilla. With the Young adults with transtibial amputation were prosthesis. which are placed on the tread or bannister posts. such as a person with bilateral knee disarticulations. described elsewhere in this book. For other transfers. enable many individuals with unilateral and bilateral leg amputations to engage in a wide variety of sports and other http://www. Even those individuals who use a prosthesis may hop to get to the swimming pool from the locker room. they could climb step over step. hand dimmer switch. With the board in place. The automobile should be equipped with hand controls for safe operation. In an emergency. The patient shifts from one box to the next with support by the buttocks and hands. The chair should have its rear wheels set back to compensate for the posterior shift of the user's center of gravity. although the pulse rate averaged 39% higher with the crutches. Climbing stairs in this fashion is more difficult but is less likely to be required. the driver with a right amputation should have a car equipped with a hand parking brake. An overhead trapeze bar facilitates moving from the bed to the wheelchair. To operate an automobile. The patient should endeavor to land lightly with a springy step on each hop to prevent spraining or fracturing the foot. 48% less efficient with crutches but only 29% less efficient with prostheses as compared with nondisabled adults. Bilateral Amputation Many people with bilateral amputation require a wheelchair. Others may find a cart or a low platform on casters suitable for scooting about the home.org/alp/chap30-01. A reclining wheelchair relieves the discomfort of prolonged sitting. The board bridges the gap between the wheelchair and the transfer goal. particularly when elbow extensors are not strong enough to lift the body weight. with the hands used for propulsion.asp[21/03/2013 21:57:26] . patients with below-knee (transtibial) amputations performed more poorly with crutches than when wearing prostheses. such as the bed. should augment rather than replace conventional foot controls so that the car can be driven by other family members or a mechanic. Another option is a series of sturdy boxes of graduated height leading from the floor to the wheelchair seat.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library Patients whose balance is poor or whose arms are not strong require the added support of axillary crutches. Such a vehicle can be used in areas too narrow for a wheelchair. Erdman and coworkers reported that nine subjects with transfemoral amputations consumed approximately the same amount of energy whether walking with axillary crutches or with a prosthesis. Stair ascent on crutches is somewhat less intimidating than descent. Descent is controlled with the hands. a wood or plastic sliding board may be used. Some individuals who can tolerate weight bearing through the ends of the amputation limbs. One can increase safety by keeping the crutch tips close to the edge of the step with the crutches inclined toward the top of the stairs. those who do not wear prostheses can transfer to and from the chair more easily if there are no foot-rests. Hopping is another means that patients in good physical condition use to move over relatively short distances. the patient may prefer to pivot on the foot. The trunk should incline slightly forward. Evaluation of ten young adults demonstrated that they consumed 49% more Ten energy on stair ascent with axillary crutches than did nondisabled control subjects. To traverse very brief distances. and the individual should lift the foot from the ground as short a distance as possible. The controls. Recreation Numerous adaptations. can walk either unassisted or with the support of short canes or crutches. Crutch use was associated with greater energy cost and slower speed. the patient can negotiate stairs by sitting on the top stair and lowering the trunk. however. The maneuver is less stressful than hopping. the individual can shift weight from one buttock to the other in a diagonal manner to maneuver from one surface to the next.30: Special Considerations. subjects had to lead with the intact leg and then raise the crutches. Six of the subjects were younger than 40 years of age. alternately on heel and forefoot. and other skills. for example. Patients with unilateral or bilateral upper-limb absence can be guided to select clothing that is easy to don. Other sports that do not require the use of a prosthesis include mountain climbing. Cleveland. such as by hopping or using Agile individuals crutches. SUMMARY Individuals with amputation. and recreational function whether or not prostheses are worn. they must have a means of moving from the dressing room to the water's edge. Occasionally. Applied Technology for Independent Living. Cleo Living Aids. accomplish many personal activities without prostheses. Department of Agricultural Engineering. Calif. be achieved. Inter-Clin Info Bull 1970. Many nonprosthetic techniques enable adults and children to complete grooming and hygienic care and eat a varied diet gracefully. Adaptability.oandplibrary. can play several sports while balancing on crutches. Cope PC. and other recreational pursuits are within the compass of those who do not wear prostheses. Ind. Activities popular with paralyzed wheelchair users also suit individuals with leg amputation. motorcycling. Bender LF: Prostheses and Rehabilitation After Arm Amputation.asp[21/03/2013 21:57:26] . the teeth are useful for grasping. Then can the goal of community entry. 4. Tennis. References: 1. for they can use their upper limbs as the power source. Ill. sports. hopping and pivoting. skateboard stunts. whether upper or lower limb. mechanically. 1974. 3957 Mayfield Rd. 1989. catalogue. children and adults who do not wear lower-limb prostheses can learn suitable clothing styles and safe bathing procedures. skiing. bowling. feeding. Swimming provides superb recreation as well as good exercise. or reentry. Post Office Box 515. Breaking New Ground: Agricultural Tools. A wide range of games. Hile J: A bathing assist. Rehabilitation of the client with amputation is not synonymous with prosthetic fitting and use. basketball. Crawford R. Publishers. Prima Publishing & Communications. The clinic team should encourage the child with bilateral upper-limb deficiency to capitalize on the tactile and prehensile capabilities of the feet so that the youngster may develop proficiency in dressing as well as writing. http://www.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library pastimes. Machinery. Equipment. Rocklin. Bilateral Amputation Swimming is popular with some people having bilateral amputation. can be done with simple adaptation of basic implements and thoughtful selection of typewriters. and sky diving. West Lafayette. 4732 Nevada Ave North. Unilateral Amputation While many clients choose to swim and scuba dive without a prosthesis. Recreational endeavors with and without prostheses and with or without special equipment are burgeoning. Writing and keyboard usage. or cosmetically acceptable options. At all ages. Other recreational pursuits enjoyed by those with bilateral leg amputation include horseback riding. Springfield. 3. and operation of a wheelchair and automobile. important for school and vocation. vocational. MN 55428. catalogue. and Buildings.30: Special Considerations.org/alp/chap30-01. Virtually all homemaking duties can be managed without prostheses. Bowker M: Flaying from the Heart. mountain climbing. The water enthusiast can obtain a wet suit or swim fins to fit the amputation limbs. 10:6-8. Rather. Purdue University. and dancing can be enjoyed by the seated individual. and weight lifting. Alternatives to prosthetic locomotion include crutches. hockey. 7. and other equipment. 2. the individual should be assisted to maximize personal. with or without prostheses. Charles C Thomas. Similarly. 6. computers. 5. A plastic wheelchair is ideal for beach use. patients do not wear any appliances because of the inordinate exertion of walking with prostheses or a preference for being unencumbered by devices or because they or their professional counselors fail to present financially. Colchester. CT 06415. kick ball and soccer. catalogue. Crystal. sometimes borrowing techniques developed for persons with hemiplegia. OH 44121. Chatterjee BB. Hotte EB: Independent Living for the Handicapped and the Elderly. Barakat AR: The habilitation of a child with multiple congenital skeletal limb deficiencies. Saez F: Comparative work stress for above-knee amputees using artificial legs or crutches. Ganguli S. 1956. NJ 08553. 1989. New York. Garee B (ed): Single-Handed: Devices and Aids for One Handers and Sources of These Devices. pp 137-149. 1989. Kerr D. 41. in Kostuik JP (ed): Amputation Surgery and Rehabilitation: The Toronto Experience. Melendez D. Churchill Livingstone Inc. 40. Bloomington. Prosthet Orthot Int 1980. 33. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. Erdman WJ. 13. Princess Margaret Rose Orthopaedic Hospital. Melendez T. Baltimore. 1985. Waggoner NR. 1986. Gullickson G: Energy cost of ambulation in health and disability: A literature review. 11. 39:225-232. Gardner WH: Left Handed Writing Instruction Manual. Patton JG: Developmental approach to pediatric prosthetic evaluation and training. Danville. Accent Special Publications. Arch Phys Med Rehabil 1978. 37. et al: Mechanical efficiencies of lower-limb amputees rehabilitated with crutches and prostheses. Inter-Clin Info Bull http://www. 28. Wash.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library 8. 23:62-69. Ill.30: Special Considerations. Edelstein JE: Musical options for upper-limb amputees. Pequannock. 16:13-15. 9. et al: Functional capabilities of lower limb amputees. Inter-Clin Info Bull 1977. 5 Crescent Ave. Rockville. 17. Mathur BP. Edinburgh. 1974. 10. Ill. Inter-Clin Info Bull 1971. 1988. Thief River Falls. Datta SR. in Lee MHM (ed): Rehabilitation. Macnaughtan AKM: Clothing for the Limb Deficient Child. New York. Boston. suppl 1. 26. catalogue. pp 150-164. Marina Del Rey. Rocky Hill. Biomed Eng 1976. Hunter JM. Singh P. St Louis. 32. Charles C Thomas Publishers. 11:380-382. Churchill Livingstone Inc. Roy BN. New York. 12:519-523.org/alp/chap30-01. Medic Publishing Co. Houghton Mifflin Co. 20. 23. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. San Francisco. Inter-Clin Info Bull 1971. Hettinger T. et al: Biomechanical approach to functional assessment for use of crutches for ambulation. Fisher SV. 36.asp[21/03/2013 21:57:26] . Friedmann L: Special equipment and aids for the young bilateral upper-extremity amputee. Harper & Row Publishers Inc. Heger H: Adaptive devices for amputees and training of upper extremity amputees. 25. Friedmann L: Toileting self-care methods for bilateral high level upper limb amputees. Fashion Able for Better Living. 19. 14. 1982. May EE. Training of upper extremity amputees. 21. Kuhn GG: Vaginal tampon applicator. Maddak Inc. Artif Limbs 1965. 31. Redmond. Springer-Verlag NY Inc. Springfield. Calif. Lifeboat Press. Md. New York. 1986. 1958. Engstrom B. Kegel B: Sports for the Leg Amputee. Friedmann L: Functional skills in multiple limb anomalies. Heinze A: Use of Upper Extremity Prostheses (video). J Assoc Child Prosthet Orthot Clin 1988. Danzig AL: Handbook for One-Handers. Everest & Jennings Avenues. 1978. 38. NJ 07440. MN 56701. 10:11-17. Ergonomics 1974. 29. 3233 East Mission Oaks Blvd. 24. Camarillo. Ring ND: Miscellaneous aids for physically handicapped children. 22. 27. 17:365-374. Bose KS. 8:43-51. The Interstate Special Education Series. LeBlanc M: Survey of arm amputees not wearing prostheses: Implications for research and service. 10:1-9. 4:29-36. Music and Human Well-Being. MMB Music Inc. Van de Ven C: Physiotherapy for Amputees: The Roehampton Approach. 59:124-133. New York. 9:26-33. in Banerjee SN (ed): Rehabilitation Management of Amputees. 15. CA 930112. Ganguli S: Analysis and evaluation of the functional status of lower extremity amputeeappliance systems: An integrated approach. 39. pp 248-252. 30. 12. Nesbitt JA: The International Directory of Recreation-Oriented Assistive Device Sources. Ill. catalogue. 1981. 18.oandplibrary. Federation of the Handicapped. J Rehabil Res Dev 1985. 34. 1986. Holliday PJ: Nonprosthetic care. Williams & Wilkins. p 263. in Atkins DJ. Datta SR. Springer-Verlag NY Inc. Aspen Systems Corp. 35. 1988. Prosthet Orthot Int 1984. A. Kessler HH: Three cases of severe congenital limb deficiencies: Twenty-year followup. Med Biol Eng 1974. Phippen W. White M: A Gift of Hope: The Tony Melendez Story. Narang IC. in Atkins DJ. 16. Kegel B: Physical fitness: Sports and recreation for those with lower limb amputation or impairment. Brunnstrom S: Training of the Lower Extremity Amputee. 1968. Karacoloff LA: Lower extremity amputation: A Guide to Functional Outcomes in Physical Therapy Management. Am J Phys Med 1960. catalogue. Techn Aid Disabled J 1983. 47. Inter-Clin Info Bull 1976. 50. Washam V: The One-Handers Book: A Basic Guide to Activities of Daily Living. WB Saunders Co. 1989. Youll WJ: Toilet aid for people with lower limb disabilities. in Moore WS. pp 13-15. 48. Iowa. Chapter 30 . Prosthetic. Contact Us | Contribute http://www.30: Special Considerations. Harper & Row Publishers Inc. 1990. New York. Perry J. Phoenix. 12:1-12. New York.Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library 1972. 1973. Wright B: Independence in toileting for a patient having bilateral upper-limb hemimelia.org/alp/chap30-01. Wm C Brown Book Co. 45. Typewriting Institute for the Handicapped. 42. New York. 49. 44. Waters RL. pp 250-260. Malone JM (eds): Lower Extremity Amputation. 1973. Chambers R: Energy expenditure of amputee gait. Cerebral Palsy Rev 1960. pp 11-12. Dubuque. 1958. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 30 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Smith LA: A method of typing for the handicapped: One-hand touch typing. Robinault IP (ed): Functional Aids for the Multiply Handicapped. Wellerson TL: A Manual for Occupational Therapists on the Rehabilitation of Upper Extremity Amputees. Philadelphia. 43. Scholastic Inc. AZ 85021. Harper & Row Publishers Inc. 15:21-24. 46.oandplibrary. White EE: Jim Abbott: Against All Odds.asp[21/03/2013 21:57:26] .Atlas of Limb Prosthetics: Surgical. 3102 West Augusta Ave. but also the parents and relatives. i. Those who were born with them.D. A prosthetic leg becomes Reproduced with permission from Bowker HK. We are greatly indebted to KublerInitially there will be Ross for her work in helping to clarify the stages of the grief process. This Atlas is about prosthetics. Prosthetic. Acquired amputees. In addition to the obvious differences brought about by growth. on the other hand. the child has parents and siblings who are growing and learning along with them. A passive arm may offer balance or a prop for sitting and crawling. Even in the discussion of surgical principles. Anything of a prosthetic nature is an aid. not a replacement. They will mourn the loss of their limb.asp[21/03/2013 21:57:32] . There are two major categories of pediatric patients with limb deficiencies. if all goes well. congenitally limbdeficient children will try to do whatever other kids do. reprinted 2002. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. the child will receive the support and nurturing that are doubly necessary to assist growth with the disability. and learning individual. the accomplishment of normal motor milestones should be facilitated. the child will reject it. ©American Academy or Orthopedic Surgeons. 1992. Health care professionals involved with a family working through these stages must learn to recognize the changes as they occur and be prepared to alter their approach accordingly. there is a different set of rules to follow when working with children. developing.e. and if it is not truly an aid. will have a profound sense of loss and undergo a period of readjustment. There will be a great sense of disappointment because of lost dreams and expectations not able to be met by their disabled child. and then denial and anger. Prosthetic. In infancy. American Academy of Orthopedic Surgeons.. IL. How well they manage this change greatly affects their acceptance of replacement prosthetic limbs. once said that the most important action that his parents took while he was growing up was to decide to have another child. The two groups of children have parents and relatives involved in their care. The chapters that follow address many of these unique concerns. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. The child is not just a small adult. they proceed through the same stages of development as anyone else. Those who lose a limb due to trauma or disease. but the needs of the limb-deficient child are not merely those of replacement parts. congenital deficiencies. In the first instance. they are very adaptable. Whether of congenital or acquired etiology. more realistic expectations will be set so that in the end. unless their amputation occurred when they were very young. want to be as they were prior to the amputation. Their motivation will be greatly influenced by their ability to resolve this inner turmoil. Click for more information about this text.org/alp/chap31-01. when we work with the limb-deficient child. their child's limb deficiency is a great source of guilt for them. born completely without arms and well known for his work with the disabled. Rosemont. Left to their own devices. and Rehabilitation Principles. shock. Thus. They will proceed through the universal grief response.Atlas of Limb Prosthetics: Surgical. The disabled child missing all or part of one or more limbs is a growing. With resolution and acceptance. We find that their only limitations are those placed upon them by adults. There are many of our patients' families who never reach this point of adjustment. http://www. new. Harold Wilke. and those who acquired them after birth. we have many different considerations beyond those involved with treating adults. That gesture showed him that they loved him for who he was sufficiently to risk having another child. As these children grow. they never completely resolve their grief. i.e. Rev. children react differently to disabilities than do adults. The pediatric limb deficiency clinic team therefore not only has the patient to be concerned with. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. M. Prosthetic. Fisk. edition 2. amputations. The motivations of the two groups are different. In the first instance. the child has no sense of loss and nothing new to get adjusted to. Equally important..oandplibrary.31: Introduction to the Child Amputee | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 31 Chapter 31 . and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). and Rehabilitation Principles Introduction to the Child Amputee John R. they will be angry and resentful. Prior to this time prosthetic components were oftentimes not available in pediatric sizes.oandplibrary. By 1970. Legs are required for mobility. Charles H. Clearly. The goal of the subcommittee was to raise the standards of prosthetic care for children in the United States. This concern can pertain to lower-limb prostheses but applies much more so to upper-limb prostheses. Lambert has reported that children followed at the University of Illinois required a new lower-limb prosthesis annually up to the age of 5 years. and then one every 3 or 4 years until 21 years of age. Strong. Assistant Executive Director of the Committee for Prosthetic Research and Development. lower prosthetic limbs. There is. As stated earlier. it will be rejected. biannually from 5 to 12 years. Upper-limb prostheses. and as soon as the child appreciates this. The Association of Children's Prosthetic/Orthotic Clinics has held an annual interdisciplinary conference since 1972. Upper-limb prostheses tend to be rejected outright when there is frustration with self. Children have many unique prosthetic needs. Michigan. Gerald F. four major symposia were sponsored by the subcommittee to reflect the state-of-clinic expertise during the 1960s. but the wearer may go to extremes to hide them. Frequently a limb is rejected as the child is confronted with a new group of peers. The fact that a cosmetic hand is easier for a parent to accept may have a far greater impact on whether or not it gets worn than what the child thinks of it. prosthetic wearing practices by the child are used as a behavior to influence their relationship with their parents.asp[21/03/2013 21:57:32] . There is little sound evidence to explain why some children adapt to a prosthesis quite readily and others reject anything that is placed on them. These actions reflect the acceptance by the child of his own body image to a greater or lesser degree. When pediatric amputees reach adolescence. they undergo the same intellectual and emotional changes that other adolescents face. Under the guidance of Hector Kay. there is little question that the child is not just a small adult. so are their residual limbs. Lower-limb prostheses may be worn because they are needed for ambulation. The clinic team is necessary to bring together professionals with expertise in addressing these many adjustment issues. acceptance into the group occurs. They may avoid swimming and clothing that fails to mask the limb loss such as shorts or dresses. however. it is hoped. Develop-mentally oriented physical and occupational therapists are an invaluable part of the clinic team. the need for an organized approach to the management of juvenile amputees across the country was discussed at a meeting in Grand Rapids. As their minds and bodies are growing.'' As. the annual conferences were expanded to include cooperating clinic chiefs and their team members. In 1954. the limb-deficient child has multiple needs that can only be addressed by the team. Chairman of the Prosthetics Research Board. may be more important. the subcommittee was charged to enlarge its sphere of activity to include children's orthoses and mobility aids. Frantz chaired the first meeting at UCLA in 1956. Members include not only individuals but also the clinic teams as a unit. appointed an interim committee of ten members to pursue the issue. and if it doesn't enhance function. The limb deficiency makes this adjustment that much more difficult.31: Introduction to the Child Amputee | O&P Virtual Library necessary when it is time to pull to stand. a difference in acceptance of upper vs. In considering all of these growth and adjustment issues. The need for frequent and regular checkups by the clinic team is obvious. the prosthesis rarely comes off. A third factor. This recognizes the importance of the team approach. It is now the primary forum for the exchange of information on the limb-deficient child in North America. Also. acceptance by the parents of the child's disability. To begin the dissemination of information and the establishment of clinic criteria. Few There have been several studies of rejection of upper-limb prostheses by children.org/alp/chap31-01. Prescriptions were withheld until the child started school and was therefore deemed to need a limb. At best it is a tool. have varying degrees of acceptance. The group officially became the subcommittee on Child Prosthetic Programs within the National Academy of Sciences Prosthetics Research and Development Committee in 1959. on the other hand. They don't want to be "different. sound conclusions have been reached.S. Dr. cosmesis and function are two major concerns. the limb goes back on to aid with function. The upper-limb prosthesis is not able to replace a missing part to the same degree that a prosthetic leg can. Subsequently. Frequent socket revisions or replacements are necessary to accommodate this growth. http://www. Socket modification can delay revision. proper documentation of growth potential is increasingly important. Histologically. It is very cosmetically pleasing in a child. forefoot amputation due to lawn mower injuries frequently leaves an infected residuum with plantar scarring. This is because the major complication of amputation surgery in children is bony overgrowth. skin breakdown occurs. Above all. alterations in fit are much better tolerated. but the results Marquardt in Germany suggests transplanting a cartilaginous apophysis are disappointing. not leave this to chance. especially for a less-than-optimal partial-foot amputation. the family is often unwilling to consider a revision as an alternative to a very clumsy partial-foot prosthesis. the relative length discrepancy experienced in a congenital limb deficiency is maintained. Concerns related to cosmesis. this is appositional bone growth of the remaining diaphysis. There is another reason to perform joint disarticulations rather than diaphyseal transections in children whenever possible. For example. This provides end-bearing ambulation with shorter length that will allow trans-femoral knee components. with resultant good sitting and standing cosmesis. It is clearly not growth from the remaining proximal physis. prostheses must facilitate function. The incidence of this complication is variously reported in the range of 10% to 30%. materials that are easily modified and lengthened should be used. The solution to this is a distal femoral epiphysiodesis.oandplibrary. after investing a lot of time and emotional effort in preserving length at all costs. Various techniques of handling the bone and periosteum during amputation have failed to decrease the incidence of this complication. When planning the proper time for surgical intervention on a proximal femoral focal deficiency (PFFD). is technically challenging. As a rule. To lengthen the useful life of a prosthesis. where malleolar size is not a problem. The residual limb does not need to be appreciably shortened overall since the appositional growth effectively adds length to the bone. revision is necessary. If a knee disarticulation is done too close to the time of physeal closure.31: Introduction to the Child Amputee | O&P Virtual Library The durability of the young healthy tissue on the residual limb of a child is quite different from that of the dysvascular adult amputee. Residual-limb length is of vital concern for the acquired amputee. Frequently a Syme ankle disarticulation fitted with a prosthesis is the best option. One must. and the bone may penetrate. With the advent of newer techniques of limb lengthening and deformity corrections. uncosmetic thigh. It does not occur with disarticulations but frequently follows metaphysealor diaphyseal-level amputations. The concept of preserving as much length as possible should be considered. Silastic caps or plugs have been tried. a long trans-femoral amputation in a 2-year-old becomes very short by the time that child becomes an adult. and function are very difficult to satisfy.asp[21/03/2013 21:57:32] . Skin grafts will frequently mature sufficiently to tolerate direct weight bearing as well as the shear forces experienced with socket wearing.org/alp/chap31-01. are easily destroyed by the abuse children give them. In that regard. it should be noted that durability of children's prostheses is more important than cosmesis. Those that the child must be careful of should be avoided. This problem should therefore be carefully considered in the initial treatment of each partial-foot http://www. soft covers. for instance. There is one area where the option of preserving length at all costs must be carefully exercised. Nevertheless. while cosmetically desirable. Skin is much more elastic and will better tolerate stretching to cover the end of the residual limb. especially by the use of disarticulation rather than transosseous ablation. the frequent changes necessary present an economic concern. making a functional partial-foot prosthesis. comfort. Consequently. however. For example. The skeletally immature child relies on growth of the residual limb to maintain sufficient length for good biomechanical strength later on. This is often required more than once until skeletal growth ceases. While it is advantageous to be able to walk barefoot without a prosthesis. there is bursal formation over the end of the bone that can become exquisitely tender. Usually from the ilium or preserving an epiphysis from the amputated portion of the limb. since 70% of the growth of the femur comes from the distal femoral physis. A knee disarticulation will avoid this problem. proper use of serial scan-o-grams is necessary. This is generally not a concern with the congenital amputee. on the other hand. Nevertheless. the relative retardation of physeal growth on that side may not be sufficient to avoid an overly long. This is the post-traumatic partial-foot amputation. Healing in a child is much different than in the adult. Occasionally. In addition. but once the residual limb becomes pencil shaped. The International Standards Organization (ISO) has recently adopted a definitive classification system for congenital limb deficiencies (Chapter 33). A recent collaborative study by a member of Shriners Hospital Clinics has demonstrated equal acceptability by the very young of body-powered or myoelectricpowered cosmetic hands. and cost-effective? More studies are needed to answer all of these questions. 1969. References: 1. This new system. As children grow and develop.31: Introduction to the Child Amputee | O&P Virtual Library amputation. partial. their efficacy needs to be demonstrated.e. Meyer LC. especially in their early years. Springfield. Ronner J: The effect of denervation on bony overgrowth after below knee amputations in rats. a number of topics unique to the limb-deficient child will be addressed. What is needed are controlled studies to evaluate the functional appropriateness of prescription ages. Kubler-Ross E: On Death and Dying. body vs.org/alp/chap31-01. No longer is it necessary to learn a series of ancient language roots to describe our patients. Deck JD. Other areas of interest are the surgical and pros-thetic/orthotic management of upper-limb deficiencies (Chapter 34A and Chapter 34B). There is good evidence that very young children are able to use myoelectric limbs. Sauer BW: The use of porous. Bunch WH. and recreational vehicles are all hazardous to the inexperienced. It is often asked whether dynamic-response feet for children should be prescribed. Clin Orthop 1977. Mac-millan Publishing Co Inc. transverse. 4. myoelectric power and tool vs. Is it necessary. Reluctance has been expressed in the past for doing revision surgery on upper-limb amputees. The developmental approach to upper-limb prosthetic training is discussed in detail (see Chapter 34D). 1969. Charles C Thomas Publishers. 3. In the past. Now it pertains to appropriate ages for specific terminal devices and feet. Lawn mowers. The two primary considerations to be addressed in the area of lower-limb deficiencies are the unique nature of some of the reconstructive surgical procedures for congenital deformities and the fact that prosthetic design must take into consideration the factors of growth and durability (Chapter 34A and Chapter 34B). MacDonnell JA: Age of fitting upper extremity prostheses in children.oandplibrary. utilizing just four words-longitudinal. tumor salvage procedures. should be addressed. Problems of Evaluation and Rehabilitation. cosmetic hand terminal devices. Ill. their motor skill capabilities change rapidly. Aitken GT: Osseous overgrowth in amputations in children. and total-has been accepted by the International Society for Prosthetics and Orthotics and the Association of Children's Prosthetic/Orthotic Clinics. http://www. There has also been an effort to develop criteria for the prescription of costly myoelectric limbs for very young children. and recreational concerns address the new frontiers being developed in the field of juvenile amputee management. To conclude the discussion of the child amputee with a chapter entitled Special Considerations is most appropriate (Chapter 36). In the chapters that follow. 7. The epidemiology of injuries causing traumatic amputations must be studied to learn how to provide a safer environment for our young. The needs of the limb-deficient child are indeed special as this introductory chapter has sought to point out.. Some clinics are claiming functional capabilities occurring earlier than we know them to happen in sound limbs. 40:655-662. Prosthetic prescription. Kruger L: Unpublished data. farm instruments. 122:333-339. Lambert C: Amputation surgery in the child. J Bone Joint Surg [Am] 1958. Orthop Clin North Am 1972. Lower-limb components are being proposed for the pediatric population based on successes with adults.asp[21/03/2013 21:57:32] . advantageous. age appropriateness for prosthetic prescription was related to the purported ideal age at which a child could use an upperor lower-limb prosthesis. The sections on the multiple amputee. in Swinyard CW (ed): Limb Development and Deformity. Due to the small body mass of the child and the frequent need for new limbs due to growth. It is time for this issue to be reconsidered. i. 2. New York. It will allow for a more concise data base and communication of statistics on an international basis. high-density polyethylene caps in the prevention of appositional bone growth in the juvenile amputee: A preliminary report. 6. Prosthetic components and training must change along with them. 5. 3:473-482. including acquired amputations (Chapter 32). 8. J Assoc Child Prosthet Orthot Clin 1990. Wang GW.Atlas of Limb Prosthetics: Surgical. Swanson AB: Bony overgrowth in the juvenile amputee and its control by the use of silicone rubber implants. 14:9-10. 42:78-91.org/alp/chap31-01. Weaver SA.31: Introduction to the Child Amputee | O&P Virtual Library Inter-Clin Info Bull 1975.asp[21/03/2013 21:57:32] . and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 31 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Contact Us | Contribute http://www. Chapter 31 . 1989 Annual meeting of the Association of Children's Prosthetic/Orthotic Clinics. 9. 11. et al: Comparison of myoelectric and conventional prostheses for adolescent amputees. 130:285-288. Am J Oc-cup Ther 1988. Clin Orthop 1978. 12.oandplibrary. Stamp WG: Epiphyseal transplants in amputations. et al: Acceptance rate of myoelectric prosthesis. Prosthetic. 8:9-18. Patterson DB. Inter-Clin Info Bull 1969. Wilke H: Presidential Guest Speech. Baugher WH. 25:73-76. 10. Skin grafts. whenever possible. Annual surveys of specialized child amputee clinics in the United States have repeatedly shown that approximately 60% of childhood amputations are congenital in origin and 40% are In contrast. Disarticulation preserves the epiphyseal growth plate and thereby ensures longitudinal growth of the bone. For the same reasons. In the 1. Prosthetic. may tolerate prosthetic use quite well in the child. In the older child. and power tool injuries are the most frequent causes of limb loss. Trauma is the proximate cause of most acquired amputations in children. followed closely by vehicular accidents. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. American Academy of Orthopedic Surgeons. open wounds may successfully be closed under slightly more tension in the child than would be permissible in similar adult patients. malignant tumors are responsible for more than half. In over 90% of acquired amputations a single limb is involved. with trauma causing roughly Although there are obviously many traumatic twice as many limb losses as disease. In either case. and a wide variety of miscellaneous disorders are responsible for the remainder of amputations due to disease ( Fig 32-2. good surgical judgment must be used since even the tissue tolerance of the child has its limitations. Of the disease processes necessitating amputation in children. and wound closure under tension may be judiciously used in the child to conserve limb length without compromising wound healing or subsequent prosthetic use.). Vascular malformations. gunshot wounds and explosions. however. In each instance. 1992. reprinted 2002. the highest incidence occurring in the 12. This discrepancy suggests that children with the more complex congenital limb deficiencies are referred to specialized child amputee clinics. conserve all limb length possible. and Rehabilitation Principles Acquired Amputations in Children Robert E. http://www.D. Reproduced with permission from Bowker HK. and Rehabilitation Principles. to perform a disarticulation rather than a transdiaphyseal amputation in a growing child. Prosthetic. Click for more information about this text. M. incidents that may result in childhood amputations. Acquired amputations are secondary to either trauma or disease.Atlas of Limb Prosthetics: Surgical. edition 2. most probably because males tend to engage in more hazardous activities. In attempting to conserve length in the severely traumatized limb. and it is a lower limb that is involved in 60% of the cases. neurogenic disorders. whereas most acquired childhood amputations are managed in less specialized settings. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists SURGICAL PRINCIPLES The well-established surgical principles for amputation surgery in the adult are just as The cardinal dictum in children is to applicable to amputations performed in children. power tools and machinery are the worst offenders. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). The increased elasticity of the child's skin coupled with an excellent blood supply allows the surgeon to apply somewhat heavier skin traction to open amputations in the child than would be safely tolerated in the adult. Loss of stump length due to epiphyseal loss is most readily apparent in trans-femoral amputations in young You can help expand the O&P Virtual Library with a tax-deductible contribution. a survey of prosthetic facilities has revealed that significantly more acquired. firm traction. IL. Males outnumber females in incidence of acquired limb loss in a ratio of 3:2. gunshot wounds. Split-thickness skin grafts. Prosthetic.to 21-year-old group. consistent with appropriate treatment for the condition that requires the amputation. Tooms. vehicular accidents. children with acquired amputations receive prosthetic services than do those with congenital limb deficiencies.32: Acquired Amputations in Children | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 32 Chapter 32 . adequate tissue vascularity of the growing child may allow the surgeon to use surgical techniques that are not successful in the adult. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical.org/alp/chap32-01.oandplibrary.asp[21/03/2013 21:57:36] .). A second surgical dictum is. the number of children with acquired amputations is relatively small but represents a significant segment of the pediatric population with major orthopaedic problems. and railroad accidents.to 4-year-old group. even over large areas of the stump. Rosemont. ©American Academy or Orthopedic Surgeons. power tools such as lawn mowers and household accidents account for most amputations ( Fig 32-1. Adventitious bursae frequently develop in the soft tissues overlying an area of terminal overgrowth. Disarticulation also precludes the development of terminal or appositional overgrowth of new bone at the transected end of a long bone-the most common complication of amputation surgery in the growing child. Many surgical techniques have been devised to prevent terminal overgrowth from developing. the appositional growth of new bone may exceed the growth of the overlying soft tissues to such an extent that the bone end actually penetrates the skin ( Fig 32-4. Stump revision is seldom necessitated by scarring alone.org/alp/chap32-01. These include using intramedullary implants of silicone rubber or porous polyethylene to cap the resected bone end and prevent terminal overgrowth. More extensive prosthetic modifications may be necessary when the scarred area is larger or is over weightbearing areas of the stumps. fibula. This is an appositional overgrowth of new bone at the transected end of a long bone.). thereby eliminating the cosmetic objection to this type of surgery when it is performed in the adult. When upper-limb amputations are complicated by extensive trunk scarring.32: Acquired Amputations in Children | O&P Virtual Library children. Conservative treatment of such symptomatic bursae by aspiration. the distal femoral epiphysis. Permanent relief from those symptomatic bursae overlying an area of terminal overgrowth usually requires surgical excision of the bursa combined with appropriate resection of the underlying bone ( Fig 32-5. http://www. However. The shoulder saddle with chest strap is an excellent solution in such cases ( Fig 32-6. necessary to correct the problem.). In this condition. but may require prosthetic modification to disperse weight-bearing forces and diminish shear Minor modifications in the prosthetic socket will stress at the stump-socket interface. the best treatment method remains stump revision with appropriate resection of the bony overgrowth. For the severely scarred transtibial stump. Wearing a nylon sheath next to the skin and beneath the stump sock or wearing multiple stump socks may prevent tissue breakdown from stump-socket interface friction over small areas of scarring. The prominent condyles or malleoli resulting from disarticulation usually undergo atrophy with further growth of the child. Bone spurs often form at the periphery of transected bone ends as a response to periosteal stimulation at the time of surgery. This approach may eventually prove to be effective. Suspension is by means of a supracondylar strap or. the most commonly used method of relieving excessive pressure and shear forces is attaching outside knee joints and a weight-bearing thigh corset to a total-contact socket. which accounts for approximately 70% of the longitudinal growth of the femur. in that order. if necessary. harnessing techniques alternative to the figure-of-8 harness may be necessary. or skin grafting is usually well tolerated by the child amputee. the resultant stump present at 16 years of age will be quite short and will be a considerably less than optimal skeletal lever for prosthetic use ( Fig 32-3.). When a midthigh amputation is performed in a young child. I have been most successful in eliminating skin breakdown in the extensively scarred transtibial stump by using a meticulously fitted hard-socket patellar tendon-bearing (PTB) prosthesis worn over two or three five-ply stump socks. COMPLICATIONS Terminal overgrowth is the most common complication of amputation surgery in the skeletally immature individual. Such bone spurs rarely necessitate stump revision and should be easily distinguished from terminal overgrowth. Check sockets made of transparent polycarbonate plastic and stump socks of pressure-sensitive fabric allow precise identification of pressure-producing areas in the socket at both the transtibial and the transfemoral amputation levels. In amputations at this level. recurrences are common and may necessitate repeated stump revision at 2. Bursae that form over bony prominences subjected to recurrent pressure from a prosthetic socket are effectively managed by appropriate socket modifications.). Extensive stump scarring from trauma. is sacrificed. tibia. This has been necessary in 8% to 12% of several Once surgery becomes reported large series of acquired amputations in children. usually relieve symptomatic pressure that is concentrated over small areas of scarring in relatively non-weight-bearing areas of the amputation stump.oandplibrary. Other successful techniques include the use of an air cushion socket or a Silastic gel socket insert with a rubber sleeve for suspension. previous surgery. It is in no way related to epiphyseal plate growth. and previous attempts to Terminal overgrowth prevent this problem by epiphysiodesis have not been successful. and femur. and stump wrapping is seldom more than temporarily effective.to 3-year intervals until skeletal maturity. with outside knee joints and a thigh corset.asp[21/03/2013 21:57:36] . corticosteroid injection. occurs most often in the humerus. oandplibrary. Lawn mower injuries and severe burns that result in partial limb loss occur in sufficiently large numbers to justify specific comments on the surgical management of these problems. a decision may be made to revise the amputation to a higher level or to continue with a more conservative approach. followed by skin traction until secondary closure is performed 5 to 7 days later. and soft-tissue-shifting plastic surgery procedures. an open amputation is preferable. it may be possible to partially close the wound at this time with minimal additional bone resection. In reviewing a large series of acquired childhood amputations. Initial bone resection should be minimized until sufficient time has elapsed to be certain how much viable soft tissue will ultimately be available for wound closure." operation. The Krukenberg procedure provides a crude pinching mechanism with preserved sensation by splitting a long transradial stump into radial and ulnar rays that are widely separated and covered with skin possessing normal sensation. or "lobster-claw. If extensive skin grafting or tissue-shifting plastic surgery procedures such as a Z-plasty are needed. For example. SURGICAL TECHNIQUES Except for the previously discussed surgical principles of limb length conservation and the need for performing disarticulations in preference to transdiaphy-seal amputations. It should be stressed that this procedure should be performed as a true disarticulation with a Syme-type soft-tissue closure and not as a supramalleolar amputation as is done in the conventional ankle disarticulation in the adult.32: Acquired Amputations in Children | O&P Virtual Library Neuroma formation in amputation stumps of children is seldom symptomatic enough to warrant surgical treatment. The initial debridement of such injuries should be limited to excision of only that tissue that is absolutely nonviable. it is better to err on the side of conservatism. Painful phantom limb sensation does not occur in growing children. Some of these injuries involve only the digits or the distal metatarsal area and present no great treatment problems. The physiologic tolerance of growing children fortunately allows the surgeon to preserve limb length by using skin grafts. may well deserve consideration in the child with a long transradial (below-elbow) amputation. The procedure has its greatest application in bilateral upper-limb amputees. most being Aitken satisfactorily managed by socket adjustment. with any tissue of questionable viability being preserved. This decision is seldom obvious. the phantom sensation is rapidly lost.asp[21/03/2013 21:57:36] . the wound is lightly packed open. The phantom limb phenomenon always occurs in children following acquired amputations. when http://www. but has been reported in the teenager. proper surgical judgment is necessary to determine which injury can reasonably be expected to provide a serviceable partial-foot amputation by using skin grafts and soft-tissue-shifting plastic surgery procedures and which injury would require revision to a higher level. Most lawn mower injuries sustained by children result in partial-foot amputations. Following thorough irrigation and debridement. If the amputation is performed on a child under the age of 10 years. The forearm muscles that attach to the two rays provide voluntary opening and closing of these rays. preservation of limb length is of major concern in both of these injuries.org/alp/chap32-01. an amputation at the midtarsal joint level that requires extensive skin grafting over the plantar surface of the heel and results in a loss of the foot dorsiflexors will be less functional and require more subsequent treatment than will revision to a higher level. If continued conservatism seems appropriate. Children who have the operation performed early in life learn to use the pincer and are not often emotionally disturbed by the unsightly appearance of the stump. several specialized surgical procedures do deserve mention. Therefore specific surgical procedures will not be outlined for any of the major levels of amputation in the upper or lower limb. However. Five to 7 days later the wound is examined with the patient under anesthesia. Others are quite extensive and involve most of the foot with multiple deep and extensively contaminated wounds. The Krukenberg. traction. As in other traumatic incidents. In these latter instances. found that only 4% required surgical treatment for neuromas. After further debridement of any nonviable tissue. these are more safely done at the time of a second wound dressing 5 to 7 days later. Syme ankle disarticulation is a frequently indicated level of amputation in the growing child. surgical techniques in the child do not differ significantly from those used for the adult. If revision to a higher level (Syme ankle disarticulation or transtibial amputation) is indicated at the time of the first wound dressing. and when doubt exists. especially in the blind. Orthot Prosthet 1973. 11:5-8. Despite splinting. Aitken GT: Surgical amputation in children. Successful prosthetic use usually necessitates modification of prosthetic sockets and suspension systems as noted previously. 15. 46:1540-1548. Univ Mich Med Center J 1970. Lyquist E. Kay HW. Prosthetic and Orthotics. J Bone Joint Surg [Am] 1963. Aitken GT: Management of the juvenile amputee. 8:9-16. New York University Post-Graduate Medical School. 18. and the resultant scarred stumps may present very difficult problems in prosthetic fitting. New York.oandplibrary. Inter-Clin Info Bull 1973. in Aitken G (ed): The Child With an Acquired Amputation. The use of pressure dressings over scarred and grafted areas helps to decrease scar hypertrophy. Chapter 32 . Frantz CH. Ebner JD: Pressure sensitive devices for de-nervated hands and feet. Meyer LC. In such circumstances. 1972. 8. Friz BR. 9. 4. 2. Inter-Clin Info Bull 1972. 10. Frantz CH: Management of the child amputee. Inter-Clin Info Bull 1968. 25:659664. Inter-Clin Info Bull 1966. 7. 27:3. DC. 3. When healing has occurred. Washington. 17:246-298. J Bone Joint Surg 1939.36:188-189. Romano RL. J Bone Joint Surg [Am] 1969. 51:109-116. Koepke GH. Rosenfelder R. Swanson AB: Silicone-rubber implants to control the overgrowth phenomenon in the juvenile amputee. 7:1-15.Atlas of Limb Prosthetics: Surgical. Instr Course Lect 1960. National Academy of Sciences. During this time. 9:6-19. Inter-Clin Info Bull 1975. Frantz CH: The juvenile amputee. 14. Aitken GT. Inter-Clin Info Bull 1975. 17.32: Acquired Amputations in Children | O&P Virtual Library granulation tissue begins to cover open areas and the danger of infection is less. Clin Orthop 1959. Tabloda C: The juvenile amputee with a scarred stump. 21:442-443.asp[21/03/2013 21:57:36] . McUmber RA: Silicone gel be-low-knee amputation prostheses. Brand PW. 13. 5. Giacinto JP. Thermal or electrical burns may cause such widespread tissue destruction that amputation of a major portion of the limb may become necessary. Wilson LA. 1:1-8. 1967. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 32 http://www. 22. 21. 12. 14:1-4. 11. Sauer BW: The use of porous high-density polyethelyne caps in the prevention of appositional bone growth in the juvenile amputee: A preliminary report. Inter-Clin Info Bull 1969. 5:11-12. in Aitken G (ed): The Child With an Acquired Amputation. Von Soal G: Epiphysiodesis combined with amputation. Aitken GT: The child with an acquired amputation. Swanson AB: Bone overgrowth in the juvenile amputee and its control by the use of silicone rubber implants. gentle massage is often beneficial in mobilizing scar tissue that is adherent to bone. J Bone Joint Surg [Am] 1953. LaNone AM: Salvage of a short below-el-bow amputation with pedicle flap coverage. late soft-tissue releases may be needed to improve joint motion. Aitken GT. 20. 16. 12:5-9. Washington. 10:5-34. Snelson R: Use of transparent sockets in limb prosthetics. Bull Prosthet Res 1968.org/alp/chap32-01. Burgess EM: Extremity growth and overgrowth following amputation in children. National Academy of Sciences. Radcliffe CW: Air-cushion socket for patellar-tendon-bearing below-knee prostheses. Inter-Clin Info Bull 1962. Lambert CN: Etiology. conservative treatment should be pursued until there is adequate demarcation of nonviable tissue to allow open amputation at the lowest possible level. References: 1. 6. Davies EJ. Clippinger FW Jr: Children with amputations. 19. Prosthetic. DC. Swanson AB: The Krukenberg procedure in the juvenile amputee. Inter-Clin Info Bull 1969. Herndon JH. 14:1-10. Aitken GT: Overgrowth of the amputation stump. 45:17351741. 9:3047. Fishman S: 1018 Children With Skeletal Limb Deficiencies. appropriate splinting of proximal joints is essential to minimize the development of joint contractures in nonfunctional positions. J Bone Joint Surg [Am] 1962. Cary JM: Traumatic amputation in childhood-primary management. Extensive skin grafting is usually necessary in children with severe burns. 1972. Hall CB. Contact Us | Contribute http://www.asp[21/03/2013 21:57:36] .32: Acquired Amputations in Children | O&P Virtual Library The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .org/alp/chap32-01.oandplibrary. Some further minor modifications.). 8548-1:1989 "METHOD OF DESCRIBING LIMB DEFICIENCIES PRESENT AT BIRTH" The standard is reproduced here with the permission of the International Organization for Standardization (ISO). made more recently. The history of classifications devised since 1961. and Rehabilitation Principles The ISO/ISPO Classification of Congenital Limb Deficiency H.33: The ISO/ISPO Classification of Congenital Limb Deficiency | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 33 Chapter 33 .org/alp/chap33-01. The use of terms derived from Greek or Latin roots may sound impressively scientific but are both inaccurate and ambiguous and are often misused. although there may be digital buds. Prosthetic.Atlas of Limb Prosthetics: Surgical. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Prosthetic. (Eng.P. reprinted 2002. and this must be capable of translation into all languages. edition 2. including the work of the International Society for Prosthetics and Orthotics (ISPO) "Kay" committee.C. http://www. Click for more information about this text. and Day.J. Rosemont.C. accurate system of classification and nomenclature is needed. ©American Academy or Orthopedic Surgeons. a logical. or epidemiology. 1992. Reproduced with permission from Bowker HK. The deficiencies are described on anatomic and radiologic bases only. 3.) In order to facilitate scientific communication about congenital limb deficiency. American Academy of Orthopedic Surgeons.R." which has been used to describe every level and type of deficiency. IL. The classification is restricted to skeletal deficiencies. peromelia.asp[21/03/2013 21:57:41] . or from any ISO member body. Classically derived terms such as hemimelia. No attempt is made to classify in terms of embryology. Swanson. have enabled the ISPO classification to be drafted and accepted by the participating nations as an international standard. METHOD OF DESCRIPTION Transverse The limb has developed normally to a particular level beyond which no skeletal elements exist. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). It is possible to use another descriptor in the phalangeal case to indicate a precise level of loss within the fingers.). Prosthetic. (Lon.oandplibrary. The lack of a suitable system has allowed the use of the term "congenital amputation"-implying that a limb segment has been lost before birth-to be used for cases that are patently failures of formation. Case Postale 56. are avoided because of their lack of precision and the difficulty of translation into languages that are not related to Greek. has been described previously by Kay. CH-1211 Geneva 20. The former resemble an amputation residual limb in which the limb has developed normally to a particular level beyond which no skeletal elements are present. and Rehabilitation Principles. and therefore the majority of such cases are due to a failure of formation of parts. It has three constraints: 1. etc. Such deficiencies are described by naming the segment at which the limb terminates and then describing the level within the segment beyond which no skeletal elements exist ( Fig 33-1. etiology. Day..R.S. Deficiencies are described as transverse and longitudinal. Copies of this standard are available from the ISO Central Secretariat.B. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. All other cases are classed as longitudinal: a reduction or absence of an element or elements within the long axis of the limb. L. 2. none more frequently than "phocomelia. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. M. Atlas of Limb Prosthetics: Surgical. Inter-Clin Info Bull 1974. and JB Lippincott. Contact Us | Contribute http://www.oandplibrary. metatarsal. Heinemann Medical books Ltd. a classification and a pattern of malformation of congenital limb deficiencies. 3. Frantz CH. 10:24-25.asp[21/03/2013 21:57:41] . radial. BIBLIOGRAPHY Burtch RL: Nomenclature for congenital skeletal limb deficiencies. N J Bull Acad Med 1964.): 1. and it can be used to indicate some treatment as well as the deficiency. The number of the digit should be stated in relation to a metacarpal. Day HJB: Nomenclature and classification in congenital limb deficiency.org/alp/chap33-01. and phalanges. 5. and Fig 33-3. Willert HG: Dysmelia. the numbering starting from the preaxial. a revision of the Frantz and O'Rahilly classification. but it must be understood that the stylized representation of the limb that is used in these figures is neither part of the original ISPO "Kay" committee work nor of the new international standard. 51:399-414. The term "ray" may be used to refer to a metacarpal or metatarsal and its corresponding phalanges. Spastics International Medical Publications. Any bone not named is present and of normal form. W. State whether each affected bone is totally or partially absent. 10:166-169. O'Rahilly R: Congenital skeletal limb deficiencies. or tibial side.. Henkel HL. Blackwell Scientific Publications Inc. Edinburgh. Chapter 33 . and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 33 The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Kay HW: A proposed international terminology for the classification of congenital limb deficiencies. J Bone Joint Surg [Br] 1969. The following procedure should be followed to describe such a deficiency (see Fig 33-2. 1975. Swanson AB: A classification for congenital malformations of the hand. Kay HW: The Proposed International Terminology for the Classification of Congenital Limb Deficiencies. in Murdoch G (ed): Amputation Surgery and Lower Limb Prosthetics. 1988. and in this case there may be normal skeletal elements distal to the affected bone or bones. but the author has found it to be the most useful way of illustrating deficiencies in clinical notes. Examples of transverse and longitudinal deficiencies are shown in Fig 33-4. 2. 43:1202-1204. 13:1-16. In the case of partial deficiencies the approximate fraction and the position of the absent part may be stated. J Bone Joint Surg [Am] 1961. Artif Limbs 1966. Swanson AB: A classification for congenital limb malformations. and Fig 33-5. pp 271-278. the Recommendations of a Working Group of ISPO. Name the bones affected in a proximodistal sequence by using the name as a noun. 4.33: The ISO/ISPO Classification of Congenital Limb Deficiency | O&P Virtual Library Longitudinal There is a reduction or absence of an element or elements within the long axis of the limb. 1:8-22. J Hand Surg 1976. Prosthetic. and Rehabilitation Principles Upper-Limb Deficiencies: Surgical Management Terry R. and tip pinch. it is usually a hindrance to the congenital amputee. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). particularly in partial hand and foot loss.asp[21/03/2013 21:57:45] . 1992. The child must be able to aim the hand so that it can precisely approach an object by using visual as well as tactile clues. Most parents have feelings of guilt and grieve that their infant is not as perfect as they had anticipated through the course of the pregnancy. Prosthetic.34A: Surgical Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 34A Chapter 34A . Conflicting advice from wellmeaning friends and relatives may create further parental tension and confusion. many parents seek a cosmetic prosthesis that will conceal their child's abnormality without regard to its functional impact. Since this posture is often employed to grasp and twist a key. Tip pinch is used to pick up a small coin from a table top. this pattern is also known as key pinch. The hand must also be capable of releasing the object from its grasp. ©American Academy or Orthopedic Surgeons. it must provide the child with the ability to either accomplish otherwise impossible activities or to carry out activities more easily or more rapidly. At times. and middle fingers. to make their child "normal" and whole. http://www. Parental concerns and expectations must be dealt with in an honest and forthright fashion by both the physician and the prosthetist caring for the child.D. the child may even express the thought that the prosthesis is to be worn merely to please parents who cannot accept them as they really are-without a prosthesis. they gradually understand the potential encumbrance of a purely cosmetic prosthesis. Prosthetic. M. The fingers are usually extended at the interphalangeal joints while the metacarpophalangeal joints are partially flexed. The predictable lack of success when a purely aesthetic prosthesis covers sensate skin in the hand should be openly discussed. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. cosmetic restoration. The birth of a child with an upper-limb deficiency leads to a myriad of confusing parental emotions. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Light. while power prehension is used to hold larger objects. Tip pinch provides contact with the distal end of the distal phalanx of the thumb with the distal phalanx of the index or of the index and middle fingers. As parents observe their growing child functioning without a prosthesis. If prosthetic wear becomes a source of conflict between parent and child.oandplibrary. The object is then grasped by the closing fingers and supporting thumb. often with somewhat greater force. lateral pinch. while the radial digits (index and middle fingers) are primarily used in precision prehension. The object itself usually does not contact the palm. index. The hand should be able to maneuver in space under volitional control and should be able to reach the body as well as the area in front of the body. In palmar pinch the flat palmar pads of the thumb and fingers secure opposite sides of the object being grasped. Many parents feel an intense need to "do something. Although an aesthetic prosthesis may aid the rehabilitation of the traumatic amputee. IL. In lateral pinch the palmar surface of the thumb's distal phalanx is brought against the radial border of the index finger.org/alp/chap34-01. If an active prosthesis is to be successfully integrated into the child's life-style. Power prehension involves the ulnar digits (most often ring and little fingers).Atlas of Limb Prosthetics: Surgical. Precision prehension is used to hold relatively small objects with modest force. Initially. In precision prehension. The two major types of grasp are precision prehension and power prehension. American Academy of Orthopedic Surgeons. edition 2. Click for more information about this text. may be considered a functional improvement. Prosthetic. the object is secured between the distal phalanx of the thumb and the index finger or between the thumb. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. The three most common forms of precision grasp or pinch are palmar pinch. The hand allows the child to explore his environment and manipulate objects within that environment." either surgical or prosthetic. Power grasp usually results in contact of the object against three surfaces: the palmar aspects of the Reproduced with permission from Bowker HK. and Rehabilitation Principles. Rosemont. reprinted 2002. The child's growing awareness of his abnormality is usually the result of comments from playmates. particularly at that time. then both hands will act together. Portions of the affected limb that are useful for prehension without a prosthesis should never be amputated. the palm of the hand. While approximately half of lower-limb congenital amputees require surgical revision prior to prosthetic fitting. If this is most easily accomplished by one hand. This will allow the child to also develop functional capabilities out of the prosthesis. grasp it. When the thumb is absent. Construction of an ulnar-buttressing digit by either distraction lengthening. Feelings may be further complicated by impending marriage and the prospect of offspring with similar abnormalities. the removal of a functionless part may facilitate the fitting of a prosthesis. however. The child usually does not become selfconscious until about the age of 6 or 7 years. the majority of the thumb power is contributed by the stabilizing effect of the adductor pollicis. only about 10% of congenital anomalous upper limbs fit for prostheses Consultation between the surgeon and prosthetist allows the require surgical revision. In some instances. These activities usually involve the transmission of force through the terminal portion of the limb to another object. conversion of a malformed part to an amputation may result in an aesthetic improvement. As the baby begins to explore its environment.asp[21/03/2013 21:57:45] . In this case. Although the distal phalanx of the thumb may wrap around the object. and the thumb metacarpal or proximal phalanx. The young child's goal is to reach the cookie. Access to knowledgeable genetic counseling is essential. TIMING http://www. The object may be secured against the chest. Other points of psychological stress occur during adolescence as dating begins and concerns arise over attractiveness to the opposite sex. It is possible to fit a prosthesis around a short phocomelic limb. shifting the index finger to the thumb position by polli-cization will improve power grasp as well as facilitate precision activity.org/alp/chap34-01. the prosthesis may allow digits to function while the prosthesis is worn. The hand also has an important role in nonprehensile activities. which resists the pressure transmitted from the fingers through the object. toe-phalanx transfer. The monodactylous hand consisting of only a thumb is capable of nonprehensile activities such as holding a shoe lace in place but is incapable of either power or precision grasp.34A: Surgical Management | O&P Virtual Library flexing fingers. surgeon to understand which anomalies will obstruct prosthetic donning and wear. The hand and the face are the unclothed areas of skin most often exposed to scrutiny. Without the buttressing effect of a thumb. When anomalous parts have an abnormal appearance and function is not compromised by their deletion.oandplibrary. Nonprehensile activities are usually unaffected by surgical reconstruction. or well-meaning adults. On occasion. At this age peer pressure may cause the child with a unilateral abnormality to conceal the hand in a pocket or may lead the child to reject an otherwise successful prosthesis. This may also be achieved by a prosthesis that provides a passive buttress. siblings. Aesthetic considerations are important when weighing different therapeutic alternatives in the management of congenital hand abnormalities. Other nonprehensile activities include the punch thrown by a boxer or pushing open a swinging door. Compensation may be achieved by flexing the fingers and wrist and securing a large object against the distal portion of the forearm. radial aplasia) and digital motion is good. and bring it to its mouth. SURGICAL TREATMENT As one considers the treatment of an anomalous hand. Nonprehensile activities include typing or button pushing. If the object is large or if singlehand prehension is not possible. The infant is unaffected by his abnormality. it learns to use its unique physical capabilities to best advantage.. it is well to contrast the effectiveness of surgical reconstructions with or without prosthetic management as opposed to doing neither. power activities cannot be readily accomplished. or free-toe-transfer may allow the hand to achieve meaningful prehension. the closest or most efficient hand will be employed. side-to-side pinch will allow the child to perform most precision activities with reasonable facility. If a hand lacks a thumb (e. When upper-limb prehension is severely compromised.g. they should be removed. a child may develop the capacity for foot prehension. In cases in which the web involves only a portion of the length of the digits. Successful surgical procedures surface both digits with durable skin.oandplibrary. SYNDACTYLY Syndactyly. The sophistication of the prosthesis is increased as the child matures. Surgical release of syndactylized digits is usually indicated to enhance digital independence. centralization of the wrist may sometimes be delayed until the child is 3 or 4 years of age. When skeletal and nail elements of the syndactylized digits are separate. particularly with profound contralateral abnormalities. the syndactyly is said to be simple. or a lack of access to prosthetic care. it is termed an incomplete syndactyly. Surgical reconstruction is rarely indicated. the condition is termed complete syndactyly. In children with TAR syndrome (thrombocytopenia with absent radius). Because the surface area of two syndactylized digits is far less than the skin surface area of two separated digits. a fullthickness skin graft is necessary to supplement local flaps. Even short digits consisting of only a proximal phalanx may benefit from separation. SHORT TRANSRADIAL AMPUTATION This common level of terminal deficiency is effectively treated prosthetically. Index finger radial abduction may be increased and pinch improved when a short index finger is untethered from the middle finger. their frustration when both hands are immobilized increases. Because the cosmetic disadvantage of this procedure is substantial. It is best to make major decisions regarding the reconstruction or deletion of digits when children are young.A and B). Syndactyly release must provide skin coverage of the adjacent lateral surfaces of the released digits and also create a proper web space floor. Initial prosthetic management begins with a passive hand.34A: Surgical Management | O&P Virtual Library It is usually preferable to begin surgical reconstruction of the anomolous hand prior to or about the first birthday. in whom low platelet counts at birth gradually increase with age. When syndactylization extends the entire length of the digit. Effective techniques employ skin flap tissue to create a sloping web space http://www. and accommodate growth of the digit without secondary contracture ( Fig 34A-1. The parental temptation to wait until the child is older to let them make up their own minds should be avoided since this places unrealistic pressure on the adolescent. the joining together of digits. As the child ages. it is usually wise to wait until before considering elective the child's platelet count has increased to at least 60. Anesthesia can usually be safely accomplished by 6 months of age.asp[21/03/2013 21:57:45] . have further suggested that syndactyly of digits containing angulated phalanges be termed complicated syndactyly. In some instances. This creates a prehensile limb that will also allow prosthetic fitting.000/mm surgical reconstruction. In such cases.org/alp/chap34-01. Many skin flap techniques have been advocated for the separation of syndactylized digits. early bilateral surgery may spare the child an additional anesthetic. Some procedures such as toe phalanx transfer must be carried out early for revascularization and subsequent growth. may be categorized as complete or incomplete. often as a result of congenital constriction band syndrome. In addition. Acrosyndactyly refers to syndactyly in which the ends of the fingers are joined. Dobyns et al. associated blindness.. For children under 18 months of age. the syndactyly is termed complex. create an appropriate web space floor. WRIST DISARTICULATION The Krukenberg procedure has been suggested as a reconstructive alternative for children with congenital absence of the hand. it is wise to delay surgery until children are older because of systemic considerations. It is inappropriate to place the burden for deciding whether a digit is to be deleted or pollicized upon an adolescent. Children undergoing digit-shifting procedures such as pollicization may benefit from early integration of the pollicized digit into evolving patterns of grasp. with subcategories of simple or complex. When there is joining of digital skeletal and/or nail elements. The radius and ulna are separated from one another by the Krukenberg procedure. it is rarely appropriate for the unilateral case (see Chapter 36A). it is possible to operate on both hands during the same surgical anesthetic. Type I deformities may present as simply a wide distal phalanx and nail.A and B). Dorsal flaps provide the best skin color match when the web space is viewed from the dorsum but may result in a hypertrophic scar traversing the inter-digital commissure. or from a combination of both palmar and dorsal tissue. care must be exercised in matching the nail matrix to avoid an unsightly longitudinal nail ridge.). while the ulnar digit possesses a collateral ligament along its ulnar border. The web palmar commissure is supple enough to allow interdigital abduction of up to 45 degrees. from the palmar aspect of the hand. as though one or more of the five mesenchymal condensations was inappropriately longitudinally split. Skin grafts are sutured in place. This flap tissue may be derived either from the dorsum of the hand. Since the web space is usually viewed from the dorsum. When multiple digits are syndactylized. The two digits abut with adjacent articular facets and are bound together by pericapsular tissue. Wassel has separated these abnormalities into seven categories. Type II duplications consist of two undersized (in comparison to normal) distal phalanges seated atop a somewhat widened proximal phalangeal distal articular surface. Osteotomies should be carried out distal to the physis to avoid growth disturbance. The web space floor normally begins just distal to the metacarpophalangeal joint and slopes to the edge of the palmar commissure approximately one third the length of the proximal phalanx segment. In black children. Preaxial Polydactyly takes many forms. The radialmost digit possesses a collateral ligament along its radial border. When the latter technique. it is usually wise to avoid releasing both sides of a digit during the same procedure. Skin incisions on the palmar and dorsal surfaces of the syndactylized digits should be planned to avoid longitudinal scars crossing digital flexion creases because these scars tend to contract with growth. the difference in color is particularly noticeable in darkskinned individuals. templates are made of the residual defects. After the web space floor has been closed and digital flaps rotated into place.oandplibrary. digits are rarely supernumerary. Simply amputating one of the duplicate digits will usually result in a residual digit that is considerably smaller than its counterpart on the opposite side. Most often polydactylous digits are abnormal and suggest an abnormal segmentation or separation of digital ray condensations. Correction of angulation is usually achieved by a closing wedge osteotomy and secured by Kirschner wires. that is. The challenge of surgery is not simply to remove sufficient tissue but rather to retain tissue sufficient to optimally reconstruct the retained digits.org/alp/chap34-01. Interdigital dressings are maintained until all wounds have healed. A palmar flap provides a better commissure contour but results in the shifting of pink palmar skin into the web space. known as the BilhoutCloquet procedure. they rarely represent parts additional to a normal hand. post-axial (ulnar) Polydactyly is the most common form. Zigzag incisions may be planned to interdigitate skin flaps and defects to effect either full closure of one digit or partial closure of two adjacent digits. two alternative treatments may be considered. metacarpophalangeal and inter-phalangeal joints are parallel. An opening wedge osteotomy using a segment of excised bone as intercalated graft is occasionally indicated.. Central Polydactylous Polydactyly is less common than either preaxial or postaxial Polydactyly. If two nails are present.asp[21/03/2013 21:57:45] . Templates are used to harvest full-thickness skin grafts from the groin crease. This effect can be lessened by soft-tissue coaptation ( Fig 34A-2.34A: Surgical Management | O&P Virtual Library floor of true anatomic proportions. The first option is excision of one nail with the underlying bone. POLYDACTYLY Polydactyly takes many forms. It is preferable in most instances to excise the http://www. combined with longitudinal phalangeal osteotomies to narrow the distal phalanx. six of which involve biphalangeal thumbs ( Fig 34A-3. The longitudinal axis of the metacarpal and phalanges should be perpendicular to the three joints. is attempted. both in width and depth. in which case no treatment is indicated. Surgical reconstruction aims to achieve a digit in which the carpometacarpal. while the second involves a central resection of adjacent nail borders and underlying bone. Angular deformity in either phalanx or metacarpal should be corrected by osteotomy. Incisions are planned to facilitate the coapting of soft tissues from both digits to provide optimal soft-tissue bulk. while in white children preaxial (radial) Polydactyly is more frequent. more effectively placing the radial digits in front of the body. unlike the thumb metacarpal head. its insertion must be detached from the skeletal elements being resected and reinserted into the retained radial little finger.A-D). When formal ray resection is required. The broad distal articular surface of the proximal phalanx may need to be tapered to a size appropriate to the distal phalanx. Frequently an Central Polydactyly often presents in combination with syndactyly. anomalous central digit will be bound to the middle or ring fingers without normal metacarpal development. but it should be recognized that the little-finger metacarpal head. When the most ulnar digit articulates with the metacarpal head in a fashion similar to that in the Wassel type IV thumb duplication. Deletion of two or three digits with pollicization of one of the digits along the "preaxial" border will improve the aesthetic appearance of the hand and modestly improve function.34A: Surgical Management | O&P Virtual Library more radial digit because it is usually less well developed. Retained flexor and extensor tendons must be examined to ensure that the course and insertion of residual tendons are centered.asp[21/03/2013 21:57:45] . it is not always indicated. and skin flaps are designed to preserve or reconstruct normal web space contour and digital bulk. aplasia. The thumb is frequently absent or. Type III abnormalities are usually dealt with by deleting the radial digit. if present. the ulnar collateral ligament of the deleted digit must be retained and reconstructed to stabilize the ulnar aspect of the residual little-finger metacarpophalangeal joint. RADIAL DEFICIENCY The radial-deficient upper limb demonstrates a variable extent of radial absence. Surgical centralization stabilizes the hand at the end of the forearm by placing the hand and carpus on the end of the ulna ( Fig 34A-4. Because there is an overabundance of flexor musculature and relative paucity of extensor musculature. simple digital excision will result in an inadequate residual digit. web space-preserving incisions should be selected. the abnormal radial deviation at the ulnocarpal level provides the child with the ability to bring the hand to the face.org/alp/chap34-01. the hand is splinted in an effort to stretch radial soft tissues. The intrinsic muscles that originally inserted into the more radial thumb are reinserted into the hood of the residual ulnar thumb component. The collateral ligament that initially secured the radial aspect of the deleted radial digit must be retained to securely stabilize the radial aspect of the new interphalangeal joint. If active elbow flexion is lacking. Centralization allows the hand to reach out away from the body. or dysplasia of the soft-tissue and skeletal elements along the radial (preaxial) border of the When the radius is absent or severely dysplastic. Type IV abnormalities usually require deletion of the radial digit. Type VI abnormalities may require shifting of the more distal portion of the radial digit onto the more proximal portion of the ulnar digit. and collateral ligament reconstruction. In such instances the skeletal elements of the unsupported digit are excised. Similarly. The excursion of extrinsic digital flexors and extensors may be focused upon digital motion and not frustrated by collapse of the hand and wrist at the ulnocarpal level. If the hypothenar musculature inserts into the more ulnar little finger. is dysplastic. Because centralization frustrates this http://www. radius is present. against the radial border of the ulna and cause the hand to assume a posture at a right angle to the ulna. The mirror hand is an unusual abnormality in which there is duplication of the postaxial Neither the thumb nor the border of the hand with seven or eight digits and two ulnae. Type V abnormalities usually require deletion of the more radial digit and reinsertion of the intrinsic muscle insertion into the residual ulnar digit. the unsupported carpus will rest limb. narrowing of the metacarpal head. Because the ring and little fingers are the most supple digits. wrist flexion release may be necessary.. Although centralization does improve function in front of the body. Postaxial Polydactyly of the digit joined only by soft tissue may be treated by simple excision. Beginning shortly after birth. they are frequently used for side-to-side prehension. contains a physis and that care must be taken to preserve physeal growth. It may be necessary to narrow the metacarpal head.oandplibrary. The tendency to use a pattern of ulnar prehension is usually a consequence of the greater mobility in the ulnar digits and their position as the presenting part of the deviated hand as it is brought in front of the trunk. The more radial digits are often stiff with limited active flexion. Surgery is useful in expanding the arc of elbow flexion and extension but does not gain forearm rotation. the object is forced against the palm by the flexed fingers and buttressed by the stability of the thumb metacarpal. Because the morphology of this condition may vary considerably from the right to the left side and from one generation to another.). including the thumb. Side-to-side pinch between fingers allows precision activity to be accomplished with relative facility. syndactyly. and should be treated in the fashion described earlier in this chapter. Because surgical releases are usually limited by tight neurovascular structures. particularly between the ring and little fingers. The hand without a thumb is nonetheless capable of great dexterity.oandplibrary. If the index and middle fingers were used for precision pinch prior to surgery. Syndactyly is common. Neurovascular structures are preserved by ligating the proper digital artery to the middle finger and splitting the common digital nerve to the index and middle fingers. Pollicization consists of four major elements. Syndactyly is frequently encountered. serial splinting or Ilizarov joint stretching have been employed to improve joint motion. In some instances. if the hand is positioned behind the body. Ectrodactyly is usually present and may be manifested in the absence of any of the fingers. The ability of the individual without a thumb to hold large objects securely is thus markedly compromised. Morphologic variation is common. Another problem is the presence of severe flexion contracture of the elbow. it is contraindicated if elbow flexion is lacking. digital fusion. The elbow may be stiff due to radiohumeral synostosis. particularly between the ring and little finger. it is likely that this pattern will persist after polli-cization. the skin incision. middle. is not a normal thumb. Care must be taken to preserve dorsal venous drainage of the digit. CLEFT HAND Confusion exists regarding the appropriate classification of children with a normal-length radius and ulna and absence of the central (index. Large objects can be held securely only by using both hands together or by flexing the wrist and securing the object against the forearm or body. Skin incisions are designed to create a web space between the shifted digit and the middle finger and to allow digital transposition without the need for skin grafting ( Fig 34A-5.34A: Surgical Management | O&P Virtual Library function. and distal Polydactyly may all be evident within affected hands. and/or ring) fingers. cases in which a true cleft is not evident are often overlooked. This shifted digit. when an object is grasped in power prehension. By resecting a major portion of the metacarpal. Digits frequently diverge from the central cleft with ulnar deviation of the ring and little metacarpals and radial deviation of the middle and index metacarpals. including the physis of the metacarpal head. Normally. Digital absence. Spontaneous use of the digit is usually noted within a few months and continues to improve as the child ages. The wrist is usually stable and rarely requires surgical intervention.asp[21/03/2013 21:57:45] . osteotomy of the radius is indicated to bring it into flexion ( Fig 34A-6. If the predominant pattern of precision prehension was between the middle and ring fingers or between the ring and little fingers. Shortening of the flexor tendons is not required. it is likely the pollicized index finger will continue to participate in precision activity against the middle finger. cross bones. The metacarpophalangeal joint of the index finger is hyperextended and secured to the residual proximal metacarpal. the resultant digit will be of a length similar to that of a thumb. skeletal adjustment. thus creating a narrow first web space. ULNAR DEFICIENCY The ulnar-deficient hand is characterized by an absence or hypoplasia of the ulna. Metacarpal osteotomies may be necessary to http://www. and musculotendinous rebalancing. however. The typical cleft hand or split hand is usually bilateral and may be associated with bilateral cleft-foot abnormalities and an autosomal dominant inheritance pattern. neurovascular dissection.). Pollicization shifts the index finger from its normal position to the thumb position along the radial border of the residual hand so that it can participate in power as well as precision activity. Syndactyly should be released as previously described. In such situations the functional advantage of pollicization is realized only with power activity. The index metacarpal is often deviated toward the thumb metacarpal. Musculotendinous balance is achieved by advancing the first dorsal interosseous and first palmar interosseous muscle insertions into the hood and by shortening the extensor extrinsic tendons.org/alp/chap34-01. The normal thumb participates in a wide variety of both precision and power prehensile activities. ). however. the resultant digital motion is often quite limited. CONGENITAL CONSTRICTION BAND SYNDROME Congenital constriction band syndrome has many manifestations ( Fig 34A-9. It is rarely worthwhile to attempt to achieve prehension in an adactylous hand by transfer of two separate digits. the procedure may still be beneficial in older children. the amputation may occur at the joint. Rudimentary flexor and extensor tendons may be defined and sutured to the palmar and dorsal aspects of the transferred phalanx. metaphyseal. When amputation occurs as a result of congenital constriction band syndrome.." a procedure in which prehension is shifted proximally to facilitate grasp between the thumb. In many instances. a sinus is usually evident proximal to the area in which the skin is joined. Free-tissue microvascular transfer of the second toe or of the second and third toes together has been employed to augment hands without digits or digital soft-tissue sleeves. http://www. resection of the index or of the index and middle metacarpals may enhance prehension through "phalangization. In acrosyndactyly. ring. Syndactyly usually is the result of a failure of normal interdig-ital web space resorption during embryonic development. The resultant tapered ends may require revision in adolescence or adulthood because of the propensity of these amputations to appo-sitional overgrowth. This form of syndactyly is termed ac-rosyndactyly or fenestrated syndactyly. noncontiguous digits may be The index finger might be joined to the ring finger. The digit will retain the form of a toe and at best will have the range of motion of a toe. Diaphyseal amputations usually occur through hand or foot phalanges or through the tibia. These include band indentation.asp[21/03/2013 21:57:45] . the skeleton may be lengthened by a nonvascularized toe phalanx transfer. Although a sinus with a web space floor is often present. however. the proximal musculature is poorly defined with restricted excursion. Bands that encircle a limb or digit may result in distal edema. Toe phalanx transfer is particularly helpful when the thumb lacks phalanges or when the thumb is present along with metacarpals but the fingers lack phalangeal elements to pinch against. BRACHYDACTYLY Treatment of the hand with short digits (brachydac-tyly) or absent digits (adactyly or ectrodactyly) engenders much debate ( Fig 34A-8. this web space floor is situated too distally and will require formal release to bring the web space to the appropriate proximal level. while the middle finger is forced joined. In most instances of adactyly.34A: Surgical Management | O&P Virtual Library gain parallel alignment of metacarpals at the time of web space closure ( Fig 34A-7. a flap derived from redundant skin in the central cleft may be rotated into the first web space at the time of first-web space release. Vascularized toe transfers continue to grow until skeletal maturity and yield a digital length approaching the predicted length of the toe.oandplibrary. affected children possess considerable physical capabilities without surgical or prosthetic intervention. and little metacarpals. acrosyndactyly.org/alp/chap34-01. adjacent digits are joined side to side in a fashion similar to the intrauterine embryonic paddle form. When these musculotendinous units are sutured to a free-toe transfer. there may be benefit in transferring a toe to the hand to provide counterpressure to the thumb and thus achieve prehension. The skin is closed after Z-plasty flap transposition. Although these transferred phalanges are more likely to continue to grow after transfer if the procedure is carried out between 6 to 12 months of age. distal edema. palmar or dorsal to the distally webbed digits. The proximal phalanx of the third or fourth toe is "harvested" with its proximal volar plate and collateral ligaments. Syndactyly release is described in the preceding section on syndactyly. When syndactyly occurs in association with congenital constriction band syndrome.). When a well-controlled thumb is present without other digits. In some cases of brachydactyly. Since these abnormalities are usually unilateral. or diaphyseal level. When digital soft-tissue sleeves are substantially longer than the enclosed skeletal elements. and/or amputation of distal parts. The toe phalanx is then secured in the finger sleeve by Kirschner wires and by suturing the volar plate and collateral ligaments to the intact proximal skeleton. In developmental syndactyly.A and B). Surgical treatment requires excision of the indented skin and of any deep fascial constricting tissue. Deep indentation from band constriction at the humeral level may result in an insensate paralyzed hand of no In some instances these hands may be functional value and subject to repeated infection. 1977. Millesi H et al (eds): Hand Surgery. 9:155-164. When thumb length is insufficient for prehension due to congenital constriction band amputation. Goldberg NH. prosthetic fitting does not require surgical modification of the upper limb. function of the residual limb out of the prosthesis should not be compromised in an attempt to simplify prosthetic fitting since children may spend considerable periods of their day without their prosthesis. Buck-Gramcko D. J Bone Joint Surg [Am] 1964. J Hand Surg [Br] 1986. 1981. 8. 4:304-315 10. 10:964-988. 6:577-588. 2. Lister GD: Syndactyly. Bayne LG. Buck-Gramcko D. vol 1.oandplibrary. Gilbert A: Congenital absence of the thumb and digits. vascular. The surgeon should consider both functional and aesthetic impact. amputated electively. 1982. 19. Buck-Gramcko D: Congenital malformation. 1988. Tondra JM. and musculotendinous structures proximal to the level of the amputation are normal. 6. Pellicore RJ: Introduction to the child amputee. et al: Congenital hand deformities. Flatt AE: The Care of Congenital Hand Anomalies. Hand Clin 1990. New York. and treatment. second-toe or hallux transfer may provide effective augmentation of the thumb ( Fig 34A-10. 7. Hand Clin 1990. 17. et al: Radial meromelia. Broudy AS. Trusler HM: Technical modifications in repair of syndactylism. SUMMARY Children with upper-limb deficiencies may benefit from surgical reconstruction. 1986. Churchill Livingstone Inc. J Hand Surg [Am] 1985. 11. 5. Barsky AJ: Cleft hand: Classification. 12. Philadelphia. 17:385-392. Klug MS: Long-term review of the surgical treatment of radial deficiencies. Mosby-Year Book. 53:1605-1617. Mosby-Year Book. Lamb DW: Radial club hand. J Hand Surg [Br] 1986. St Louis. 18. Watson HK: Composite toe (phalanx and epiphysis) transfers in the reconstruction of the aphalan-gic hand. Evans DM: Soft tissue anatomy of mirror hand. 13. Barton NJ. 11:307-319.34A: Surgical Management | O&P Virtual Library Although lower-limb amputation through the tibia occurs occasionally. 16. J Bone Joint Surg [Am] 1977. Aitken GT. New York. Smith RJ: Deformities of the hand and wrist with ulnar deficiency. pp 213-450. 11:320-336. 14:617. J Hand Surg [Br] 1989. in Atlas of Limb Prosthetics. WB Saunders Co. Eaton CJ. et al: Mirror hand treated by true pollicization. J Bone Joint Surg [Am] 1970. 52:966-979. 6:555-575. The transferred toe will continue to grow as the child's hand grows. Bayne LG.59:1-13. nerves. et al: Polydactyly of the thumb: A surgical plan based on ninety-five cases. amputation through the arm or forearm is rare as a result of congenital constriction band syndrome. Buck-Gramcko D: Pollicization of the index finger. Buck-Gramcko D: Radialization as a new treatment for radial club hand. Cheng JCY. . Bora FW: The Pediatric Upper Extremity: Diagnosis and Treatment. prostheses should be fabricated to fit the limb as it is. 21. Because the blood vessels. Ezaki M: Radial Polydactyly. incidence. 20. 12:169-179. Buck-Gramcko D: The role of nonvascularized toe phalanx transplantation. In other words. 15. 4. pp 493-500. J Hand Surg [Am] 1987. The deformity and its treatment. In most instances. Chan KM. 14. 6:643-659. J Hand Surg 1979. http://www. J Hand Surg [Am] 1984. Barton NJ. 7:454-459.asp[21/03/2013 21:57:45] . References: 1. Thieme Medical Publishers Inc. Bauer TB. in Nigst N. Hand Clin 1990. St Louis. J Hand Surg [Am] 1982. satisfactory ultimate neural. Evans DM. Buck-Gramcko D. in Green DP (ed): Operative Hand Surgery. 3. 46:1701-1720. and motor function may be anticipated. Prosthetic fitting of such limbs may be complicated by the insensitivity of the residual forearm. Ma GFY. vol 2.org/alp/chap34-01. J Bone Joint Surg [Am] 1971. 9. Bora FW. that is. Wood VE. Dobyns JH.A and B). Plast Reconstr Surg 1956. oandplibrary. part 2. ed 2. NI: A centralization procedure for radial club hand. 1985. et al: Duplication of the thumb: A retrospective review of two hundred and thirty-seven cases. 33. J Hand Surg [Am] 1985. Tada K. 25. Law HT: Upper-Limb Deficiencies in Children: Prosthetic. Watson HK. Tubiana R. 71:99. Flatt AE. Boston. McCarroll HR. 4:556-564. 31.34A: Surgical Management | O&P Virtual Library 22. 61:562-565. 44. 39. Contact Us | Contribute http://www. Clin Orthop 1980. The Hand. Plast Reconstr Surg 1982. (eds): Pediatric Orthopaedics. et al: Central Polydactyly-A review of 12 cases and their surgical treatment. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 34A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 34. Philadelphia. 23. 37. Bohne W: Ulnar dysmelia. Walsh RJ: Acrosyndactyly: A study of twenty-seven patients. Instr Course Led 1989. May JW. Wassel HD: The results of surgery for Polydactyly of the thumb: A review. Toledo LC. Lamb DW. operative technique and results. Ogden JA. Winter RB. Miura T: Congenital constriction band syndrome. Litler JW (eds): Plastic Surgery. 58:467-475. 148:55-61. J Hand Surg 1978. 1987. 43. 40. 5:423-433. in McCarthy JG. in Atlas of Orthotics. 41. J Bone Joint Surg [Am] 1976. 27. Swanson AB. and Surgical Management. 26. Cruz. Indications. 28. Bayne LG: Polydactyly of the thumb: Abnormal anatomy and treatment. Brown & Co. in Lovell WW. J Hand Surg [Am] 1984. Marks TW. Roux JP: Phalangization of the first and fifth metacarpal. 38. Swanson AB. St Louis. 10:603-613. Yonenobu K. vol 8. Miura T. Ger E: Evaluation of the operative treatment of syndactyly. J Hand Surg 1981. Plast Reconstr Surg 1979. Clin Orthop 1969. MosbyYear Book. Tsuyuguchi Y. J Hand Surg 1982. 56:447-457. 69:470-479. Prosthetic. J Bone Joint Surg [Br] 1974.org/alp/chap34-01. Chapter 34A . median and ulnar nerve dysfunction associated with a congenital constricting band of the arm. 9:82-88. Kurisaki E. J Bone Joint Surg [Am] 1983. Swanson K: Centralization of the radial club hand: An ulnar surgical approach. Watari S. WB Saunders. Clin Orthop 1970. Plast Reconstr Surg 1979.asp[21/03/2013 21:57:45] . J Hand Surg 1979. 65:584598. 35. Tsgue K: A classification of cleft hands. J Bone Joint Surg [Am] 1979. 9:658-664. Tada K.Atlas of Limb Prosthetics: Surgical. Cooper RR: Annular constricting band. Little. 69:333-336. Swanson GD: The Krukenberg procedure in the juvenile amputee. Light TR: Kinesiology of the upper limb. 1990. pp 714-719. Miura T: Duplicated thumb. Light T. 42. 24. JB Lippincott. 7:460-462. Philadelphia. Manske PR. Orthotic. pp 126-138. 64:381-389. 64:175-193. Upton J: Congenital anomalies of the hand and forearm. Co. Watson HK. Yonenobu K: Ulnar ray deficiency: Its various manifestations. 9:541-547. 64:65-67. J Hand Surg [Am] 1984. Tada K. 1978. 32. Komada T: Simple method for reconstruction of the cleft hand with an adducted thumb. J Hand Surg [Am] 1984. McCarroll HR: Index finger pollicization for a congenitally absent or nonfunctioning thumb. Plast Reconstr Surg 1982. 36. Manske P: Congenital hand malformations and deformities. Manske PR. 29. based on clinical findings. Beebe RD. 30. 3:107-116. Riordan DC: Congenital absence of the ulna. 37:31-71. Weeks PW: Radial. 45. Moses JM. Although we are fortunate that some entrepreneurs have been willing to invest in such a small area as upper-limb prosthetics. a plethora of new components. Prosthetic. and techniques were developed A specific attempt was made at the end of the decade to for the adult or geriatric amputee. materials.oandplibrary. The development of simplified myoelectric control and a battery-saver circuit allows the fitting of infants with a practical control scheme. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Reproduced with permission from Bowker HK. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. The preschool amputee may need a new socket annually because of growth. C. reprinted 2002. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. but the expensive myoelectric hands and electronics should be reusable in the new prosthesis. "How soon?" is probably best answered by "when http://www. Traumatic amputees now receive their first prosthesis in a matter of days.S. American Academy of Orthopedic Surgeons. The modularization of upper-limb components during this period offers the potential to recycle parts into the child's next prosthesis. Myoelectric hands. the development of shoulder-hand coordination is delayed until after 9 months. Prosthetic. government did not underwrite this developmental cost. stronger new materials could be used for children. automatic closing when the child relaxes. No longer must we wait until the teenage years to fit a myoelectric prosthesis. and controls were miniaturized and simplified ( Fig 34B-1. The key difference is that children's prostheses must also be developmentally appropriate. While hand opening and thumb adduction usually begin around 4 months. the U. redirect this effort toward the pediatric patient.O.S.34B: Prosthetic and Orthotic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 34B Chapter 34B . The function and design principles of prostheses for children are similar to their adult counterparts. This type of prosthesis is easier for the infant to learn to use because any electromyographic (EMG) signal detected within the socket creates hand opening. and Rehabilitation Principles Upper-Limb Deficiencies: Prosthetic and Orthotic Management Terry Supan. our goal should be to provide the most functional and cosmetic design possible when and if the rehabilitation team and the family decide that the child should be fitted with a prosthesis..org/alp/chap34-02. ©American Academy or Orthopedic Surgeons.Atlas of Limb Prosthetics: Surgical. Nor do we wait until the child has lived a year before fitting after tumor surgery. provided that the size remains appropriate. and a stall condition detector to save battery capacity automatically. The new myoelectric circuits provide controlled opening. There are no simple answers.asp[21/03/2013 21:57:50] . Age guidelines for optimum fitting have changed as we have gained more experience. This resulted in increased costs as the manufacturers amortized research expenses.P.). Prosthetic. RECENT DEVELOPMENTS During the 1980s. Rosemont. Because of training difficulties. elbows. WHEN TO FIT AND WITH WHAT The key questions are when a child should be provided with a prosthesis and what the best type is. and Rehabilitation Principles. Whether the child has an acquired amputation or a congenital anomaly. The lighter-weight. In a break with the past. Thermoplastic socket designs allowed for more adjustability and adaptability for growing limbs. Click for more information about this text. A. he also spontaneously improves his prosthetic function. the substantial cost for newer technology is an ongoing concern. IL. 1992. As the child develops normal coordination of the contralateral hand.A. edition 2. cable-controlled prehension of the prosthesis is seldom feasible until 12 to 18 months. Redesigned lower-limb components also became available for the younger amputee. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). not months. They are heavier. Cable-controlled mechanical elbows are smaller versions of the adult models. However. The cosmetic gloves must be replaced routinely to prevent moisture and dirt from entering the electrical and mechanical parts. will stimulate further advances in the science of prosthetics. Children with unilateral conditions will readily adapt to their "one-handedness. and electric elbows are all available for the child amputee. and is not as adept at picking up smaller items. The acquired unilateral amputee should be fitted with the most cosmetic." The child with a traumatic or acquired amputation should ideally be fitted within 30 days ( Fig 34B-2. Unfortunately. the elbow must be locked for the cable's force to be transferred to the hook. and the second controls the locking mechanism. and technology. and more complicated but are easier for the patient to control because they require less force. It can be argued that fitting the child. the 6. As children mature. The well-informed prosthetist can guide the physician through this ever-changing area of new terms. and are less susceptible to damage. despite the uncertainty of future results. more costly. They are often used with short residual limbs or congenital limb remnants. When a mechanical terminal device is used. Voluntary-closing devices like the Adept have a graded pinch force that is controlled by the individual. Electric elbows for children are usually switch controlled. it cannot be submerged in water. Weight and function are the best guidelines to use when recommending elbow components.oandplibrary. only one type of prosthesis should be used for the very young child.) to encourage acceptance of the prosthesis and the continuation The child with a congenital condition may be provided with a passive of bimanual activities. each has advantages and disadvantages. techniques. if a myoelectric hand is used with the cable elbow. Like the terminal devices. One cable controls elbow flexion. There is a lack of functional prostheses for the young child with only digits or metacarpals missing. mechanical.to 9-month-old can spontaneously develop control of the prosthesis without extensive training. excursion. they should be given the opportunity to experiment with different Mechanical terminal devices are lighter." with the noninvolved side becoming the dominate hand. have fingertip prehension. Although the fitting of a singlefunction myoelectric terminal device for infants is controversial. Passive elbows are light but must be operated by the other hand. RECOMMENDATIONS BY LEVEL Infants with partial-hand amputations or congenital deficiencies probably would be best served by not fitting them with a prosthesis.org/alp/chap34-02. however. Therefore. "What type of prosthesis?" is much more difficult to answer. which is sometimes difficult. functional components available. Multiple prostheses with differing control patterns. hand within 60 to 90 days after birth. and coordination. voluntary-opening hooks have much less pinch force than do electric hands and are not as cosmetic. A myoelectric hand has greater pinch force and is capable of controlled opening and closing throughout the full range of motion of the arm. Reliability of electric prostheses has improved significantly and will continue to do so as long as we continue fitting such devices. and they can often be used in combination. can lead to confusion and frustration. However.34B: Prosthetic and Orthotic Management | O&P Virtual Library technically possible. Passive.asp[21/03/2013 21:57:50] . The streamlined design of hook devices permits visual inspection of the objects to be grasped. then terminal device and elbow function are independent. It also can be operated independently of elbow function. which can be advantageous. Heavy-duty use would preclude the use of a passive elbow. The child must learn more complicated shoulder motions to achieve both flexion and locking of the prosthetic elbow. but myoelectric controls are available for the older youth. Whether they will continue to use the prosthesis or reject it later in life can only be determined by a longitudinal study. Children over 3 years of age can be trained to control all available devices. is heavier. Younger patients or those with congenitally deficient limbs sometimes do not have sufficient neuromuscular control to operate complex devices. Each has its own advantages and disadvantages. This theoretically allows the child to acquire more normal bimanual and quadripedal development. "Should powered or mechanical components be used?" "Both" is the best answer to that question. The available cosmetic partial-hand prostheses compromise the sensory feedback to http://www. The exception would be the child who has a limb-length discrepancy that would allow the fitting of a functional prosthesis of equal length to their sound side. The challenge of these children requires familiarity with a variety of prosthetic components and the ability to combine them for the optimum function for the amputee. cable control of the terminal device of the prostheses should help the child's function ( Fig 34B-6.). Then the recommendation would be to give the family the option to fit the infant with a prosthesis when possible ( Fig 34B-4. the ease of control offsets the extra weight and may increase the potential for prosthetic use. All the available children's-size shoulder joints are passive. As with the traumatic transradial amputees. Combining this with an increase in length usually results in a rejection of the prosthesis. Inequality of limb length and loss of sensation related to prosthetic fitting are likely to lead to rejection of a prosthesis in congenital conditions. The needs of the bilateral upper-limb amputee are also best met by the experienced rehabilitation team. The wrist disarticulation level raises concerns similar to those of the partial hands.org/alp/chap34-02. acquired transhumeral amputees must be fitted very quickly to allow the individual to retain normal bimanual functions. if desired. The available electric elbows should be primarily considered for patients with shorter residual limbs. These prostheses will function more quickly and quietly and with more proprioceptive feedback (via the cable and harness) with mechanical elbows. More effort should be concentrated on adaptability without the use of prostheses or orthoses. enough positive anecdotal evidence has been reported that it should be investigated further. This would allow the prosthesis to become part of the child's natural development. http://www." Although this concept has not been proved.oandplibrary. The transradial level has seen the most change in design for the younger patient. Newer components have allowed the prosthetist to take a more aggressive approach with these patients. This allows a more natural assimilation of the prosthesis without having to battle through the "terrible twos.). Midshaft or longer transhumeral conditions with normal shoulder function do not require the heavier electric elbows. Recent modifications to myoelectric components also have allowed this level of amputation to be fitted before 18 months.34B: Prosthetic and Orthotic Management | O&P Virtual Library the limbs inside the prostheses. who needs more than just prehension. The child must learn to function both with and without the prostheses for the greatest independence. They can be expected to master either dual cable control of the elbow lock or electric control of the motorized elbow. The older amputee should be provided with an active elbow joint. Although attempts at fitting opposition posts and platforms can be made. long-term use of these for the unilateral patient has been inconsistent ( Fig 34B-3. or he will reject it. At this level. With the development of "user-friendly" myoelectric controls. Elbow and terminal device choice is based on a needs assessment of the amputee. so the child must manually preposition the prosthesis' shoulder in the desired location.asp[21/03/2013 21:57:50] .). The additional requirement for prosthetic shoulder function at the shoulder disarticulation and forequarter level leads to more complications and more rejection. The bilateral amputee. will benefit from referral to a rehabilitation center that has experience with this type of condition. traumatic injuries in older children should be treated very aggressively with prosthetic fitting within the first 30 days to facilitate the incorporation of the prosthesis into the amputee's lifestyle. As the control and speed of electronic components improve. the child under I½ years can learn to develop control of the prosthesis ( Fig 34B-5. The evaluation of the shoulder and forequarter amputee should ideally be conducted by an experienced clinic team due to the large number of prosthetic component combinations possible. The approach for hand function should parallel the transradial case. The younger child with a transhumeral condition should be fitted with either a static or friction elbow mechanism. this trend may be reversed. Because of their proprioceptive feedback.). Transverse anomalies or amputations can be provided with an orthosis to prevent deformities or increase prehension. A compromise between weight and control simplicity must be made. The prosthesis must provide a functional benefit for the amputee. On the other hand. Fredericton. 1984. They need to belong to the group and not feel like an outsider. and cosmetic. should be managed by clinic teams with more experience. ADDITIONAL READING Atkins DJ.. A child with a congenital anomaly or amputation will experience the reaction of others to their "difference. The physical changes that children normally go through must be considered when designing their prostheses. The use of multilayered sockets replacement. The life-style of the child requires that the prostheses be functional. Little. et al: Twenty-three years of clinic experience. The Rio-Engineering Institute. They want to be independent. J Assoc Child Prosthet Orthot Clin 1987. cosmetic appearance does become an issue for both child and family. Bansavage J: The psychological and social factors related to successful prosthetic training in juvenile amputees-A preliminary study. 22:17. Perry R: Satisfaction and self-esteem in patients attending a juvenile amputee clinic. 3:1-9. Orthotic and Surgical Management. 5. Several centers use the concept of "limb-banking" electric components to help reduce the cost of the prostheses. http://www. Their life-styles and attitudes are different. the greater the chance of a positive reaction to the child. The prosthesis must be designed to take as much abuse as possible. "Captain Hook" still conveys a negative image for most of our population. The rapid growth of their limbs requires replacement of all or part of the or thick limb socks will delay the prosthesis annually.). Pellicore R: The juvenile amputee program: Its social and economic value. Spencer D. Children can be very destructive in their normal active life-style. They also should be provided with the adaptive equipment to have as normal a childhood as possible. Lamb DL. 7. New materials and equipment are allowing the fitting of lighter and more advanced prostheses.asp[21/03/2013 21:57:50] ." The more cosmetic the prosthesis is. Orthop Clin North Am 1981. 1989. The use of thermoplastics that are adjustable will also help. References: 1. Scott H: Management of congenital and acquired amputation in children. Scott RN: An Introduction to Myoelectric Prostheses.org/alp/chap34-02. Hamilton R. University of New Rrunswick. Hamilton R: The juvenile amputee in athletics. 1963. 40:1-8. 6:1-9. The prosthetic fit of the growing limb must be revised annually. Campbell E.34B: Prosthetic and Orthotic Management | O&P Virtual Library SPECIAL NEEDS OF CHILD AMPUTEES Children are not just small adults. but they also want to fit in with their peers. Rlakslee R: The Limb Deficient Child. the challenges of the child amputee have not.e. 6. 2. New York. 51:1135-1138. This only works if there is technical and financial support to maintain the parts. Rrown & Company. Inter-Clin Info Bull 1964. Roston.oandplibrary. 3. Lambert C. i. Prospective studies of these new methods of patient treatment are needed. Springer-Verlag NY Inc. durable. Lamb D. As noted above. CONCLUSION Although technologies have changed. Lambert C. high-level and bilateral amputations. Therefore. Hamilton R. Canada. Law HT: Upper-Limb Deficiencies in Children: Prosthetic. The more complicated cases. Inter-Clin Info Bull 1976. 40:15-20. 4. 12:977-994. Lyttle D. Inter-Clin Info Bull 1976. 1987. Dillon S: Technical description: Applying the generic control system to a juvenile above-elbow amputee. Rerkeley. J Bone Joint Surg [Am] 1969. University of California Press. The use of terminal devices designed for recreation should be encouraged ( Fig 34B-7. the more expensive parts of electric prostheses can be reused in the next device. Pellicore R. Inter-Clin Info Bull 1966. Meier RH III: Comprehensive Management of the Upper-Limb Amputee. 9. J Assoc Child Prosthet Orthot Clin 1987. 11:45-48. Literowich W. et al: Variety Village electromechanical hand for amputees under two years of age. Mifsud M.asp[21/03/2013 21:57:50] . Sauter W. 12.oandplibrary. 11. Contact Us | Contribute http://www. 13. Chapter 34B . 22:57-59. Mifsud M. Supan T: Transparent preparatory prostheses for upper limb amputations. et al: Development of layered "onionized" silicone sockets for juvenile below-el-bow amputees.Atlas of Limb Prosthetics: Surgical. 23:479-481. J Bone Joint Surg [Br] 1983. Dakpa R. 10. J Assoc Child Prosthet Orthot Clin 1987. Reid D. Clin Prosthet Orthot 1987.34B: Prosthetic and Orthotic Management | O&P Virtual Library 8. Prosthetic. 65:346-349. Milner M: Energy-saving power bridge for children's artificial hands. Galway H: A long-term review of children with congenital and acquired upper limb deficiency. Galway R. Scotland TR. Fay L: Survey of juvenile hand amputees. Sauter WF. 22:41-46.org/alp/chap34-02. J Assoc Child Prosthet Orthot Clin 1987. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 34B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 20:51-55. Al-Temen I. Med Biol Eng Comput 1985. ). ©American Academy or Orthopedic Surgeons. but despite some http://www. Trost. Efforts to improve and refine these devices have resulted in the development of a valuable adjunct used in the treatment of amputees. Other methods have been tried experimentally but have not yet appeared on the market. Further work in this field. Because of the complexity of factors and components used in externally powered prostheses and because of the considerable cost involved. two external control systems are commercially available: myoelectric and electric switch.D. edition 2. is not surprising that the most common externally powered prosthesis used clinically is the unilateral transradial prosthesis ( Fig 34C-2. Canada. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. and Rehabilitation Principles Upper-Limb Deficiencies: Externally Powered Prostheses Francis J. While much has been accomplished in this field. Tasks requiring fine manipulation. Reproduced with permission from Bowker HK. American Academy of Orthopedic Surgeons. EXTERNAL POWER COMPONENTS In discussing external power components. reprinted 2002. It should also be noted that teenagers who have reached adult size will have adult components available to them. and Germany. Powered components for the adult are discussed in Chapter 6A. externally powered prostheses were fabricated for the adult amputee. who have the greatest need for prosthetic assistance. including miniaturization of components. external power is not the complete solution for all of the amputees' problems but. and Rehabilitation Principles. is a valuable additional tool in the prosthetic armamentarium. IL. Prosthetic. in addition to downsizing.34C: Externally Powered Prostheses | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 34C Chapter 34C . allowed children to be fitted with externally powered prostheses. Externally powered prostheses were first discussed by Reiter in a publication shortly after World War II.P. Pneumatic power was used initially. attention was again focused on the possibility of producing externally powered prostheses. Prosthetic. amputee and the influx of thalidomide babies. M. Click for more information about this text.org/alp/chap34-03. Initially. some components have been redesigned to meet the needs of the child amputee. but currently. it is felt that most of these prostheses are best prescribed in specialty clinics composed of team members from the various disciplines concerned with the treatment of child ampu-tees. and the Because of the needs of the juvenile components were frequently too large for children. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. Rosemont. components for small children were simply downsized adult components. Prosthetic. emphasis will be placed on the child amputee and the differences and special considerations that have to be given to them as children. many problems remain to be solved. In the case of bilateral and high-level amputees ( Fig 34C-1. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). however. Italy. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. particularly in Europe. For unilateral amputees any prosthesis will always be an assistive device. C. Dan Rowe.asp[21/03/2013 21:57:55] .oandplibrary. it their needs in regard to spatial placement of the prosthesis and reliability. 1992. Efforts to accomplish this were undertaken in the Soviet Union. various modifications. Initially. will always be accomplished by the normal or nonamputated limb. Control Systems Basically. fueled by technological advances and the need created by the thalidomide disaster.Atlas of Limb Prosthetics: Surgical.). externally powered prostheses still fall far short of meeting In view of this. and at this time. was not actively pursued until the late 1950s and 1960s. unless bimanual.O. At that time. rather. England. 0 cm (1. The myoelectric system works by picking up the electrical activity generated by the muscles like an elec-tromyogram. response is graded depending on the force of the muscle contraction. Any of these switches can be controlled in a variety of ways.34 to 2. and their weight. These components put the terminal device in a position where it can successfully accomplish a given task ( Fig 34C-4. Although cycling the elbow while holding something in the terminal device (live lift) is possible. moisture present in the socket. regardless of the strength of the muscle contraction.1 kg (4. and sent to the motor. Powered elbows for children are primarily switch controlled. but this is not often used. the active index and middle fingers opposing the fixed thumb and the remaining fingers being passive. Another type of three-position pull switch can flex and extend an elbow and operate either a prehension activator or electric hook. If the smooth filtered signal exceeds a certain basic threshold. The signal may be processed in a digital or analog fashion. Although the cosmetic gloves are usually made of polyvinylchloride (PVC). side and a cable-operated hook on the other. and other factors. it has some major drawbacks and currently is seldom used as a power source. The amplifier may be contained in the electrode or be separate.). The hand usually contains the motor and other mechanical parts. There is one powered split hook commercially available.36 in. The other commonly used system is that of an electric switch that opens or closes a circuit and activates a component or turns it off. They are built with a three-finger pinch. as is the wrist (forearm) rotator. the fingers of the hand will open from 3. one function or one site. Rocker and toggle switches are also available.org/alp/chap34-03. rotational limb. the motor activates. The nudge control switch is a type of push switch. The time to cycle the fingers depends somewhat on the type of control system. functional limb residuals may be used to operate switches.asp[21/03/2013 21:57:55] . Attempts have been made to insert more functions in one site. there are some made of silicone. the elbow is primarily a positioning device.) and will develop a closing force of 9. They are also a positioning device. The electrode is placed over that portion of the muscle that or. although myoelectric elbows are also available. small electric toys. There are no large series addressing this issue of combinations of power. for cosmetic purposes it is fabricated into the prosthesis. The power source most commonly used for these prostheses is a 6-V nickel-cadmium rechargeable battery. Elbows are added to a child's prosthesis some time after the terminal device is fitted just as with body-powered prostheses. amplified. while some are pushed by use of the chin or other hand.). Electric wrist (forearm) rotators are available for teenagers. In the high-level congenital amputee. Occasionally the elbow will be too fast for small children until they get used to it. Because of weight it should be kept as proximal In long transradial amputees it may have to be placed in a pod that protrudes as possible. The myoelectric signal therefore is simply a method of switching the component on and off In a digital mode. and the component is engaged and continues its movement until its limits are reached or the signal is discontinued.5 to 5.34C: Externally Powered Prostheses | O&P Virtual Library advantages. the component is on or off. two functions.). but these are not yet widely available. Humeral rotation and shoulder motion are done passively with friction joints. Interesting combinations of external power as well as external power combined with body power can be used ( Fig 34C-5. Many are fixed to the harness to allow pull by body movements. There are a number of hands available from different manufacturers. A common combination is that of an externally powered Another possibility is a powered hand on one elbow with a body-powered terminal device. Switch location must be individualized and can be very innovative ( Fig 34C-3. may make them burdensome for an amputee with a short residual They are not used nearly as often as hands and elbows. along with all the other components. positioning of the hand is done passively. temperature. Some are very small so that the very young can be fitted with an appropriate size. http://www. Electrodes are usually one site. These are usually push or pull switches. in the case of young gives an optimum response as determined by a myotester children.1 to 6. Whenever possible. This activity is picked up by an electrode.5 lb). so fitting these various components still tends to be individualized and subjective.9 to 12. Characteristically. Without them. Components Most of the powered terminal devices for children are hands. Other voltages are occasionally used. In the analog mode.oandplibrary. rectified and filtered. weight. The same rationale applies to the amputee who lacks the body excursion or strength to operate and control a body-powered prosthesis but can activate a switch or electrode in an externally powered component. the greater friction of the glove. Patients have shown a tendency to prefer the externally powered hand when grasping larger objects but to prefer the body-powered terminal device when handling small or flat things. on the other hand. The externally powered prosthesis will provide a superior prehension force.). the the lack of harnessing straps and control cables. Extra charged batteries should be available for uninterrupted use. to avoid frustration and prosthesis rejection. Another major benefit in these prostheses is Beside being uncomfortable at times. straps and cables detract from the appearance of the prosthesis. In certain selected circumstances. which is particularly useful in high-level amputees who lack the power to operate a terminal device successfully ( Fig 34C-8. The placement of control sites. ADVANTAGES OF EXTERNAL POWER The major advantage of externally powered prostheses for below-elbow (transradial) amputees is the ability to combine cosmesis with function ( Fig 34C-7. In children with limited shoulder or chest excursion. The number of cycles before recharging and the eventual life of the battery depends on the number of components it is powering and the care it is given. The disadvantages. Typically. These can be eliminated if electrode placement can be successfully carried out. (especially that of the battery) should be as proximal as possible.org/alp/chap34-03. particularly in areas where suspension straps or a control cable can exert excessive friction or pressure.asp[21/03/2013 21:57:55] . as in the axilla. Care must be taken to avoid "overgadgeting" amputees. the ability to operate the prosthesis in any position. DISADVANTAGES OF EXTERNAL POWER Many of the advantages of externally powered prostheses are subjective and dependent on amputee response. An uncommon but definite advantage of the powered prosthesis is found in the fitting of amputees whose residual limb is extensively scarred. again. may be highly individualized. With above-elbow (transhumeral) prostheses using an externally powered elbow. many chargers now have an automatic shutoff when the battery is fully charged. To avoid the hysteresis effect a battery should be discharged sufficiently before it is recharged. It should be noted that operation of externally powered components requires less energy expenditure than operation of body-powered components does.). To address this problem. especially important for the high-level amputee. comfort. The http://www. especially when compared with voluntary-opening devices. This may be related to a number of factors including the larger grasping surface of the hand. are more objective and specific. One of the biggest problems still to be solved in externally powered prostheses is that of durability of the various components. switches. and the bulk of the hand. Additional advantages claimed by amputees are ease of operation. it takes about 12 hours to recharge a battery with a 50-mA charger. especially children. an externally powered elbow allows the available excursion to operate a body-powered terminal device. Resistance to wire breakage with remote units has improved with the advent of new materials ( Fig 34C-6. Fabrication In fabricating externally powered prostheses it is important that the prosthetist be familiar with the prostheses and well trained in their fitting and repair.34C: Externally Powered Prostheses | O&P Virtual Library somewhat from the prosthesis. suspension is especially important for powered prostheses. With good care a battery will last about 2 years. This feature appears to be of major importance to the parents of young children where the child has little or no input into the selection of the prosthesis.oandplibrary. which is. the battery may have to be placed remotely on a belt or some type of harness.). the transradial myoelectric system has achieved a high degree of reliability and durability. A battery should never be completely run down before it is recharged. The flexible socket has been very helpful for the high-level amputee and seems to give superior suspension. the ability to use visual cues. Through years of research and improvement. The prosthetist should be skilled in the fabrication of self-suspending sockets allowing the amputee as much range of motion as possible while maintaining adequate suspension. in particular. "live lift" is possible. In general. and superior grip strength. Because of the weight of the components. and batteries. and it should not be overcharged. A very important factor to consider in prescribing externally powered prostheses is the cost. these functions are not available in body-powered prostheses either. upper-arm rotation. Although this varies in different parts of the country and is dependent on the type of prosthesis. Amputees at times will complain of inadvertent cycling of a powered component. It has been stated by some that proprioception. While large-grasp functions with the externally powered hand are equal or superior to split hook terminal devices. they appear to be inferior when used for fine motor activities or manipulating small objects. and only one model is commercially available.9 repairs per Very young children do not year. It tears quite easily and becomes soiled. Because of the bulk of the hands. the weakest link in this system is the cosmetic glove. Over a period of time. must be located remotely. At this time. wrist flexion and extension.34C: Externally Powered Prostheses | O&P Virtual Library electrical system rarely fails. the use of these prostheses demands certain restrictions of an amputee's activities. The weight of externally powered prostheses is a frequent complaint of amputees using them. By far. AGE CONSIDERATIONS At what age should a child be provided with an externally powered prosthesis? Probably no http://www. sizes and tend to be heavy. this has improved significantly. These are passive only. Powered hook-type terminal devices for children are rarely used. Certain stains such as ball point pen ink and newsprint are virtually impossible to remove. The durability of externally powered elbows has been rather poor to date. both initially and for repairs. but the incidence of repair due to breakdown in children is still rather high and frequently means that the amputee will be without a prosthesis while Many of the powered elbows are not available in children's the repairs are being made. but it is a common source of dissatisfaction. However. Batteries need frequent recharging and periodic replacement. which is limited with any prosthesis. There has been reluctance on the part of many third-party payors to assume the cost of externally powered prostheses. For example. a feature that is particularly cogent when considering very young children. the functions that can be fabricated into an externally powered prosthesis for small children include prehension and elbow motion. In clinics fitting a number of children. although when it does. Much work needs to be done to improve its durability. This is particularly relevant for the higher-level amputee and for small children. They are still quite heavy and. They cannot be used to hammer. This growth factor can be somewhat ameliorated by using socket liners.). and thus an even greater force must be overcome when using the prosthesis. and this group included only a few very young children. In addition. the minimum cost for these devices is several thousand dollars. particularly those with short residual limbs. An additional problem in children who are still growing is that this expense will have to be repeated as the child grows out of the prosthesis. externally powered prostheses have been shown to be twice as slow as body-powered prostheses and five times slower than the normal or nonamputated limb.oandplibrary. it is expensive to repair. if they cannot be built into the prosthesis. In tests done on measured tasks. but one would anticipate that with further research these functions could be made available to child amputees using externally powered prostheses. much of the weight is located distally in the limb. it is sometimes difficult to get the prosthesis through the sleeves of garments.org/alp/chap34-03. The thumb axis and hand frame commonly need repair and realignment in children. It does not appear to be a frequent cause for rejecting the prosthesis. myoelectric prostheses cannot be immersed in water. One series of 47 children wearing myoelectric transradial prostheses required 1. the heavier the prosthesis becomes. establishing a limb bank and recycling components can defray the cost somewhat. The greater the number of components used. The cost of replacing cosmetic gloves is significant ( Fig 34C-9. Not yet available commercially for small children are forearm (wrist) rotation. although this is disputed by others. or This is not an indictment of powered limbs since shoulder motion. or to play in water without some risk of damage to the device. to pry objects. understand that they must make certain concessions to avoid damaging these devices. is poorer with externally powered prostheses than with body-powered prostheses.asp[21/03/2013 21:57:55] . The reasons for this relate to the available components and particularly to the residual-limb characteristics and the number of functions that need to be replaced. sensation.. usually is not a significant problem because the amputated limb is almost as long as the nonamputated limb. that is. This function is usually accomplished with the opposite hand. even for several years. as well as the motivation. To make an intelligent choice and give valuable advice to the amputee one must be aware of and consider a myriad of factors.oandplibrary.e. and goals of the child and parents. It is hoped that future research will solve these shortcomings and provide these amputees with a better. distance from a prosthetic facility. In another series of children initially fit with body-powered prostheses there did not appear to be any difficulties encountered when they were switched from body power to external power at a later age. providing that the motivation to use external power was present. and attention span must be considered. Initially. there are those who would recommend fitting children at a very young age with externally powered prostheses. the following observation will be directed at unilateral amputees. It is a common occurrence for infants and very young children to wear and use a prosthesis for some time. The incidence of rejection is high. the amputees with the greatest need (i. These needs have to be met in the most appropriate manner possible. Unfortunately. In addition. the rejection rate and incidence of failure to use these prostheses are highest in this group. before they begin to use the prehensile capabilities of the prosthesis in a meaningful fashion. they have some wrist and hand motion and lack only finger prehension. available components and their advantages and disadvantages. the higher-level amputees) are the least served by external power due to technological shortfalls. and patients. expectations. more useful assistive device. availability of knowledgeable prosthetists. so the controversy continues. These include life-style and activities of the amputee. Another reason is that the externally powered transradial prosthesis is functionally a better prosthetic device than the prosthesis for highlevel amputees. Among the children under 6 years of age there was a much higher percentage of "passive" wearers. and those who rejected them. in young children. Historically. length type of prosthesis.34C: Externally Powered Prostheses | O&P Virtual Library question in the field of prosthetics in recent years has evoked so much controversy. With retained carpal and metacarpal segments. widespread prescription will be warranted. Externally powered prostheses have practically no use http://www. All the evidence would suggest that very young children can learn to operate externally powered prostheses. Age alone should not be the criterion by which a certain prosthesis is selected. Fishman and Kruger in their survey of children with myoelectric and body-powered prostheses took special note of the children who simply wore their prostheses. Working in a fully funded program under ideal circumstances. they showed a high rate of compliance among their Other investigators. Needs of the amputee change. The main requirement to be addressed in selecting a specific type of prosthesis for any amputee is the patient's needs. The ability to evaluate all these factors is one of the advantages of the multidisciplinary amputee clinics. Based on the work of Sorbye and others.org/alp/chap34-03.asp[21/03/2013 21:57:55] . those who used them functionally. characteristics of the residual limb and supporting structures. Bilateral amputees will be specifically discussed later. Because of this. availability of training. but until then each amputee should be evaluated on an individual basis. It has been shown that children benefit from early (under 1 year) fitting with a body-powered prosthesis in terms of prosthetic acceptance and use and in the development of bimanuality. In summary. when externally powered prostheses have been developed to the point that they are clearly superior in every facet of prosthetic care to any other type of prosthesis. however. so this is not the issue. the transmetacarpal level of amputation has been a difficult level to fit with any In amputees of this level. One reason for this is that there are many more child amputees in this category than there are at higher levels. namely. they retain that marvelous sense that any prosthetic device eliminates. children who wore the prosthesis but did not use it functionally. whether acquired or congenital. and one must never be fixated on a certain type of prosthesis but be flexible and sensitive to the needs of the amputee at a given time in his life. strength. financial considerations. There is no one type of prosthesis that is optimal for every amputee. comprehension. CONSIDERATION OF AMPUTATION LEVEL The majority of externally powered prostheses have been fitted to transradial amputees. have not been able to reproduce those results. Additionally. Successful fitting of the bilateral amputee. can be fabricated without creating an unsightly long arm. with externally powered prostheses has been disappointing to date. Long transradial amputees may have problems in concealing the battery pack so that it will not protrude from the volar aspect of the socket. The powered hand with a three-finger pinch is the most common terminal device used. There is an extremely high rejection of external power by these amputees who are so dependent on their prostheses. at any level. ). The transradial is by far the most common and most successful level of amputation that utilizes external power ( Fig 34C-10. At the carpal level. selection of control sites. In addition. as in the case of high-level transverse deficiencies (phocome-lia). to be cooler. Midforearm length is the ideal length for a myoelectric prosthesis. and for some reason. to give better suspension. especially if some of the carpal elements are retained. Training may be harder because these sites are situated on muscles that do not normally control the comparable prosthetic function. and this is seldom utilized. Location of adequate myocontrol sites may also be difficult. although this can be alleviated somewhat by fenestration. A powered shoulder has yet to be made available. usually myoelectric. High transhumeral. ). they are able to use adult components. As children assume adult proportions in their adolescent years. depends somewhat on the length of the residual limb and the purchase necessary to stabilize it. is equal or superior to that of a prosthetic device. and forequarter amputation levels have numerous problems: the rejection rate is relatively high. may be used to control microswitches or myoelectric controls ( Fig 34C-13. ). Although congenital amputees are classified prosthetically as to certain http://www. The flexible socket and frame have also been helpful for these levels. durability. the forearm becomes disproportionately long and also because the function of the residual limb at this level. Conversely. although this socket configuration eliminates any residual forearm rotation. The prosthesis can be donned either by simply inserting the residual limb or with the use of a pull sock. Forearm rotators are available for the larger child. is also easier ( Fig 34C-11. amputees with very short residual limbs. which in turn. and this increases their options for external power. an externally powered prosthesis. The amount of elbow flexion varies with the height of the anterior trim line.34C: Externally Powered Prostheses | O&P Virtual Library at this level because. They can become hot. Some of the same prosthetic problems mentioned above are encountered. especially for myoelectric use.org/alp/chap34-03. One advantage of this level is that suspension can be achieved with a modification of the expandable wall socket. specifically in regard to length and sensation. and functional use is diminished. If the humeral segment is long enough. with the addition of the usual components. With the longer residual limb. In some cases. thus eliminating the need for a Miinster-type socket and allowing the amputee to use whatever forearm rotation remains while retaining full elbow flexion and extension. Shoulder motion at these levels is only passive. Components for children are readily available. shoulder disarticulation. The long to midshaft transhumeral amputation is ideal to accommodate an electric elbow. such as in the short transverse deficiencies. socket and suspension fabrication may have to be very innovative. particularly in small children because the surface area available for body support of the socket is reduced ( Fig 34C-12. but clinically they are not used a great deal since they add weight and battery drain. they will have functional shoulder motion and be able to support the weight of the prosthesis. Only one powered hook-type terminal device is available for small children. reliability. ). Elbow disarticulation amputees again have problems with relative residual limb length in that the space required for an electric elbow will create an excessively long upper-arm segment and an asymmetrically short forearm segment. on balance. and ease of operation of bodyand externally-powered types of prostheses. Weight is a problem. Vestigial limbs. It is felt by many amputees to be more comfortable.asp[21/03/2013 21:57:55] . may have problems with suspension and in supporting the weight of the prosthesis. Sockets for these levels tend to get bulky and oppressive. Suspension is usually achieved by means of a modified Munster socket.oandplibrary. MISCELLANEOUS CONDITIONS Congenital amputees often present the clinic team with unique characteristics that require imagination and ingenuity to fit prosthetically. This choice on their part probably relates to the comparative weight. bilateral amputees usually reject prosthetic hands and prefer alternative terminal devices. In general. These include testing for controllable myoelectric signal and training in the care.oandplibrary. and conceptual abilities. TRAINING THE CHILD AMPUTEE WITH EXTERNALLY POWERED PROSTHESES It has been well demonstrated that children of all ages. and the complexity and speed of the prosthetic components. differential or graded muscle contraction. In addition to this. Another surgical consideration is the decision about the fate of vestigial limbs or residual-limb anomalies. elbow function. These sessions may have to be very short for the young child but can be supplemented later by watching the child play and encouraging him to use the prosthesis in his play activities. maintenance. One site should be taught at a time. in the context of externally powered limbs. although most amputees can be taught to generate signals. This is easily accomplished in elective amputations. In fitting with a myoelectric prosthesis. In the young child the parents should be incorporated into the training program at the onset since their participation and cooperation is essential to a favorable outcome. The format followed is similar to that followed in the training of an amputee with any type of prosthesis. However. It is always better to customize the prosthesis to meet the needs of the amputee than to modify the amputee to fit a preconceived prosthetic design. can be trained to operate externally powered prostheses. This can be facilitated by the use of movements of the phantom hand. gradually giving way to the amputee as he incorporates the prosthesis into his normal living patterns. the functional use of the powered prosthesis. after very careful consideration. Training time will vary. Although very young children can be taught to operate an externally powered prosthesis. The training method comprises several phases. combined function can be taught. and finally. ). While terminal devices can be fit at a very early age. or both. they should not be ablated unless they have demonstrated themselves to be detrimental to the amputee's rehabilitation or prosthetic progress or unless they can be shown. to be of no value to the amputee ( Fig 34C-14. in the case of one site-two function controls. it is worthwhile to mention again. Other factors to consider are the developmental age of the patient. certain concessions have to be made to the very young child because of his age. There are other special considerations for amputations in children.34C: Externally Powered Prostheses | O&P Virtual Library functional levels. Various authors recommend using a myoplastic closure in upper-limb amputations to facilitate externally powered control. This is done to cope with the weight and control site placement requirements of externally powered prostheses. Training sessions should be kept to 30 minutes or less. and this does not seem to depend on the length of time since the amputation. attention span. but in traumatic amputations this consideration may have to be sacrificed to the maintenance of length and skin coverage. when needed. although this is not available in very young or congenital amputees. A myotester is used to accurately locate the optimum The muscles to be used are palpated. until a maximum response is obtained on the myotester. the importance of retaining length and normal skin coverage. but they are covered elsewhere in this text.org/alp/chap34-03.asp[21/03/2013 21:57:55] . therapist. even if it means shifting skin flaps. is usually added somewhat later. except that location and control of the switching device is unique to external power. his ability to follow instructions. and after they are all learned. it has been our experience that the motivation of a very young child with any prosthesis generally resides primarily in the parents. location of control sites and muscle training is done by the pros-thetist. who have to be motivated to accept this role. In fact. much of the responsibility for care. http://www. including toddlers. These will be referred to specifically as the process is described. maintenance. The amputee must learn independent contractions of muscle groups and. and then the test electrode is moved control sites. depending on the attention span and endurance of the child. Short training sessions avoid muscle fatigue and soreness. the unusual features of their vestigial limbs frequently present opportunities to fabricate a unique prosthesis. the use of toys that move when activated by the myoelectric activity of the child should be substituted for the myotester. and actual training will fall to the parents. control. In very young children. It is here that individuality should be stressed as well as the interaction of one limb with the other (e. Interaction and playing with siblings is helpful. Gentle soaps and hand lotions can be used to clean and keep the glove supple. This phase of training focuses on accomplishing individual tasks with the prosthesis. Children 5 years and older can be taught to dress themselves. than the therapist can. If there is difficulty in inserting the residual limb. prosthetic wear should be discontinued until the problem is rectified. acceptance rates for transradial powered prostheses is from 60% to 90%. In one study in a group of 40 children using transradial prostheses with external power. Antiperspirant sprays are sometimes used successfully. They learn that the elbow and wrist (forearm) rotators are primarily positioning devices so that the terminal device can accomplish the task in the best possible position. Various compounds are available to control odor or excessive sweating.g. and perform various other tasks. In multifunctional prostheses. but in general a charge will last about a day. Stains from ball point pens and newsprint are particularly hard to get out. The amputee or parents are then instructed on how to don the prosthesis. The amount of time the prosthesis is worn each day should be gradually increased. In the final phase of training. the battery should be removed from the prosthesis and charged. Stress the fact that the prosthesis is a helping hand. It is at this point that parents can be effectively used as an effective and cost-efficient extension of the training program since they spend much more time. Wearing a prosthesis in summer can be exceedingly hot. More typically. the method of "live lift" with a powered elbow. This should not be a cause for undue alarm or fears of prosthetic rejection. each function should be learned individually and then combined or alternated. Teenage boys frequently respond to challenges to accomplish various tasks. If additional protection of the cosmetic glove from soiling or staining is needed. At the first sign of any significant irritation or breakdown. When the powered component slows down or operates erratically. Activities that cause excessive jarring of the prosthesis should be avoided. eat independently. Many of these studies are http://www. Rechargeable nickel-cadmium batteries are used to power the prostheses. the next step is to apply this to the control of the assembled prosthesis on the amputee.oandplibrary. After the operation of the individual components of the prosthesis has been learned. Children over the age of 5 years can follow this pattern.. RESULTS OF FITTING WITH EXTERNAL POWER Fitting amputees with externally powered prostheses has previously been more prevalent in Europe and Canada than in the United States. Basic control and function must be learned before proceeding to the functional use of the prosthesis. another ordinary glove should be worn over it. especially with the young child. These gloves are quite easily stained or torn. Amputees learn to operate the components in various positions. The residual limb and socket should be cleaned each day to avoid irritation and odor. although sometimes a pull sock can be used to facilitate entry. The length of time they will keep a charge or their longevity is dependent on use. It should be noted that all these children are unilateral amputees and that half of them have been monitored for 1 to 3 years. although it has become much more common here in recent years. its care and maintenance should be thoroughly discussed with the amputee and the parents. and it is not uncommon for the unilateral amputee to discontinue or reduce prosthetic wear during this season. especially if he is on vacation from school. these learned functions are extended to include the more complex activities of daily living at whatever level is appropriate for the child's age. Normal recharging time is about 12 hours. The location and function of each component of the prosthesis should be fully described. compounds such as talc or surgical lubricant can be used. This is done by inserting the residual limb. and how to "troubleshoot" simple malfunctions of the prosthesis. No one else has shown this high rate of success. and the battery lasts about 2 years. Age-appropriate games and toys are useful in the very young child.asp[21/03/2013 21:57:55] . Object training can then be started beginning with grasping objects of different shapes and sizes and moving them from place to place and then progressing to objects of varying densities and learning to moderate the force of grasp. Older children can be instructed in the use of the internal hand switch. stringing beads). The gloved terminal device can be immersed in water only if the glove is intact with no cuts or tears.org/alp/chap34-03.34C: Externally Powered Prostheses | O&P Virtual Library Once the prosthesis has been fabricated. Parents are invaluable in giving encouragement and suggestions to the amputee on how he might use his prosthesis in daily activities. only 2 children rejected the powered prosthesis and preferred the split hook. Cosmetic gloves are made of PVC. Batteries occasionally can be totally discharged but should be recharged promptly. 10:62-77. Few studies of children with higher-level amputations have been done. transhumeral and proximal.. 23 very young children. except perhaps in research situations. Lambert TH: An engineering appraisal of powered prostheses. 1989. Inter-Clin Info Bull 1980.asp[21/03/2013 21:57:55] . but in one a 50% rejection rate was encountered.B. the less likely they are to reject it. 10. or they become particularly adept with the use of their feet if they have usable lower limbs. The prostheses are heavy. In an interesting study done by Fishman and Kruger with a 3-year follow-up. whether body powered or externally powered. http://www. Gingras G. Bull Prosthet Res 1970. as well as awkward and imprecise for them to operate. Clin Prosthet Orthot 1985. 44% preferred the myoelectric prosthesis. At the very high levels (very short transhumeral. Keagy RD: Amputations of the upper extremities. Mongeau M. the rate of rejection also varies from series to series. The results of fitting them with external power. 67:654-657. Available funds would be better utilized. cumbersome. 12. The needs of the higher-level amputees are more complex and with current prostheses are not as well served as are the prosthetic needs of transradial amputees. Galway HR. has been disappointing. Clin Orthop 1986. for her help in preparing the training section of this text and to Eileen Hansen for her generous work in processing the manuscript an untold number of times. Day found that in a study done on young children. et al: Management of the upper limb deficient child with a powered prosthetic device. their parents will frequently look after their bodily functions. pp 361-375. Day HJB: The United Kingdom Trial of the Swedish myoelectric hand for young children: An interior report. as for example. shoulder disarticulation. if anything. H. 67:273-277. In addition.oandplibrary. in Vernon MN (ed): Orthopedic Rehabilitation. 209:202-205. 49:333-341. 5. Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation. Heger H. or forequarter). and 22% rejected all prostheses. Millstein S. J Bone Joint Surg [Br] 1985. Churchill. 6. J Bone Joint Surg [Br] 1985. 47:232-237. rejection is high among unilateral amputees. Brooks MD. for adaptive equipment for this group of small children rather than spending them for externally powered prostheses. Kruger L: Comparison of myoelectric and body-powered hands for below elbow child amputees. whether unilateral or bilateral. if they have a choice of body power. The ability of the child to have the cost of his prosthesis underwritten probably also significantly affects whether or not external power is continued. et al: Bioelectric upper extremity prosthesis developed in Soviet Union: 7. 17:5-9. New York.org/alp/chap34-03. Sharperman J: Infant prosthetic fitting: A study of the result. Preliminary report. Bilateral amputees are obviously very dependent on their prostheses.T. Hubbard S. Review study for Shriners Hospital for Crippled ChildrenSpringfield Unit. is poor in small children with very high-level limb loss. it tends to be somewhat higher than in transradial amputees. 11. Hunter G. only 25% actively used their Fishman and Kruger's study had prostheses and the rest wore the prostheses passively. References: 1. Am J Occup Ther 1965. Use of prostheses. R. although. Childress DS: Historical aspects of powered limb prostheses. 8. 1982. Arch Phys Med Rehabil 1966. 19:329-334. 3. 34% preferred the body-powered one. Milner M: Myoelectric training methods for the preschool child with congenital below-el-bow amputation.J. and the rejection rate among these children was higher than age average. body-powered hook. J Bone Joint Surg [Br] 1967. at least initially. 9:2-13. Kritter AE: Myoelectric prostheses. Acknowledgments We would like to express our gratitude to Donabelle Hansen. In higher-level amputees. They also noted that 68% were active users of their prostheses and 32% were passive wearers. of 120 children. Sherman ED. and hot for these little children with a small body mass. 4. Salway HR.P. Childress DS. 67:278-281. Billock JN: An experiment with the control of a hybrid prosthetic system: Electric elbow. 2. phocomelia or amelia. Fishman S. Glynn MK. 9. that is. A comparison of two training programs. 13.34C: Externally Powered Prostheses | O&P Virtual Library difficult to compare because of different variables in the study. J Bone Joint Surg [Am] 1985. which casts some doubt on the premise that the earlier the children are provided with external power. Seamone W: A five-year review of clinical experience with Johns Hopkins University externally powered upper limb prostheses and orthoses. Stein RB. 34. Proc R Soc Med 1973. 21. 21:52. 19. Med J Aust 1969. 64:243-248.asp[21/03/2013 21:57:55] . 28. pp. 32.Atlas of Limb Prosthetics: Surgical. Hunter G: A review of the failures in use of the below elbow myoelectric prosthesis. J Bone Joint Surg [Am] 1968. Scotland TR. Leszczynski J: Juvenile upper limb ampu-tees:Early prosthetic fit and functional use. Stein RB. Tucker FR: Surgical implications of myoelectric control. Sorbye R: Myoelectric prosthetic fitting in young children. 13:124-128. Thyberg M. 50:524-534. J Bone Joint Surg [Br] 1980. 35. 33. Millstein S. Chapter 34C . Clin Orthop 1980. Prosthetic. Techn Rep 1981. 36. 18:9-16. Scott RN: Myoelectric prostheses of very young children. J Med Eng Technol 1988. Liberty Mutual Research Center: New Products Bulletin. Adv Neurol 1983. 15. Scott RN: Myoelectric control of prostheses. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 34C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 66:637-638. Heger H.org/alp/chap34-03. Northmore-Ball MD. Gillespie R. Scott RN. Arch Phys Med Rehabil 1966. 31. Walley M: Functional comparison of upper extremity amputees using myoelectric and conventional prosthesis. Crit Rev Biomed Eng 1986. J Assoc Child Prosthet Orthot Clin 1986. 22. 16. Inter-Clin Info Bull 1983. Scott RN. Galway HR: A long term review of children with congenital and acquired upper limb deficiency. Artif Limbs 1971. Plettenburg DH: Electric versus pneumatic power in hand prostheses for children. Hunter G: The below elbow myoelectric prosthesis. Charles D. Arch Phys Med Rehabil 1983. O'Shea BJ. Orthot Prosthet 1982. 23. 148:34-40. 18:11-15. 61:248-260. Clin Orthop 1968. Simpson DC: Externally powered artificial arms. 64:451-455.oandplibrary. 29. Bull Prosthet Res 1980. Le Blanc MA: Clinical evaluation of externally powered prosthetic elbows. 18. 10:21-33. Dunfield VA: Myoelectric training for preschool children. Trost FJ: A comparison of conventional and myoelectric below elbow prosthetic use. Schmeisser G Jr. Tervo RC. Heger H. 37. 8:278-280. 82:1. Maureielo GE: Some electronic problems of myoelectric control of powered orthotic and prosthetic appliances. 211-217. 65:346-349. 20. Walby M: Bioelectric control of powered limbs for amputees. Arch Phys Med Rehabil 1983. Wedlick LT: External power and recent concepts in control of limb prostheses. Spring. J Med Eng Technol 1989.34C: Externally Powered Prostheses | O&P Virtual Library 14. Porter PA: Myoelectric prosthesis: State of the art. 12:143-151. Arch Phys Med Rehabil 1986. 17. 25. Johansen PB: Prosthetic rehabilitation in unilateral high above elbow amputation and brachial plexus lesion: Case report. J Bone Joint Surg [Br] 1983. Scott RN: Myoelectric control of prostheses. 13:283-310. Bull Prosthet Res 1975. 1989. 24. Trost FJ: Fitting above elbow amputees with externally powered prostheses. 15:70-77. 47: 174181. 67:260-262. 39:1093-1108. 62:363-367. 27. 36:29-34. Inter-Clin Info Bull 1983. Parker PA. Paciga JE. Contact Us | Contribute http://www. et al: Clinical evaluation of UNB 3-state myoelectric control for arm prostheses. Gibson DA. 26. 30. The author wishes to express appreciation to Springer-Verlag for permission to use the selected content. edition 2. is less likely to hamper movement. American Academy of Orthopedic Surgeons. babies between 4 and 15 months of age are receiving their first myoelectric prosthesis. *This chapter is adapted from material presented in Comprehensive Management of the Upper Limb Amputee. IL. Click for more information about this text. what to fit. reviewed the literature in 1972 and reported on the various rationales for early Sypniewski upper-limb prosthetic fitting for children. she discussed both the definition and is meant by "early fit. and Rehabilitation Principles Upper-Limb Deficiencies: Developmental Approach to Pediatric Upper-Limb Prosthetic Training Joanna Grace Patton. The staff at the Child Amputee Prosthetics Project (CAPP) at both the University of California at Los Angeles and Shriners Hospital for Crippled Children. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). the prosthesis sitting balance. The approach has gained media attention and generated much interest and controversy among professionals and families who have limb-deficient children. The practice at CAPP is based on clinical experience as that identifies the developmental period prior to well as a study by Brooks and Shaperman 2 years of age as a good time to fit the first prosthesis. She cited research that supports the belief that the development of visually guided reaching is dependent on the opportunity to see the limb moving in space. However. She questioned whether fitting the baby before 3 or 4 months of age would aid visually guided reaching and thus influence future prosthetic wearing and use patterns.R.org/alp/chap34-04. prescribing prostheses. Prosthetic. and Rehabilitation Principles. ©American Academy or Orthopedic Surgeons. the first prosthesis with no active control is fit when the baby achieves independent Since the baby has progressed beyond the stage of rolling. O. Prosthetic. Los Angeles Unit. Prosthetic. B. http://www.S. Michael JW (eds): Atlas of Limb Prosthetics: Surgical.. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. adhere to this philosophy of care. and training children who have limb deficiencies or acquired amputations. published by Springer-Verlag. In fact. reprinted 2002. myoelectric programs. the development of myoelectrically operated components for children in the 1970s and the manufacture of lightweight electric hands and miniature circuits are changing In selected centers that have well-established the prescription and training process. Rosemont. there is and always has been a difference of opinion about which developmental milestones are most appropriate as a basis for planning treatment. Clinicians still debate what In a 1976 article by Fisher. Reproduced with permission from Bowker HK. These same questions concerning when to fit. 1992. children who received the Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.asp[21/03/2013 21:58:02] . They feel that pediatric prosthetic treatment is not and should not be a duplication of adult treatment. Early fitting is clearly cited as an important concept.T.Atlas of Limb Prosthetics: Surgical. Chapters in that book by Joanna Grace Patton entitled "Developmental Approach to Pediatric Prosthetic Evaluation and Training" and "Upper-Limb Prosthetic Components for Children and Teenagers" are used as a basis for this format." practice of early fitting. For example.oandplibrary. THE CHILD WITH A UNILATERAL TRANSVERSE FOREARM DEFICIENCY Child Development-Foundation For Early Prosthetic Fitting and Treatment Principles of child development are important as a foundation for evaluating. and how to do training will continue to have an impact on both health professionals and the general public in the 1990s. At CAPP.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 34D Chapter 34D . Provide accurate information about prostheses. the CAPP TD with its large grasping surface and both able to hold an object. The occupational therapist observes fit. When parents have the opportunity to select the type of terminal device they want. including self-help. Parents frequently ask whether a prosthesis has a real value. With the prosthesis. Some parents are totally overwhelmed by the birth of their child with a limb deficiency. comfort. The therapist sees the baby and family two or three times during the first month to provide http://www. They also need to receive appropriate information about the baby's limb deficiency and future treatment.asp[21/03/2013 21:58:02] . 2. they may be more committed to the total program. By watching the baby move and play. An infant chest harness is used instead of the traditional figure-of-8 harness ( Fig 34D-1.org/alp/chap34-04. Then he is able to complete the more complex part of the task with the sound hand. a Dorrance 12 P hook. Parents are asked to bring siblings and extended family members so that the CAPP staff may provide the following types of information: 1. and function of the prosthesis during normal use.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library prosthesis before the age of 2 years develop better wearing patterns and skills than do those children who received one between 2 and 5 years of age. school. the prosthesis for the infant is a lightweight endoskeletal or exoskeletal transradial (below-elbow) prosthesis with a nonactive terminal device. It prevents the baby from sliding when the prosthesis is used for support on a hard surface. A polyvinylchloride (PVC) gauntlet covers the socket to provide a friction surface. Family's Introduction to the Prosthetic Program Early intervention and support are most important for families. avocational. while others seem more able to The early opportunity to discuss feelings and concerns is most cope with the birth crisis. the child can hold the object away from the chest and at the midline of the body.). Even though the little passive hands provide no grasp function. vocational. Even though the team provides information. Infant Prosthesis/No Active Controls At CAPP. support. Certainly a child can use substitute grasp patterns like clasping an object under the arm or against the body with the residual limb. They are encouraged to see the clinic team as soon after the baby's birth as possible. Evaluation of and Training With the New Prosthesis The prosthesis should be evaluated when it is delivered to the patient to make sure that it conforms to the prescription and standards of the clinic. Most clinicians agree that fitting the first prosthesis when the child is entering the "terrible twos" can be a very negative experience for everyone and should be avoided when possible. 4. Explain that the child will be able to perform most activities of daily living. the parents must follow through on a day-to-day basis. good friction cover provides a secure hold on objects. Any signs of restriction or discomfort are reported to the prosthetist so that the necessary changes and adjustments can be made. Skills will develop because of the child's natural abilities and interests.oandplibrary. families do request them because of appearance. or a Centri infant hand. They help the child develop both a consistent wearing and use pattern when performing daily activities. and training. and household tasks with or without a prosthesis. Families need time to assimilate the information provided by the team because they are the ones who must make informed decisions concerning the prosthesis for the child. Parents are given the choice of a CAPP Terminal Device No. Reassure the family that the child should be treated the same as other siblings or children in terms of performing daily tasks. Explain how the child performs activities with and without a prosthesis. The advantage provided by the CAPP TD and hook is that they are In addition. a Steeper foam-filled infant hand. recreational. and enrolling in regular school. 1 (CAPP TD). Reassure the family that the baby with a transverse forearm deficiency has the potential to develop normally unless there are other medical or neurologic problems unrelated to the limb deficiency. and clarify misconceptions about stateof-the-art technology. valuable to the family. 3. the therapist evaluates the stability of the socket and harness. receiving discipline. siblings. his body and arm movements may be awkward for a few weeks or so. encouraged to include the prosthesis to stabilize body weight when creeping on all fours ( Fig 34D-2. Grandparents. baby-sitters. clean the inside of the socket.) or when pulling to stand. takes a bath. 1." When the baby receives the first prosthesis. Some of these behaviors become apparent near the child's second birthday and are based on principles of development. the toddler will become aware of the holding function and mimic this Gesell and Ilg describe a similar developmental activity in which babies learn to behavior." The mental activity is demonstrated by the child's According to Gesell ability to follow simple directions and to understand cause and effect.asp[21/03/2013 21:58:02] . http://www. The terminal device may be a CAPP TD No. 2. Evaluation of the Prosthesis With the Active Terminal Device The control line and figure-of-8 harness are added to the current prosthesis. No harm is done if the therapist and family remain flexible. It is reasonable and desirable for the prosthesis to be worn the entire time the baby is awake. place cubes in and out of a cup. Learn to recognize when the socket and harness are tight. Take the child to see the prosthetist for necessary adjustments. these cognitive and motor skill changes do take place during the everyday play.oandplibrary.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library both information and support as well as tell parents how to do the following tasks: 1. "However. The child is able to follow simple directions that have no more than two steps. This adaptive behavior becomes more meaningful and To make it easy for the toddler to engrossing as the baby gets closer to 18 months of age. open the terminal device. the child is no longer cooperative. the CAPP TD should have a soft spring. The child shows an interest in activities that require the use of two hands.org/alp/chap34-04. Maintain the prosthesis in good condition by washing the harness. or swims. Since the manufacturer issues the terminal device with a regular spring. a 10X Dorrance hook. 5. 3. The 8. 4. the 2. The child shows some willingness to be handled by the parent or therapist. The child integrates the opening of the terminal device with fine motor bimanual activities and then relates it to However. Sometimes after the control line is added and everyone gears up for the training. The child demonstrates an awareness that the terminal device can hold an object and attempts to open it with the sound hand. Pulaski says "the child at two makes a transition from sensory motor experience to mental activity.. or a new prosthesis may be fabricated. 2. Over time. Parents are child learns to clasp between the sound arm and the prosthesis also asked to place a toy or cookie in the terminal device. Correctly apply and remove the prosthesis. wearing patterns may vary with climate changes and individual parental needs. middle of the "terrible twos" when the child may resist being handled.). Large balls or stuffed animals are presented so that the ( Fig 34D-3.to 12-month-old may try to remove the item or totally ignore it. as the parents continue to place objects in the terminal device. the prosthetist should be reminded to make the change. Encourage the baby to use the prosthesis in normal play activities. motor development by introducing the active control line or cable. It may be removed when the baby sleeps. but should provide assistance if The baby is the prosthesis becomes pinned under the baby's body or caught in furniture. He also has an elementary interest in It is therefore appropriate to capitalize on this period of cognitive and imaginative play. The family need not be overprotective. 4. and other extended family members are encouraged to attend one or more sessions. or a child's size mechanical hand. The child demonstrates an attention span of at least 10 minutes. They may postpone the training time or pursue alternative nonstruc-tured training methods. et al. The readiness criteria are as follows: 1. and use clean stump socks each day.to 2½-year-old has the beginning of interest in constructive activity such as building with blocks and fitting simple toys together. Their role is vital in cooperating with parents to establish the development of a consistent wearing pattern. 3. Readiness to Activate the Terminal Device-The CAPP Approach At CAPP the control line or cable is added to the transradial prosthesis when the child demonstrates certain developmental behaviors that indicate the ability to learn how to use an active terminal device. The result is slack in the control system. The cross point of the harness is stitched in the center of the back a little lower than C7 rather than toward the sound side. Have the harness adjusted as the child grows. has a unilateral limb loss to use the prosthesis to perform dominant hand skills. Whenever a new prosthesis is issued. To counteract the problem and minimize frustration." It is best to use developmentally appropriate bimanual toys and games in order for the At CAPP we do not ask the child who child to relate the control motion to purposeful play. prosthesis. The cable housing should be lined with Teflon to increase the efficiency of the cable system. The child holds a toy in the sound hand while the therapist moves the shoulder on the side of the prosthesis into humeral flexion ( Fig 34D-4. Adjust the wrist friction so that the terminal device does not inadvertently move during use. 1. The parents must be included in the therapy sessions in order to assist the child at home.org/alp/chap34-04. Once the child has completed the activity. Immerse the ball bearing of the hook in alcohol to clean. Use an air hose at the gas station if necessary. the 10X hook should have a quarter to half of a rubber band. Brush dirt or sand from the pulley system of the CAPP TD. The therapist helps with the secure and correct placement of the toy and extends the child's shoulder to relax tension on the control line to close the terminal device. Although the focus is on learning the control motion. the therapist stabilizes the shoulder on the sound side and encourages the child to reach forward to place a toy in the terminal device.asp[21/03/2013 21:58:02] . When the child bends over or reaches forward toward a toy. Pressure is exerted by the harness under the axilla on the sound side. Remove and replace the top with the sound hand). Control Motion Training Controls training or initial training is conducted by the occupational therapist to teach the child The therapist sits behind the child or next to the arm with the to open the terminal device. 5. Change the CAPP TD covers when they wear out. or a special detergent such as "Simple Green. http://www. Two or three short training sessions a week for 2 to 3 months are reasonable to reinforce learning the control motion and to provide a successful experience for the child. The therapist definitely provides "hands-on" assistance during this period. Remove all rubber bands from the hook when the elastic deteriorates. Therefore the following components and adjustments should be standard for a child's prosthesis to maximize efficiency and ease of operation. the control attachment strap may be tightened. 2. a manufacture's glove cleaner. 2. (Hold the barrel or the jar in the terminal device. Clean the inside of the socket each night. The CAPP TD needs a soft spring. 4. Replace with new ones. 1. 1. which prevents ease of operation of the terminal device. he may remove the item with the sound hand. and both should open and close smoothly.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library The size and contour of the child's anatomy as well as the range of motion and strength of the shoulder girdle are certainly not the same as the adult's. 7. the child does not respond well to "drills." 6. Appropriate activities that provide repetitive opening and closing of the terminal device may be used for this phase of training. Go to the prosthetic shop every 4 months. The control attachment strap and lower axilla loop strap should pass over the lower third of the scapulae.oandplibrary. but rather to assist the sound hand in two-handed tasks. The therapist or parent then calls attention to the open terminal device. the terminal device opens. 4. Retread the neoprene lining of the hook when it wears out to maintain complete closure of the hook fingers. 3. The child usually moves the shoulder or upper part of the body to avoid the pull of the axilla loop.). Wash the harness at least once a week. If the child is less inclined to sit at a table to learn the controls. 3. Clean the glove of a mechanical hand with alcohol. the following care and maintenance procedures are reviewed and reinforced with the family. Use threaded nesting barrels such a "Kitty in the Kegs" or small jars and bottles with toys or treats inside. and remove the cap with the sound hand to scribble on paper. Refine the size of terminal device opening. Stages of prosthetic training overlap with each other.) To assist the child to learn specific skills the therapist demonstrates the activity and provides verbal instruction. While functional use of the prosthesis cannot be compartmentalized. If the child appears awkward when doing the task. To master the basic control motion the child must learn to independently perform the following skills: 1. the child may practice reaching forward with both the terminal device and It is best to avoid "one-handed drills" sound hand to grasp a stationary object in space. 2. If the child has difficulty. There are many ways to approach an activity. Hold the marker in the terminal device.oandplibrary. many children either avoid prepositioning the terminal device or repositioning an object in the terminal device. As new. young children do not assimilate all facets of training at once. A helpful hint about the CAPP TD No.asp[21/03/2013 21:58:02] . To open the terminal device at the midline of the body the child must use biscapular motion. 1 is to position it so that it mimics the sound hand. see-saw-swing. Initially the therapist focuses on the following skills: 1. and use a more spontaneous two-handed approach with toys such as. especially if the sound hand is occupied. Place an object securely and accurately in the terminal device. wheel barrow.org/alp/chap34-04. Time the closing to prevent the object from falling out. However. http://www. the child must learn to actively grasp an item from a surface with the terminal device. shopping cart. Extend the shoulder to relax tension on the control line to close the terminal device. Although it will always be appropriate to place an object in the terminal device with the sound hand. 4. 3. Actively release an object from the terminal device by using the control motion. manipulative tasks are presented. Skills that relate to prehensile function are introduced as the child is ready to learn them. Use fat felt-tipped pens with loose caps. and place an object securely inside. tricycle. The therapist may need to do part of a more complex task and then allow the child to complete the activity. In time only verbal cues may be necessary. and Play-Doh ( Fig 34D-7. Some children learn automatically. the therapist asks how the task may be done another way. The focus during this period is on the prehensile use of the terminal device. doll carriage. Others may need assistance. (Learn to drop the object on the table or floor. tike bike. (Hold the bead in the terminal device and hold the string with the sound hand). Either pull it out with the sound hand. Reposition or change the position of the terminal device as required for different activities. Use Training During use training the child acquires prosthetic skills that facilitate use of the prosthesis as he works to develop a natural and spontaneous use pattern. 2. the child is encouraged to motor-plan and problem-solve for the new activity without assistance. or actively release it by using the same control motion. to achieve a fluid movement pattern with the prosthesis. rocking horse. Open the terminal device. They frequently substitute shoulder motion to place the terminal device in a position of function and need reminders to perform the task more efficiently. Actively toss the object from the terminal device into space. the therapist should correct the method of prosthetic performance. Likewise.). Performance will vary depending on the child's natural abilities and motivation. For example.). and learning takes place over a period of time along with the acquisition of other developmental skills.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library 2.). String large wooden or plastic beads with a strong cord or leather lace. the child should continue to use the prosthesis as a unit to stabilize or support objects ( Fig 34D5. especially for small or thin items ( Fig 34D6. 3. fine-motor. Reposition the object as needed. rolling pin. 3. This opportunity allows for a trial-and-er-ror approach before the therapist intervenes. Release an object from the terminal device. the therapist introduces or reviews specific prosthetic and self-help skills. 2. Voluntary-closing Adept terminal devices from Therapeutic Recreation Systems (TRS) also http://www. or other appropriate team member. and dress-up play with costumes and makeup. crafts. formal therapy is no longer necessary. 2 with its automatic thumb-locking mechanism and heavy-duty closing This component is appropriate for the spring provides excellent grip force and function. there is no magic to the training process. The school-age child learns additional skills that are a refinement of prosthetic use. at different developmental periods the child may need assistance with specific selfhelp. 6. Before the child goes to kindergarten. Open a milk carton and package of cookies. When the child acquires some degree of skill with the prosthesis. cosmesis. interests. A third and much harder spring is available for the older school-aged child. the therapist does much to enhance training by being creative. In fact the preschool youngster does well with activities that encompass imaginary play such as a tea party.oandplibrary. The child who has the CAPP TD No. 3. a quarter to half of a band may be added at a given time according to the youngster's available excursion and operating force. The Hosmer-Dorrance voluntary-opening hook uses rubber bands to provide grip strength. While the 2-year-old delights in repetitive bimanual tasks. more independently in the classroom 1. and avocational activities. 4. and the option of adding rubber bands to increase grip strength. Some preteen and teenage boys may actually switch to a hook from some other device because they like the configuration. games. the focus in training shifts Although some children become more spontaneous than to developing more spontaneity. therapist. Playing baseball with a plastic bat and a large ball as well as outdoor fun on playground equipment is also highly recommended. recreational. In order to hold a soft or fragile object in the terminal device.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library Since the child's work is play. 1 will need to replace the soft spring (Hosmer 71622) with the regular spring (Hosmer 71623).org/alp/chap34-04. for tool use. This skill is important in order to hold a sandwich or crack an egg without a mishap. ). Practice in the following type of activities may help the child to function ( Fig 34D-11. grocery shopping. the child controls the pressure grip by maintaining a slight amount of tension on the control line. the therapist or child will identify a need for more prehension force. Practice and repetition are a definite part of building a habit pattern. The CAPP TD No. washing dishes ( Fig 34D-9. ). This exchange is made as soon as the child has enough operating force to pull against the increased resistance. The hook is especially versatile for grasping the handle bars of a bike. athletic. function. Begin to learn to tie shoelaces. and skill levels change. For the young child. planting flowers or seeds in a pot ( Fig 34D-10. and other purposeful bimanual tasks are used to integrate these skills into the child's use pattern ( Fig 34D-8. These maneuvers will help to relax tension on the control line to keep the terminal device closed to tie shoelaces or shoot a toy bow and arrow ' ( Fig 34D-12. the fine tip prehension. Therefore the youngster should always have access to the prosthetist. Don and doff the prosthesis independently. washing doll clothes and hanging them on a line. To keep the terminal device closed when bending over or extending the shoulder.asp[21/03/2013 21:58:02] .). The therapist is usually aware of these needs and may be in a position to introduce different prosthetic components or recommend changes to existing ones. However. Early in the use-training period. By the time the child enters kindergarten. Hold paper to cut with scissors. the child must pinch the scapulae together or shrug the harness high up on the back.). Stabilize clothing to zip a jacket or button a shirt. others. Open and close glue bottles and jars. Functional Need and Prosthetic Options As the child grows and develops. Parents must be present during training sessions because their involvement and cooperation are essential for ongoing success. teenager and adult and will soon be commercially available. toys. and for heavy-duty work. The child may become repeatedly more frustrated when he is not able to hold an object securely in the terminal device as resistance is applied by the sound hand. 5. ). two-site control system and the appropriate electric hand to fit children as young as 3 years of age. as well as good cosmesis. Guidelines for handling the baby's special needs are also presented. Because myoelectrically-operated prostheses are more expensive than the cable-operated ones. The benefits are twofold. may be pleasing in ( Fig 34D-13. They are frequently very hot and perspire excessively around the head and neck. An increasing number of parents will not accept any other terminal device except a hand. "We were in so much shock we did not know how to act or what to do. Over time. "This device is made of soft.oandplibrary. 2. if the patient and/or family decides not to pursue prosthetic fitting. The voluntary-closing device makes it easier to lift heavy objects and to grasp cylindrical shapes such as a bicycle handlebar and a baseball bat. the family needs emotional support.org/alp/chap34-04. elimination of the cable and harness system." The type of prostheses and components that are offered in a particular amputee center may depend on the following: 1. and the feet are free to touch and explore the environment. sensitive team can share the family's fears and concerns and. The TRS Super Sport Hand can be used as an alternative." An experienced. guidance. Older youngsters who are involved in school or community-based athletic programs are For certain activities. The center's history and experience with certain components and control systems. The occupational therapist evaluates the infant's development and explains what to expect as the baby matures. Research components developed in a particular center. The child must use excessive operating force to achieve only minimal opening. the hands do not have the same power pinch as the electric hands and do not provide the same potential for function as the CAPP TD No. 1 and the Dorrance hook. patients and their families have an ongoing need for up-to-date information about new and available components and should have some say in the prescription process. For the 2-year-old who is just learning active operation of the cable-controlled terminal device and for the therapist doing the training. and information. when funding is available. The baby remains cooler. CAPP does not have a myoelectric program for infants.asp[21/03/2013 21:58:02] . the Steeper 2-in. 3. 1. Use of this type of transradial prosthesis usually depends on available funding resources. THE CHILD WITH BILATERAL UPPER-LIMB AMELIA Support and Guidelines for the Family When a child is born with bilateral upper-limb ame-lia or other severe limb deficiencies. Parents are instructed to use lightweight clothing and allow the baby's lower limbs to be exposed. As one CAPP mother so poignantly said. but the terminal device is perceived to be a problem.. hand may not close completely. appearance and may be acceptable as an alternative to other devices Unfortunately. Therefore the child's-size mechanical hands from Steeper. help them to refocus on the child's abilities. The Baby's Ability to Adapt http://www. Available financial resources and subsidized funding for prostheses and components. Depending on the spring setting. The voluntary-closing device provides increased prehension force as well as greater control over the amount of force exerted to do an activity. Crandall and Hansen report a study in which 16 amputees out of 20 with transverse forearm deficiencies who originally used voluntary-opening hooks switched to the Adept devices. babies with severe limb loss have less skin surface from which to disperse body heat. ease of operation. The children cite specific advantages for themselves.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library provide a variety of benefits. Electric hands that are myoelectrically controlled provide excellent grip force. Ltd. However. two-state. flexible polymer and is shaped like a "cupped hand. youngster may wear the socket. the usually required to remove the prosthesis for body-contact sports. 2. this hand may provide more frustration than function. Nonetheless. state agencies and some insurance companies may not routinely pay for them. ). the clinic team should accept that decision and keep the "door open" for future assistance. For example. we use the Otto Bock. over time. Schmid which imitates that of the upper extremity. the baby should receive the first prosthesis before the developmental period of the "terrible twos.oandplibrary. it may be easier to suspend two sockets on the body and give the child a greater These options depend on the child's size as well as the contour and sense of balance. U. Manufacturing Company. One or two shoulder disarticulation prostheses may be suggested for the first fitting. Gesell describes adaptive behavior "as the child's ability to make adjustments in perception. Children with high-level upper-limb loss learn very early to substitute foot use for missing says "that the foot skills of these children develop in a sequential pattern arms.org/alp/chap34-04. The terminal device must reach the mouth at the midline of the body when the elbow http://www. ). The elbow joint is usually assembled from but a new push-button elbow joint is commercially available from the CAPP components. It may include an aluminum frame or vented laminated socket and a 10X hook or CAPP TD with no control cable. Is the child able to use the components and control systems currently available? 3. babies with no arms or with short transverse deficiencies above the elbow will not be able to creep on all fours. Later the child may come to standing from a prone position by pushing up with head and legs or use the body as a lever against a stationary object ( Fig 34D-14. One socket covers less of the chest area and may keep the weight.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library It is important to understand that a baby with no arms has a structural deficit and not a neurologic impairment. Obviously. the parents need to know when and how to assist the baby through various stages of neuromuscular development. However. and push to a standing position to walk. use of prostheses is presented as an option or an alternative way to perform selected activities." With neuromuscular maturation and voluntary control over body movements. ). and heat to a minimum. However there are variations in the establishment of specific fine and gross motor milestones. development should follow a specific sequence according to the maturation of the neuromuscular system. the child may be more enthusiastic about wearing the prosthesis. Rationale for Prosthetic Fitting For the child with bilateral upper-limb amelia. Even grasp between the great and second toe occurs within the same time frame as the grasp between the thumb and finger. the baby may learn to use the parent's leg as support to push to an upright position. sometimes wait until the child is walking. Essentially. the baby explores ways to move in space and to manipulate objects in the environment. Some babies experience delays. as well as manual and verbal skills. Unless there is a secondary problem. The team provides the family with information on appropriate components and discusses the real function of prostheses. Does the child have a functional need for a prosthesis? Will the prosthesis interfere with the child's development? 2. With encouragement. The forearm and humeral segment lengths are made of pieces of PVC tubing ( Fig 34D-15.S. children also hold and carry objects in the mouth or between the chin and shoulder. the following questions must be addressed: 1. these children do come to a sitting position. scoot on their bottoms. while others perform developmental skills within the normal time frame." In addition to using the feet.asp[21/03/2013 21:58:02] . Before a prosthesis is prescribed. Although no special therapy is needed. which then allows him to initiate new experiences. muscle mass of the chest and trunk. These segments must be the appropriate length to allow for the following functions: 1. Do the parents want a prosthesis for the child? Are they ready to commit to the training process? If at all possible. orientation. The First Infant Prosthesis With No Active Controls At CAPP the prosthetic fitting of choice for the child with no arms is an endoskeletal shoulder disarticulation prosthesis. bulk." It may be prescribed when the baby achieves independent sitting At CAPP we balance as long as it does not interfere with the ability to move freely. When the feet are used for ambulation. However. the clinic team must determine which fitting will provide the best comfort and meet the child's functional needs. but if there is interest and motivation. the hook closes by rubber band action. To bring the spoon to the mouth. When the child wears shoes so that his feet are not accessible. Likewise. they cannot reach out and clasp large or small objects between the segment lengths. however. Push or maneuver cars. A swivel spoon is placed in the hook and secured by a rubber band. the child leans the forearm on the table and forces the elbow to flex. Rubber band loading on the hook is minimal during this phase of training. however. Children It is without arms may also show signs of readiness to perform this task with the feet. Since children without arms do not have active shoulder motion. ): 1.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library is fully flexed. The need to do selected dominant-hand activities with the prosthesis prompts the activation of the terminal The terminal device as soon as the youngster has the cognitive ability to learn the controls. 5. The child will not gain independence in this skill for several years. and objects may easily fall out during use. the child must use body motion to push or move an object with the prosthetic forearm or terminal device. Parents will need to assist the child with many of the activities such as unlocking the elbow to bring food to the mouth. Because the toddler can perform most age-level play activities with the feet. Hit a drum or xylophone with a mallet secured in the hook. The older child who uses either an electric elbow or one with a dual-control cable system will be able to lift the forearm to the mouth with much less effort. The terminal device may be activated with either a Michigan External Power System (electric hook) with a push-switch control or a body-powered single control cable and a thigh strap. This method allows the terminal device to open and close in a stationary position. and the child hits the button to open the hook. Each system has its advantages and disadvantages. is a consistent wearing pattern. ). With practice the youngster will learn to scoop food by pushing the spoon against the high rim of a special dish. but the prosthesis should not interfere with foot use or the development of other gross motor skills. This method of eating is very complex and requires not only practice but assistance from the parent ( Fig 34D-17. The key. The child uses trunk motion to place the spoon in the dish. Activating the Terminal Device and Learning the Control Motion The passive prosthesis provides only minimal function for the child without arms. An extra band placed over the hook tip will secure most thin items and prevent them from slipping. The Michigan External Power System can be used with the endoskeletal type of prosthesis and retain the manual elbow unit. It is possible. The Training Period After the prosthesis is evaluated for fit. 2. 4. Pull a toy with a string that is secured in the hook. If more bands are applied. Scribble with a crayon that is secured in the hook. this system provides limited pinch force because the motor tolerates only about three fourths of a rubber band." Secure a brush in the hook. The method of bringing the spoon to the mouth depends on the control system that is used to power the elbow unit.org/alp/chap34-04.asp[21/03/2013 21:58:02] . When the child relaxes away from the switch. 3. the parent must learn how to encourage the child to use it. comfort. As the parents repeatedly place toys and finger food in the terminal device. the child will learn about the holding function. Unfortunately. to carry a large lightweight toy that is wedged between the forearms. The daily wearing pattern may be full-or part-time. The team must decide which one will meet the individual patient's needs and abilities. or other toys on a table surface. the following types of activities may be used in the training process ( Fig 34D-16. trains. At 15 to 20 months of age the toddler begins to feed himself with a spoon. the activity may be introduced during this developmental time period.oandplibrary. and a clear view of the objects to be grasped. and function. device of choice for the active prosthesis is a Dor-rance 10X hook because it provides fine tip prehension. The forearm must clear the table top when the elbow is flexed at 90 degrees. Soft food will stick easily. the motor usually malfunctions. Paint in a "Paint with Water Book. nonprehensile hooking action. http://www. The pushbutton control is placed inside the top of the socket. The push-button elbow is unlocked and placed in the free-swing mode. difficult to learn to eat with a spoon in the terminal device. it takes creativity and perseverance on the part of the therapist and parent to encourage use of the prosthesis. 2. The Fisher Price barn. provide imaginary play opportunities that encourage fine prehension and manipulation of objects with the hook terminal device. specific skills are integrated into the use pattern. The child may use the shoulder disarticulation prosthesis to eat. The child must master this skill as soon as possible to lessen dependence on adult intervention. use shoulder elevation and trunk rotation to open the hook. Later he will learn to push an object into the desired position with the unopened hook before attempting to grasp it ( Fig 34D-18. 3. elbow turntable. the child frequently uses the foot ( Fig 34D-19. The prostheses never provide total independence and were never meant to replace foot skills ( Fig 34D-20. The youngster then assumes an upright position. This refinement allows the youngster to perform tabletop activities at the midline of the body.oandplibrary. The child pushes either the humeral or forearm segment of the prosthesis against a stationary object in the environment to move the shoulder or elbow turntable. Even with a half of a rubber band on the hook. "Feedback" through the cable system.org/alp/chap34-04. and move objects in space. This type of prosthesis has a nudge control on the socket to lock and unlock the positive-locking internal elbow unit. the therapist stabilizes the child's pelvis and assists the child to bend the trunk to open the hook. will also provide a better friction surface. plays. However.asp[21/03/2013 21:58:02] . grasp. play food and dishes. schoolhouse. wearing patterns vary. it is necessary to place the stationary hook finger against Rubber tubing applied to the stationary finger the object before closing the terminal device. and carry toys from place to place. and proficiency with this type of prosthesis. ). cars. these components must be loose enough for the child to reposition them when necessary. Activities of Daily Living and Alternative Methods of Performance The concept of adapted performance is essential to the child with severe upper-limb loss. and carry objects. manipulation of objects on a table surface is impossible. the lack of pinch force soon becomes a problem when toys and other items are easily dislodged. speed. To minimize this problem. Initially. First. ) and other problem-solving methods. Without active shoulder motion this type of limb provides limited function. The shoulder. 2. The potential excursion provided by the thigh strap allows for the following results: 1. it requires extensive practice to achieve a degree of skill. An activity may be introduced during the same time frame in which an able- http://www. The other alternative is to use an exoskeletal prosthesis with a single control cable to close the hook. the child does not have sufficient chest expansion to move the cable. To preposition the hook or to secure an object like an eating or writing utensil in the terminal device. write.. simple card games with cards in a rack. or uses the prosthesis for function. Sometimes an item will slide across the table when the child tries to grasp it with the hook. ). ). the therapist prepositions all the friction components to place the terminal device in the desired position of function. Some children will always use prostheses to perform selected activities. Full or at least functional opening of the terminal device without undo exertion on the part of the child. zoo. while other individuals will wear and use them for only a specific developmental time period. Initially the child learns to grasp.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library While the hook is easy to operate. and wrist must be tight enough to maintain friction and not move unnecessarily when the child walks. In fact. The therapist must place the toy in With practice the child learns to the hook instead of asking the child to actively grasp it. Celikyol describes adapted performance "as encouraging the patient to approach and solve tasks by using the entire body adaptively and to look beyond conventional methods of arm and hand use to stabilize. In the beginning it may be more time-consuming and a little more frustrating for the child to learn the control motion with this system. lift. Use Training Once the control motion is refined. etc. Therefore a thigh strap control is necessary to open the hook. and trains. Potential to add rubber bands to increase grip strength. Because the terminal device cannot open and close in the same position." The occupational therapist helps the child to participate in activities of daily living by demonstrating adapted techniques and experimenting with adapted equipment ( Fig 34D-21. The child works best when motivated with toys such as wooden puzzles with large knobs. as well as small trucks. Over time. garage. These youngsters go to regular school. A treatment program that considers the psychosocial. 148:47-52. 157. 1972. pp 13. 186. Fisher AF: Initial prosthetic fitting of the congenital be-low-elbow amputee: Are we fitting early enough? Inter-Clin Info Bull 1976. 14. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. 5. New York. Dennis J: Shoulder disarticulation-type prostheses for bilateral upper extremity amputees. They respond positively to a treatment program that provides the following: 1. Hopkinton. Celikyol F: Prostheses. 9. J Assoc Child Prosthet Orthot Clin 1989. Gesell A. NY Inc. Thompson H. 121-123. Mass. 15. Liberty Mutual Research Center. New York. 198. 25:30. Mifsud M. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. For some activities. Brooks MB. Clarke S: Occupational therapy for the limb deficient child: A developmental approach to treatment planning and selection of prostheses for infants and young children with unilateral upper extremity limb deficiencies. 1946. Presented at the Conference on Occupational Therapy for The Multiply Handicapped Child. coordination. Clinical experience. 366. A developmental approach. 3.37:11-12. and prosthetic needs of the child and family. Occup Ther Health Care 1984. http://www. exchange of information with other health professionals. Al-Temen I. 16.oandplibrary. Solomon C: The two stage myoelectric hand for children and young adults. J Assoc Child Prosthet Orthot Clin 1990. in Atkins DJ. References: 1. Patton J: Developmental approach to pediatric prosthetic evaluation and training. Shaperman J: Infant prosthetic fitting: A study of the results. April 1965. 235. 8. 2. assistance may always be needed. Harper & Row Publishers Inc. 7. 13. 211. 22-23. Baron E. 4:71-73. Detroit experience from 1981 to 1990. Berkeley. University of California Press. Sauter W. 10. pp 83-96. pp 99-118. pp 108-110. pp 119. these children need to maintain slim. Inter-Clin Info Bull 1963. and effort. 2:2. flexible bodies. Brooks MB. Liberty Mutual Research Center. 15:8. Am J Occup Ther 1965. 3.org/alp/chap34-04. et al: Variety Village electromechanical hand for amputees under two years of age. J Assoc Child Prosthet Orthot Clin 1987. The limb-deficient child may accomplish part or all of a task quite easily. Mass. Brenner C: Fitting infants and children with electronic limbs. 240-334. and accumulated lecture material from the Child Amputee Prosthetics Project. 173. 6. 1940. 1989. Because dressing and toileting skills require considerable practice. pp 137-149. Any excessive weight gain or limitation or loss of range of motion may compromise adapted performance and independent function. Halverson H. long-term observation. 4. the individual may not achieve independence until the teen years. 19:333. 2. Crandall RC. pp 35. Patton J: Prosthetic components for children and teenagers. Springer-Verlag. University of California at Los Angeles.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library bodied child attempts the task.asp[21/03/2013 21:58:02] . 1988. 22:41-46. pp 46. participate in neighborhood and community activities. In addition to experimentation and practice. New York. et al: The First Five Years of Life. Blakeslee B (ed): The Limb Deficient Child. Harper & Brothers. 12. functional. Gesell A. Hopkinton. 1989. Ilg F: The Child From Five to Ten.1992. New Products Bulletin. 1989. In Symposium on Congenital Malformations-Its Clinical Management. 1963. equipment. New York. Patton J. New Products Bulletin. Clarke S. 11.4:89-115. SpringerVerlag NY Inc. Clin Orthop 1980. CONCLUSION Most children with upper-limb loss have the potential to live full and productive lives whether they wear a prosthesis or not. 10. 18. Hansen D: Clinical evaluation of a voluntary closing terminal device for below elbow amputees. Orthot Prosthet 1983. adapted performance: Reflections on these choices for the training of the amputee in occupational therapy strategies and adaptations for independent living. An understanding and experienced clinic team. 17. in Atkins DJ. 8. Dennis J: Research in upper extremity prostheses for children. University of Illinois. and develop skills based on their natural abilities and interests. 114. 95-97. 22. 23. 14:9-10. Prosthetic. Physical disabilities special interest section newsletter. Unpublished printed information flyer. Charles C Thomas Publishers. 20. 32. Am J Occup Ther 1970. 1978. Artif Limbs 1972. 21. Clin Orthop 1980. Talbot D: The Child With A Limb Deficiency-A Guide For Parents. University of California at Los Angeles. Harper & Row Publishers Inc. size #2: A new alternative for adolescents and adults. Mass. 113. Shaperman J: Clinical application of the infant modular below-elbow prosthesis. 1979. 29. Rosenfelder R (eds): The Limb Deficient Child. In Symposium on Congenital Malformations-Its Clinical Management. Shaperman J. Hopkinton. 14:11-15. in Newsletter: Amputee Clinics. Shaperman J: The CAPP terminal device. Sypniewski BL: The child with terminal transverse partial hemimelia: A review of the literature on prosthetic management. Vol 4. 31.asp[21/03/2013 21:58:02] . Setoguchi Y. pp 3-4. Shaperman J. 186. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 34D The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Sumida C: Another look at modular prostheses. Child Amputee Prosthetics Project. Springfield. Wendt J. Sorbye R: Upper extremity amputees: Swedish experiences concerning children. pp 227-229. Williams TW: One muscle infant's myoelectric control. 212237. Shaperman J: The infant with a cable-controlled hook. Schmid H: Foot studies in children with severe upper limb deficiencies. 27. New York. Am] Occup Ther 1971. in Atkins DJ. 30. pp 14. Inter-Clin Info Bull 1974.Atlas of Limb Prosthetics: Surgical. Washington. 1975. 16:35-36. Sumida C: Recent advances in research in children's prosthetics. Chapter 34D . Liberty Mutual Research Center. 1989. 10:3. Springer-Verlag NY Inc. 23.34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library 19. 25. Shaperman J: Early learning of hook operation. Ill. p 5. Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York. 26. National Academy of SciencesNational Research Council. Pulaski MS: Your Baby's Mind and How It Grows: Pia-get's Theory for Parents. Contact Us | Contribute http://www. 180-192. Sumida W. 140-158. 25:160. 24. 24:393. Inter-Clin Info Bull 1975. 148:26. Setoguchi Y.oandplibrary. 13:9-14. 28. pp 87-89.org/alp/chap34-04. 56. Shaperman J: The CAPP terminal device-A preliminary clinical evaluation. Inter-Clin Info Bull 1975. DC. 1982. 255. Am Occup Ther Assoc 1987. Click for more information about this text. By their very nature and fortuitously. it can be stated that the child with a unilateral lower-limb transverse deficiency can and should be fitted when he shows any tendency to stand. whether the deficiency is distal or proximal. these deformities occur infrequently and therefore are not likely to be seen on any recurring basis in the office practice or general hospital.Atlas of Limb Prosthetics: Surgical. This cycle will probably be repeated as he approaches the teenage years until definitive equalization can be attempted. 1992. and http://www. Surgical intervention on these children requires that certain basic principles be understood and applied: (1) early communication and explanation of treatment concepts to the parents as well as to the pediatrician. Emphasis should be placed on early prosthetic fitting and rehabilitation whenever possible. this path would occupy the entire childhood. Recognition of the shock. the clinic chief will have the opportunity to examine the child in the newborn nursery. One should anticipate that the child will become ambulatory promptly. a lift will be required until the child is old enough for lengthening. M. the family must completely understand the difficulties they will face. IL. particularly on those with longitudinal deficiencies. Rosemont. American Academy of Orthopedic Surgeons. if possible. in which it is likely that surgical revision will be necessary. The child should be brought to independent walking as early as possible. Early Communication With Parents and Pediatricians Those clinics caring for limb-deficient children should attempt to establish rapport with pediatricians and obstetricians so that when such a child is born. and Rehabilitation Principles Lower-Limb Deficiencies: Surgical Management Leon M. grief. (2) maintenance of muscular development in the residual limb. By the same token. Prosthetic.D. In general. with surgical intervention and resultant scarring kept to a minimum and with the best physiologic restoration available.asp[21/03/2013 21:58:08] . In effect. all surgical procedures can be carried out in one stage.org/alp/chap35-01. especially in joints proximal to the deficiency. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. in unilateral longitudinal limb deficiency. the introduction of the Ilizarov technique of limb lengthening by callus distraction has once It should be pointed out that prior to again appealed to some orthopaedic surgeons. edition 2. Prior to embarking on such an ambitious surgical program.oandplibrary. the total predicted discrepancy must be calculated in advance. and that if overlengthened he will require a lift on the normal side. limb lengthening for congenital longitudinal deficiencies has been considered and largely abandoned (with the possible exception of the congenital short femur). This problem will be further discussed under the individual deficiencies where lengthening may be an option.35A: Surgical Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 35A Chapter 35A . reprinted 2002. Reproduced with permission from Bowker HK. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). should be undertaken only by the experienced orthopaedic surgeon and preferably in those centers that are accustomed to dealing with these children. discussing limb lengthening for longitudinal deficiency of the femur or fibula. during which period the patient will be either in the lengthening apparatus or immobilized or braced after healing. as have general surgical considerations and planning for the care of the juvenile amputee. Prosthetic. Kruger. (3) prevention of progressive deformity. and (4) retention of all long-bone growth plates. ©American Academy or Orthopedic Surgeons. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. Prosthetic. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. and the impact that this choice will have on the childhood of the patient must be considered. that at least 9 to 12 months will be required. Surgical intervention on the limb-deficient child. While in the past. a treatment plan should be developed so that. BASIC PRINCIPLES The physiologic differences between children and adults have already been discussed. The family must recognize that when the child is just beginning to walk. and Rehabilitation Principles. Many parents. the more complicated problems of the limb-deficient child may be insoluble. The physician should emphasize the remaining normal limbs. including any sports activity that the child is capable of carrying out and in which he is interested. and deficits in the skin. Assistance in these discussions may be sought from the social worker and pediatrician. basketball. Even when an individual is missing a hand.. If there is a problem with the parents. and particularly if surgical conversion of the limb deficiency is anticipated. Torode and Gillespie as well as Johansson and Aparisi have reported on the missing cruciate ligaments in patients with congenital short Recognizing the deficits in the proximal musculature at the femur and fibula deficiency. however.35A: Surgical Management | O&P Virtual Library guilt experienced by the new parents of a child with one or more deficient limbs dictates the physician's responsibility to assuage these feelings by presenting to the parents not just the diagnosis or anatomic description of the deficiency. and expectations of the child's physical development. Once out of the hospital. basketball." and they should encourage normal physical activity. but a positive approach to the child's immediate status and future capabilities as well. In many patients.). initial evaluation is important if progressive deformity is to be prevented.asp[21/03/2013 21:58:08] .'' There they should be encouraged to observe older children with the same or similar deficiencies. The new parents should be assured of the child's potential for ambulation. These parents should be encouraged to raise their child as "a normal child. in fact. The parents should be brought into the physical therapy department for instruction by the therapist in setting up a home program. and nerves. However. baseball. orthotic management without revision may http://www. are impressed with the athletic accomplishments of children with limb deficiencies.org/alp/chap35-01. ankle.A and B). In fact. even with a major deficiency such as an amelia. particularly. Concerns about social acceptance of the deficiency and. Experience has shown that a child who is missing a leg can play competitive football. and particularly to discuss the child's physical and social development with the parents of these older children. and tennis or. the parents should be invited to the "clinic. Maintenance of Muscular Development in the Residual Limb A congenital limb deficiency may not be simply the absence of a long bone or the peripheral it may also include inadequacy of the proximal musculature joint distal to the deficiency. Without this open communication between parents and clinic team. Competitive sports should not be prohibited for a child with a limb deficiency but. should be encouraged. and school activities. parents should also be encouraged to consultation is mandatory. in the more complicated limb deficiency such as proximal femoral focal deficiency (PFFD) and longitudinal deficiency of the tibia and fibula. Genetic consultation is important. absence of brain damage. Prevention of Progressive Deformity Prevention of deformity in the child with a lesser deficiency may pose no problem. In those instances in which there is a known heritable defect such as deficiency of the tibia. and golf are not outside his abilities. Airing their concerns to parents of other children with the same problems eases new parents through this difficult transition period and assimilates them into the clinic team. for that matter. and knee deformities can be pursued until the child is ready for definitive surgical conversion ( Fig 35A2. psychological or psychiatric consultations may be indicated. Such "group therapy" enables the parents to comprehend the need for and accept the recommendation to proceed with ablative surgery when it is indicated. advise the obstetrician of the history and to be certain that a sonographic study is carried out in the early stages of the pregnancy. They should be encouraged to ask questions about the child's participation not only in family activity at home but also in social. particularly those with PFFD. play. nails. and normal mental development. To this end a program must be developed that includes not only institutional physical therapy but also education for the parents in the techniques of development and maintenance of muscle strength. Orthotic management for the control of foot.oandplibrary. genetic Should pregnancy occur. any other sport ( Fig 35A1. independence of daily living. there is no concern with progressive deformity. of indicated prosthetic restoration may subconsciously prejudice a parent against any recommended treatment program. They become integral members in the planning and implementation of the program to habilitate their child. on visiting a limb deficiency clinic. It is particularly important to stress to the family that most limb deficiencies occur sporadically and are not genetically transmitted. an exercise program for strengthening or stretching of the remaining musculature may be inadequate to prevent deformity of the remaining joints. flex the hip. as in carrying out a knee fusion in the patient with PFFD. We have not used this procedure. The sacrifice of a knee joint in the small child may severely limit his ability to climb stairs. Similarly. Should the surgeon elect to carry out a transfemoral (above-knee) amputation with sacrifice of the distal femoral growth plate. Patients with classes A and B PFFD are recognized as having a hip joint at birth. disarticulation should not be carried out so that the below-knee segment of the limb can be preserved. Bilateral Limb Deficiencies http://www. the patient with a longitudinal deficiency of the tibia should be treated by disarticulation at the knee level. Prevention of progressive deformity is an important ingredient of the long-range planning for these patients. stabilization of proximal joints where necessary (i. manage ramps.e. in a longitudinal deficiency of the tibia. in adult life the patient would have a slightly shortened knee disarticulation. osteotomy and bone grafting or osteosynthesis between the two fragments will stabilize the hip. Preservation of Proximal Joints Particularly in transverse deficiencies of the leg in the upper quarter or higher. sufficiently long transtibial stump. Functional restoration of the trans-tibial (below-knee) amputee is far superior to what can be expected of the transfemoral amputee. have described iliofemoral fusion for PFFD-fusing the femoral segment to the pelvis so that the femoral segment will be parallel to the floor. and take part in many physical and sports activities. neck. in effect. On occasion. To this end we must consider the many facets of surgical intervention. We should also think in terms of the preservation of functional proximal joints. and the judicious use of skin grafting when necessary. knee fusion). the epiphyses may be destroyed. As an example. Unnecessary sacrifice of any of these three longitudinal growth centers in the infant or very young child may result in major prosthetic problems in adult life. including the retention of all long-bone epiphyses as indicated. and in adult life the patient would have a very short transfemoral residual limb. In such a case. preservation of the knee joint is important. By the same token. Extending the knee would then.oandplibrary. the sacrifice of such an epiphysis in the very young child can be catastrophic. which is ideal for prosthetic fitting. sturdy. be described in more detail in the section on PFFD. In some instances. it is important to determine by ultrasound or magnetic resonance imaging (MRI) the possibility of a nonossified proximal epiphysis of the tibia.35A: Surgical Management | O&P Virtual Library be indicated until the optimal time for surgical intervention is reached.. The knee is thereby flexed at a right angle when the patient stands. Steel et al. Assuming normal growth in the distal and proximal femoral growth plates. and distal tibial growth plates have been determined ( Fig 35A-3. Disarticulation ensures a long residual limb with all of its advantages in adult life. Retention of All Long-Bone Growth Plates The percent contributions to the longitudinal growth of the distal femoral. When hip instability is present due either in type A to the subtrochanteric defect or in type B to the lack of contact between the head. functional knee joint and a good. they later conceded that it may not be necessary and that early exploration may damage the joint. Although Lloyd-Roberts and Stone had recommended early exploration of all of these joints. It is not possible at the time of birth to be sure of the integrity or the stability of that joint. with the distal femoral epiphysis left intact. appropriately planned. when the femoral segment is quite short.asp[21/03/2013 21:58:08] .) may be rewarded in adult life with a competent. it would deprive the child of 70% of the eventual length of the femur. efforts to preserve such a very short tibial segment ( Fig 35A-4. In Aitken types C and D.org/alp/chap35-01. plans should be laid out in such a manner as to anticipate the result in terms of the adult patient. In such a case.). When surgical intervention is considered. proximal tibial. it can be anticipated that the amputation level will leave one with a prosthetic knee joint that is below the level of the knee joint on the normal side. Stabilization of Proximal Joints Where Necessary Stabilization of proximal joints is particularly applicable to patients with PFFD. and shaft fragments. which would indicate a partial deficiency. knee These procedures will fusion may be necessary in order to have a good prosthetic result. Prosthetic fitting may have to be staged or delayed until surgical intervention can reasonably be accomplished. In a transfemoral amputation. including athletics. The surgeon should not hesitate to use a skin graft to preserve an epiphysis where there is a deficiency of skin.). The child who requires bilateral Syme ankle disarticulation should be expected to walk independently without crutches or canes ( Fig 35A-5. If preservation of a knee joint requires a posterior release and skin is a problem. split-thickness grafting may be carried out.). Similarly. the stubbies may be lengthened. the operating surgeon should take into consideration the patient's ultimate amputation level. and should be able to don and doff the prostheses independently early in life. but most splitthickness grafts mature and tolerate prosthetic wear well. Skin Grafting Skin grafting in the child is very well tolerated. Such scarred stumps require special attention http://www. Stubbies are modified sockets with either a rocker or rubber-soled bottom. Emphasis must be placed on the therapist's evaluation of the child's muscular coordination and ability to manage prosthetic devices. When independent walking has been accomplished. he should be independently ambulatory. The final prescription is for articulated limbs ( Fig 35A-7. When bilateral surgical conversion or a revision procedure is planned. Consideration must be given to the ultimate amputation level and the type of prosthesis that the patient will ultimately wear. The child. These procedures should be planned so that there will be no unnecessary scarring in areas of weight bearing or in areas where a strap or stump-socket interface may occur. on the other hand.). Split-thickness grafting in weight-bearing areas may ultimately require revision and/or a pedicle graft ( Fig 35A-9. Denuding of a short transtibial residual limb is no indication to proceed with higher amputation in a child. Even as the levels of amputation go higher.oandplibrary. Ambulation without crutches or other external aids should be expected. thereby increasing the child's height and confidence in the erect position. psychological differences between the child with bilateral limb deficiencies and the adult with a bilateral amputation must be recognized when contemplating the bilateral fitting. based on the team evaluation of the child. He should be expected to take part in all normal activities. As an example.). if he is to walk. In the very young child.asp[21/03/2013 21:58:08] . The resurfaced limb should then be toughened up in anticipation of prosthetic application. Instruction and dietary regulation should be available to the family and their responsibility at home stressed ( Fig 35A-8. It is generally appreciated that the adult bilateral transfemoral amputee. Instead. Although the problem of the patient with bilateral PFFD will be dealt with later in this chapter. as in the very old patient with bilateral transfemoral amputations.). will require crutches or canes. in which case the scarred thigh would be a problem. Newer improved materials for sockets have been developed to reduce shear forces at the stump-socket interface and lessen the possibility of breakdown of grafted surfaces. rehabilitation goals for the infant or juvenile should take these differences into consideration. one should anticipate that as long as the child has functional upper limbs with which to improve balance. skin grafting should be carried out. The parents of the bilateral lower-limb-deficient child must be made aware of the importance of weight control. but in general an effort should be made to fit prostheses as early as possible. The surgeon should keep this philosophy in mind when dealing with the limb-deficient child. can be expected to walk independently when properly trained. in which case this would be directly over the scarred area. the ipsilateral thigh should not be chosen as the donor site for skin grafting for a transtibial stump. the child with a bilateral transtibial fitting should have very high rehabilitation goals ( Fig 35A-6. No area should be chosen as a donor site if there is the possibility that it may later interfere with prosthetic wear. When there is a need for a pedicle or flap graft. the pelvic brim area should never be chosen as a donor site for skin grafts since a pelvic belt or Silesian bandage may be necessary for suspension. There may subsequently be the need for a thigh corset. it cannot be repeated often enough that this is the one situation in which any consideration of amputation of the feet should be deferred. initial fitting with stubbies is recommended. The physiologic and.org/alp/chap35-01. The use of stubbies permits the patient to develop balance in the erect position. particularly.35A: Surgical Management | O&P Virtual Library These decisions will be somewhat altered with regard to the bilateral limb-deficient child. Selection of a donor site for a skin graft in the lower-limb amputee should not be casually undertaken. Early fitting and appropriate training can be a very rewarding experience in such a patient. Split-thickness skin grafts on the residual limbs of children will mature and withstand the shearing or frictional forces of socket contact. 35A: Surgical Management | O&P Virtual Library from the pros-thetist. The vestigial phalanges may become irritated and even ulcerate. consideration must be given to other prosthetic restoration. Care must be taken not to damage the distal tibial epiphysis in this procedure. with Syme ankle disarticulation as the procedure of choice. ). No surgical intervention is necessary. the http://www. the deficit may be managed by prosthetic restoration. proximal amputation of the toes will be necessary. The dissection is carried medially. whether short or atrophied. up to 3 years of age. excision is recommended. Patients so treated are left with an end-bearing stump that is the most functional type. the skin graft will mature and be able to withstand the stress of a socket. with appropriate prescription and prosthetic restoration. The anterior part of the incision is carried down through the subcutaneous tissue and the superficial vessels clamped and ligated. If associated with congenital constriction bands. revision surgery is not usually necessary for metatarsal deficiencies. Occasionally. end-bearing stump. This procedure is because the articular cartilage is frequently referred to as a modified Syme's amputation left intact. In the very early years. In the older child. Prosthetic devices are available. shoe fitting problems are the major concern. surgical intervention should be directed at the constriction bands. The second half of the incision is then carried from these two points across the plantar surface of the foot in a slight arc to carry the incision just distal to the calcaneocuboid level ( Fig 35A-12. the malleoli may be left intact and will present no problem in prosthetic fit or restoration. The incision starts anteriorly at the tip of the medial malleolus and is carried directly across the ankle joint to the lateral side. ). the malleoli may be transversely sectioned at the level of the tibial articular surface to provide a broad. Partial or Complete Metatarsal Deficiencies As in transverse deficiencies of the phalanges.asp[21/03/2013 21:58:08] . In an older child in whom the epiphyses have closed. The plantar portion of the incision is carried directly down to the bone and the plantar flap dissected off the inferior aspect of the os calcis by sharp and blunt dissection. ). These may present not only cosmetic and hygienic problems but also a serious problem in shoe insert fitting. With such problems. Those patients with very short remaining metatarsal elements and those with complete transverse metatarsal deficiencies must be treated as though they have a tarsal deficiency.oandplibrary. whether partial or total. Partial tarsal deficiencies with a normal distal tibial epiphysis and no length discrepancy may require conversion surgery. The anterior ankle capsule is opened. flat. and the medial and lateral ligaments are divided. If there is insufficient residual foot on which to fit a shoe with an insert. There is no concern for the phenomenon of bony overgrowth so frequently observed when transtibial amputation is performed. When the residual metatarsal elements are extremely small. Proximal revision for functional as well as cosmetic reasons will be considered ( Fig 35A-11. TRANSVERSE DEFICIENCIES Phalangeal Deficiencies Transverse deficiencies of the phalanges. The anterior tibial tendon and toe extensors are divided and held with a clamp or suture for later attachment. The Boyd amputation may also be considered as an alternative to disarticulation. Procedure for Syme Ankle Disarticulation The procedure for Syme ankle disarticulation should be carried out with tourniquet control.org/alp/chap35-01. it is necessary to remove vestigial phalanges that have either no bony component or insufficient bony component for functional value. Occasionally. but function and cosmesis are less than ideal ( Fig 35A-10. With the foot pulled forward. In the very small child. do not usually require revision surgery. one may have to model the stump or shave the malleoli to achieve acceptable cosmetic result in a Syme-type prosthesis. Complete or Partial Tarsal Deficiencies For the patient with a complete transverse tarsal deficiency (apodia or congenital ankle disarticulation). The patient may walk without the prosthesis. these children may walk with a high-top laced shoe. and the posterior tibial vessel and nerve are identified and traced distal-ward to preserve the circulation of the plantar flap. partial transverse hemimelia) may occur as a true deficiency or in association with Street-er's dysplasia (congenital constriction band syndrome). hence. ) should be fitted with their first prosthesis as soon as they are standing independently on the normal opposite side. bilateral articulated hip disarticulation prostheses may be prescribed at about 4 or 5 years of age. Transverse Deficiency of the Leg. Until recently it was thought that these congenital amputations were not subject to the phenomenon of bony overgrowth.asp[21/03/2013 21:58:08] . If the knee joint extends completely at the time of birth. Surgical intervention is seldom if ever indicated. implementation of a range-of-motion program should be maintained until the child is ready for the prosthesis. it may be necessary to surgically relieve this condition prior to considering prosthetic restoration. particularly the knee joint. The dissection is completed by separating the os calcis from the plantar flaps and care taken not to puncture the skin posteriorly. Dressing may be done by using either the rigid dressing or dry compression technique.oandplibrary.org/alp/chap35-01. and attention should be directed to the maintenance of range of motion in the proximal joints. All major bleeders are ligated. the tourniquet released. Pellicore et al. The heel cord is now sutured to the posterior capsule. In those true deficiencies. When it is associated with Streeter's dysplasia.35A: Surgical Management | O&P Virtual Library posterior capsule is divided and the heel cord dissected off the superior aspect of the os calcis. The heel pad is stabilized with a Kirschner wire or Steinmann pin through the heel pad and the articular surface and across the epiphysis. he may progress to the swivel walker. LONGITUDINAL DEFICIENCIES Longitudinal Deficiency of the Fibula. Transverse Deficiency of the Leg. Total and Transverse Deficiency of the Thigh. They are ready for prosthetic restoration at this time ( Fig 35A-13. have now reported the observation of bony overgrowth in the remaining tibia of these children. Children with transverse deficiencies of the leg in the proximal portion will demonstrate good standing balance on their sound limb somewhere between 9 and 15 months of age. If the child is born with a flexion contracture of the knee joint.). The anterior tibial tendon is sutured to the anterior capsule. Such appendages may range from one metacarpal or metatarsal ray to five vestigial digits. Management is prosthetic restoration ( Fig 35A-7. surgical attention to other constriction bands may be necessary. Lower Third Transfemoral deficiencies occur less frequently in children than do transtibial deficiencies. Partial Upper Third A partial transverse leg deficiency (congenital transtibial amputation. this phenomenon has been observed through the period of symptomatic overgrowth until surgical revision was required. and these may require surgical removal. and the plantar flap is brought forward. Partial http://www. ). The skin is closed with loose interrupted sutures. The deficiency is apparent at the time of birth. Drainage is discontinued at 48 hours. either above the level of amputation or on other limbs. As with other deficiencies. can be incorporated into the socket without difficulty. vestigial digits may be present. there may be a vestigial digit attached. Drainage may be accomplished with a soft-tissue drain or suction drainage if desired. The infant with bilateral amelia will require a plastic "bucket-type" socket fitted to a firm base to achieve sitting or "standing" balance. Transverse Deficiency of the Thigh. As he grows older. If the child has normal upper limbs. Surgical intervention is seldom indicated. The plantar fascia flap is sutured to the anterior capsule. and bleeding controlled. Total (Amelia) Children with total transverse deficiency of the thigh (amelia) ( Fig 35A-14. This usually is not a problem since the vestige has no rigidity and. longitudinal deficiency of the fibula has received a great deal of attention in the literature. and even the skin. by 1991 there were over 2. by a combination of lengthening and growth arrest. Treatment of Unilateral Longitudinal Fibula Deficiency. this problem translates to a failure to attain normal height. Total Because of the frequency of its occurrence. one is impressed by the fact that fibular deficiency The tibia may be is a true limb deficiency. Experience has shown that this is a progressive discrepancy that the progress of this discrepancy can be predicted on growth charts. Efforts at equalizing the discrepancy by tibial lengthening have generally been unsatisfactory. Although O'Rahilly was able to find only 296 cases in the literature prior to 1935. bowed and usually has an abnormality of the distal epiphysis.congenital absence of the fibula. In our experience.oandplibrary.asp[21/03/2013 21:58:08] . Total Leg length discrepancy is the major problem in the patient with total unilateral longitudinal and deficiency of the fibula. it would appear that only in the unusual patient can leg length equalization.org/alp/chap35-01. dysgenesis. from a shortening of the fibula. ). nerves. Deficiency also exists in the muscles. tendons. with or without shortening of the femoral segment. there may be a very hypoplastic short fibula. fibular deficiency. cases of congenital absence of the fibula and mentioned amputation as a form of treatment but stressed the reconstructive approach. The very small remaining segment of the fibula will frequently be treated as a total longitudinal deficiency of the fibula. in fact. For the patient with total unilateral longitudinal deficiency of the fibula.) by contralateral growth arrest or shortening are contraindi-cated because this amount of loss in overall height of the patient is too great a price to pay. In the patient with bilateral fibular deficiency. not simply the absence of a single bone (fibula). there has been a reappearance of interest in preserving the foot and lengthening these limbs. To consider an effort at leg length equalization the patient should have a straight tibia with no anterior bow. which will frequently be associated with a ball-and-socket ankle.35A: Surgical Management | O&P Virtual Library Partial longitudinal deficiency of the fibula may take on many forms. most authors have emphasized amputation and prosthetic restoration. As mentioned earlier.200 cases in the Shriners Hospitals for Crippled Children. to almost complete absence of the fibula with only a small segment present. with the fibular deficiency as a secondary consideration. Our experience at the Springfield Unit increased from 60 patients in 1961 to 120 in 1991. then the treatment of choice remains ankle disarticulation (Syme type) and http://www. whereas the full-length fibula with shortening is treated primarily as a length discrepancy problem. Definitive treatment of patients with fibular deficiency will depend on two major considerations: (1) is it associated with PFFD.5 cm (3 in. Hootnick et al. In between. etc. lateral rays. as evidenced by the dimpling frequently present over the deformed tibia. Coventry and Johnson reported 29 several hundred cases have been reported. He then has a protracted period of wearing the lengthening apparatus and protecting the limb. as well as a normal or near-normal foot and a length discrepancy that is not expected to exceed 7.5 cm. Longitudinal Deficiency of the Fibula. Therefore. The titles are varied. he will have to wear a lift to compensate for his discrepancy until he is old enough for his limb to be lengthened. O'Rahilly reported on 296 cases of this deficiency that he had reviewed in the literature prior to 1935. which will be associated with a leg length discrepancy. Efforts at equalizing discrepancies in excess of 7. The patient with unilateral fibular deficiency and PFFD on the contralateral side is an exception to this. Since Aitken's report of 1959. There may be a minimal shortening of the femur or coexistent PFFD. With the advent of the Ilizarov technique of lengthening by callus distraction. and this process will probably have to be repeated a second time in order to obtain adequate equalization. an effort is made to lengthen the tibia in such a child. and (2) is it unilateral or bilateral? Patients with longitudinal deficiency of the fibula and associated ipsilateral PFFD must be treated primarily as having a PFFD. described a midline metatarsal dysplasia associated with an absent fibula in addition to the deficiency of the The classic clinical picture is a foreshortened limb with an equinovalgus foot. Since that time In 1952. A congenitally short femur may be present. paraxial fibular hemimelia. with or without absence of the metatarsal rays and tarsal anomalies ( Fig 35A-15. if. Clinical Picture As with other longitudinal limb deficiencies. if the child has a 5-cm length discrepancy at birth and an abnormal foot. be accomplished. progressive length discrepancy is the major clinical problem. One sees dimpling of the skin over this anterior bow. transtibial amputation is accompanied by a high incidence of bony overgrowth at the amputation site ( Fig 35A-17. a good Syme-type ankle disarticulation. On the other hand.oandplibrary. In these patients early ankle disarticulation at the age of 1 year to 18 months is indicated. Reconstruction has been recommended but. in our opinion. this anteriorly bowed or kyphoscoliotic tibia should be corrected by rhomboid resection of bone ( Fig 35A-18. When indicated. it is still important to appreciate that if this epiphysis is sacrificed at 1 year of age.35A: Surgical Management | O&P Virtual Library prosthetic restoration. One should also look for the presence of an anterior tibial bow. It may be a result of contracture of a lateral band but is more appropriately recognized as a central defect of the tibia. can be carried out at the same time as the rhomboid resection and straightening of the tibial bow. Length discrepancy is progressive and is the indication for amputation. ). retains the extra length and normal attachment of the heel pad to the os calcis. Even after repeated surgical procedures. or as soon as the child is able to stand and indicates a readiness to commence walking. Many of these children have already undergone triple arthrodesis or other surgical procedures in an attempt to restore a functional foot. Excision of this lateral band. the child will be left with a short transtibial residual limb when he attains full growth. It is important that the procedure be a Syme ankle disarticulation or Boyd amputation. Trans-tibial amputation is contraindicated for two major reasons: (1) loss of longitudinal growth at the distal tibial growth plate and (2) bony overgrowth at the amputation site. in whom cosmesis is not so important ( Fig 35A-19. at worst. Patients with five-rayed feet that are reasonably aligned beneath the tibia will have no problem in shoe wear. and (3) a normal femur. Bilateral Longitudinal Fibula Deficiency. (2) foot deformity. When symptomatic. )between 9 and 12 months of age. and treatment. most children with unilateral fibular deficiency require ankle disarticulation and prosthetic restoration. When the tibia at birth is disproportionately short as compared with the femur or when there is a severe anterior bow in the tibia. With fibular deficiency there may be a deficiency of the distal end of the tibia and its growth plate. Severe foot deformity may then be an indication for amputation and prosthetic restoration. if the growth plate is retained. normal shoe wear may be precluded by the shape and deformity of the foot. fusion of the ankle joint and amputation through the mid-tarsal level. The procedure is therefore usually reserved for boys. During the operation the articular cartilage should be left on the distal portion of the tibia and the heel pad fixed to it. one may anticipate that there will be.) and progressing. never transtibial amputation.asp[21/03/2013 21:58:08] . Even if it is known that the distal tibial epiphysis may not be normal. http://www. a long transtibial stump or. The disarticulation procedure also provides an end-bearing stump on which the child may walk without the prosthesis. In these patients. or a modified Boyd procedure. at best. it is recommended that early conversion be carried out ( Fig 35A-16. consideration should be given to modification of the disarticulation procedure. On the other hand. The presence of a lateral band should also be taken into consideration. Total There are two major considerations for patients with complete bilateral longitudinal deficiency of the fibula and a normal femur: (1) the condition of the feet and (2) the anticipated overall height of the patient. revision of the amputation is necessary. Indications for early amputation and prosthetic restoration may then be summed up as (1) length discrepancy in excess of 5 cm (2 in. The procedure for ankle disarticulation has been described. ). In summary. which may be a deforming force. Prior to 8 years of age. In the older child. Therefore. Ankle disarticulation is the procedure of choice for girls. is not optimal. ). its prevention.org/alp/chap35-01. those patients with a three-or four-rayed foot and associated severe equinus and valgus may require considerable surgery to align the foot plantigrade. This has been described as a kyphoscoliotic tibia and becomes a problem in prosthetic fit. one can anticipate that the discrepancy will be progressive. The broad stump contour does require a more bulky prosthetic socket and is cosmetically less desirable. The distal tibial epiphysis contributes 20% of the growth of the limb as a whole and 45% of the growth of the tibia itself. Much has been written about bony overgrowth. this has occurred in only one patient. but growth charts should be maintained for the patient. the child himself should enter into the decision making concerning such ablative surgery and prosthetic restoration. ). less than one third the length of the normal tibia. Grissom et al. If the tibial segment is short. consideration of amputation should be deferred. Its occurrence is much less frequent than fibular deficiency. bilateral ankle disarticulation and prosthetic restoration may be recommended prior to school age ( Fig 35A-21. If the discrepancy is a progressive one and it is apparent that the patient is going to be unduly short in adult life. Partial Tibial Deficiency Since the presence or absence of a proximal segment of the tibia is crucial in the treatment decision. Procedure for Tibiofibular Synostosis http://www. Severe varus of the foot is present. Tibiofibular synostosis should prevent this from occurring if it is done early enough. There they can see similar children with prosthetic restoration and have an opportunity to talk with the parents of these children rather than having to rely completely on the recommendation of the clinic chief. ). concluded that 50% should have had amputation ( Fig 35A-20. If there is a suggestion that a proximal tibial segment is present. have described the use of sonography in the management of tibial deficiencies since ultrasound examination can define the cartilaginous anlage of the proximal tibial segment that cannot be visualized radiographi-cally at birth. Massachusetts. but at birth it is difficult to be sure of this differential diagnosis. and particularly if he has been permitted to enter his early teens without surgical intervention. As the child grows older. ). In our experience. in reporting their four cases stated that "no familial cases have been Eaton and Mc-Kusick has cited 13 case reports of familial occurrence of tibial deficiency that she recorded. Longitudinal Deficiency of the Tibia Longitudinal deficiency of the tibia may occur either unilaterally or bilaterally. but ultrasound is a simpler and less expensive examination and does not require the sedation necessary for the small child who is to have an MRI examination. even though it is not visualized on a radiograph. it is desirable to introduce parents to the limb deficiency clinic. as well as with Polydactyly. Length discrepancy is the most obvious part of this deficiency. In such patients. Several patients have an exostosis or osteochondroma of the femur ( Fig 35A-23. ) When length discrepancy between the and prosthetic restoration to provide normal stature." Clark found in the literature.oandplibrary. Partial deficiency of the tibia should be treated with an orthosis or an orthopros-thesis until one is certain of the ossification of the proximal fragment and of the presence of the knee joint. A pterygium may be present. the fibula may migrate proximally above the knee joint ( Fig 35A-26. On occasion. it is important to rely on the clinical examination. Gross instability of the knee is evident.asp[21/03/2013 21:58:08] . ).35A: Surgical Management | O&P Virtual Library A retrospective study of a small group of unampu-tated patients at Shriners Hospital in Springfield. and it may be either partial or complete. If the discrepancy in proportional length of the tibia and femur is small and there is a good foot. the size of this tibial fragment is the next concern. arthrography and other techniques may be of assistance in making a diagnosis. the procedure of choice is synostosis of the fibula to the tibia and disarticulation of the foot ( Fig 35A-25. She added to it her report of a patient with nine affected descendants in three generations. The knee joint is so unstable that the foot can almost be brought up against the medial portion of the thigh. Ossification of a proximal tibial segment may not occur for months or even up to 2 years of age. ( Fig The characteristic clinical picture of tibial deficiency can usually be recognized at birth 35A-22. The deficiency may be total or partial. Resection of the proximal half of the fibula was carried out. with the sole of the foot facing toward the opposite leg or even toward the knee or perineum. This produces a long transtibial residual limb. and stability of the knee joint was maintained. ). it is important to ascertain this knowledge early in life ( Fig 35A-24. There have been several reports of the association of longitudinal deficiency of the tibia with Although deficiency of the first metacarpal (absent thumb). Having established the presence of a proximal fragment and knee joint. tibia and femur is sufficiently great to make this decision at an early age.org/alp/chap35-01. ). MRI may also be used. with or without flexion contracture and lateral displacement of the fibula. the picture is altered by the few centers continue to perform this procedure. When the proximal tibial fragment is very small.oandplibrary. Drainage with either a soft-tissue drain or suction is instituted. Bone graft is then packed into the defect between the two. Seattle.] the high incidence of recurrent deformity and the need for repeated operative intervention was such that only a On occasion. and allowed to retract. The residual limb was fitted into a "transtibial" socket with outside hinges. At this point. and carried to well below the level of the femoral condyles. thus treating the patient as a Syme disarticulate ( Fig 35A-27. This procedure may be employed instead of simple disarticulation at the ankle. Resection of the fibula may also be necessary when there is a severe pterygium. the os calcis can be implanted into the distal end of the fibula and amputation carried out. and the tendon is sutured to the hamstring tendons or posterior capsule. and the lateral aspect of the tibia is turned distalward. Disarticulation at has described implantation the ankle is then accomplished in the usual fashion. The anterior incision is made and carried down through the subcutaneous tissues. this procedure may be considered as soon as the individual is standing on the normal limb. when he complete longitudinal deficiency of the tibia. Procedure for Knee Disarticulation In the procedure for knee disarticulation.org/alp/chap35-01. The treatment of choice is disarticulation at the knee. which is also wide at its distal portion. It should be noted that the long anterior flap provides good coverage of the femoral condyles and good weight-bearing skin for subsequent prosthetic wear. Since that time. Brown first reported his experience with construction of a knee joint in patients with His experience dated back to 1957. Prosthetic restoration and good functional rehabilitation should be anticipated. The great vessels are clamped and doubly ligated and the nerves drawn distally. The gastrocnemius origin (if discernible) is severed from the femoral condyles. or until there is evidence of firm cross-union between the tibia and fibula. The capsule and ligaments are divided and the limb removed. and the hamstring tendons. 1975.35A: Surgical Management | O&P Virtual Library The proximal tibial segment is exposed through an elliptical incision between it and the fibula. If a patella and its tendon are present. the tourniquet is released and all bleeding controlled. In 1965. We have resolved this problem by making an L-shaped incision from the base of http://www. Disarticulation in the presence of a pterygium may pose a surgical dilemma for placement of the incision. The subcutaneous tissue and skin are closed in layers. ). The hamstring tendons are sutured to the capsule or ligamentous structure as available. Marquardt of the fibula into the os calcis to create an end-bearing stump. first implanted the fibula beneath the femur and disarticulated the foot. The fibula is now exposed subperiosteally at a level opposite the remaining tibia. are divided somewhat long and tagged for later suture. The anterior capsular structures are divided to enter the knee joint. With a sharp gouge. one must wait until adequate ossification occurs and then attempt to implant the fibula into the tibial segment to create a one-bone leg. The capsule is closed over the cartilage of the femoral condyles. a skin incision is marked out with a long anterior flap. A limb deficiency that had always been considered for transfemoral amputation was converted into a "transtibial" prosthetic However. Posteriorly. If the proximal segment of the tibia is sufficiently long. the clinical picture is the same as just described.asp[21/03/2013 21:58:08] . The postoperative care may be with rigid dressing or soft dressing according to the surgeon's preference. many of these procedures have been accomplished. the incision is made and deepened. The distal portion of this tibial segment is dissected subperi-osteally and completely exposed. restoration. presence of a pterygium between the femur and the fibula. and the closure is completed. The fascia is not sutured. if identifiable. The posterior portion of the incision should be marked out at or just below the popliteal crease. Syme ankle disarticulation or a modified procedure (Boyd type) and fitting with a transtibialtype prosthesis may be carried out early in life. divided. In those patients with unilateral deficiency.[*Cooperative Clinic Chief's Meeting. Complete With complete longitudinal deficiency of the tibia. the patella is left in place. Longitudinal Deficiency of the Tibia. the medial surface of the fibula is turned proximalward. at a long-term review. tibiofibular synostosis is not necessary. There may not be a patellar tendon. After this is done. The limb is immobilized in a long-leg plaster cast with the knee in full extension for 8 weeks. This pterygium may determine the incision location for surgical intervention. (2) malrotation. ). used the designation "proximal femoral focal deficiency. ). Michigan.oandplibrary. with 50% of the patients having deficiency of the fibula in the same limb. in 1987 suggested iliofemoral fusion for stabilization of the hip in PFFD.asp[21/03/2013 21:58:08] . Kruger and reported 31 of 38 patients to have other limb abnormalities. and drugs. C." Aitken recognized "the existence of a group of partial deficiencies of the proximal femur involving the iliofemoral joint" and. including stunting or shortening of the entire femur. In his early description of the biomechanical losses of lower-limb skeletal deficiency. His type 1 included those patients with what has been described by Aitken as a congenital short femur or coxa vara with bowing. A very short triangular femoral segment is present. More recent reports have included a larger number of patients. Most reports of PFFD have included only small numbers of cases. Steel et al.35A: Surgical Management | O&P Virtual Library the pterygium down to the "knee joint. Class B presents with an acetabulum and a capital fragment within the acetabulum. and there is a subtrochanteric deficit. with fibular deficiency in Rossi 50% of their patients." al. distal femoral epiphysiodesis may be considered when the child is 10 to 12 years of age. toxic chemicals.org/alp/chap35-01. partial condylar ostectomies medially and posteriorly. In class A there is an acetabulum. Femoral shortening may be considered. http://www. Sen-Gupta and Gupta reported four patients with PFFD in one family and stated. the Area Child Amputee Center in Grand Rapids. exposure to known teratogenic factors such as irradiation. However. and D. Shatz and Kopits reported that "A review of radiographs obtained on one patients maternal Hillmann et great aunt showed that she had a PFFD with absence of the ipsilateral fibula. Prior to Jan 1. PFFD has all four of these elements of biomechanical loss. and (4) instability of proximal joints. This can include distal shortening of 2. Although malrotation. As the patient grows older. a length discrepancy of the remaining femur may occur that will permit use of a knee joint other than the outside hinge. the distal end of the femur may be modified to allow for a more cosmetic prosthetic fitting. If this discrepancy does not occur. Amstutz and Ait-ken noted a high incidence of fibular deficiencies in the same limb. Aitken (1) inequality of leg length. others have not been pleased with this procedure since fusing the femoral segment to the ilium at 90 degrees and permitting the knee to act as a hip joint puts the weight-bearing line of the limb anterior to the body.0 cm. which may be bulky proximally but shrinks down rapidly thereafter ( Fig 35A-28. or Only male members maternal viral infection. These morphologic classifications offer assistance in treatment decision primarily with regard to the hip. In class C there is no acetabulum." The fibula is then filleted out extraperi-osteally and removed and the L incision closed to leave a good end-bearing cover of the femoral condyles. since no appropriate terminology existed. reported that a review of 49 patients showed no genetic basis for the diagnosis. 1968. Longitudinal Deficiency Femur. In Class D there is also no acetabulum. "In the absence of a history of maternal diabetes. described their 50-year experience in the management of PFFD. had only 35 cases. B." were affected. Amstutz further expanded this classification and developed five types. If the child is seen when it is considered too late for epiphysiodesis and spontaneous differential femoral shortening has not occurred. Westin and Gunderson reported a 65% incidence of other defects. mechanical trauma. King was able to review over 100 cases of PFFD collected from various juvenile amputee In 1968.5 to 3. Langston described a "congenital defect of the shaft of the femur. There is a short shaft fragment with no bony connection between the two. Newer design of joints for the knee disarticulation prosthesis may render this option unnecessary. A lateral scar is also left. inadequacy of proximal musculature. One finds a short femoral fragment with a tuft on top. The head of the femur is within the acetabulum. and patellectomy." Amstutz has defined PFFD as the "absence of some quality or characteristic of completeness of the proximal femur. In his report. the defects appear to be genetic in origin. as well as other skeletal deficiencies. premature child birth. (3) inadequacy of has stressed four points: proximal musculature. Westin and Gunderson were able to gather clinics throughout the United States. 165 cases collectively recorded from Shriners hospitals. His other four types approximate the Aitken classes A. Koman et al. Partial (Proximal Femoral Focal Deficiency [PFFD]) In 1939." Aitken described four classes ( Fig 35A-29. The Aitken class B PFFD is characterized by the presence of a head and neck fragment that has no continuity with the shaft fragment that rides proximal to it.oandplibrary. femoral neck. It is important to institute an early stretching program to prevent knee and hip deformity. As ossification of the capital epiphysis. ). if osteosynthesis is delayed too long. and external rotation. and a two-stage procedure may be necessary. which indicates the presence of a femoral head within the acetabulum. Muscle insertions. especially if abductors are attached to the proximal fragment. as opposed to the growth of the normal limb. The lateral portion of the neck is usually covered with fibrous tissue and/or a cartilaginous cap. then foot and ankle function will be normal. a firm union between the shaft and neck fragment can be attained. The theory of proportionate growth has been expanded by Mosley in his technique of charting the proportionate discrepancy. is present. The clinical picture of PFFD ( Fig 35A-30. between the ages of 3 and 6 years osteosynthesis is indicated to create a stable hip ( Fig 35A-31. Class A PFFD can be recognized by radiographic examination when the cartilaginous anlage of the head and neck have ossified. and foot deformity will be present. Although in most patients with PFFD the discrepancy early in life is sufficient to suggest that eventual amputation will be indicated. If correction is deferred. recognized this progressive discrepancy in the length of limbs thus Amstutz and Wilson affected and developed a concept of proportionate inhibition of growth in all patients over the age of 5 years. If the tibia and fibula are essentially normal.asp[21/03/2013 21:58:08] . Procedure for Osteosynthesis A lateral incision is made over the proximal shaft of the femur with extension proximally to the anterosupe-rior spine of the ilium. The neck is now exposed.35A: Surgical Management | O&P Virtual Library and instability of proximal joints all contribute to the poor gait and complexity of treatment. in this case. have found a connection either by fibrous tissue or cartilage between the two fragments. These efforts should be delayed until there is adequate evidence of bone in the neck fragment so that with grafting. and the capsule is opened to inspect the hip joint. If the patient is very young. only a small area of bone is available. osteosynthesis should not be carried out since an unstable mobile hip is preferable to a rigid hip. If ignored. it is the length discrepancy that is the ultimate indication for definitive surgery-amputation and prosthetic restoration. as with the Watson-Jones approach. resection and bone grafting are indicated. abduction. are left intact. the length discrepancy will be much greater. the distinction can be made. When associated with fibular deficiency. growth charts can be of assistance in decisions as to the total treatment plan. On the other hand. The goals should be the creation of a neck shaft angle of between 120 and 135 degrees. this condition may become a fixed deformity with secondary knee flexion deformity. ) is that of a short femoral segment that is positioned in flexion. This lateral aspect of the neck is nibbled away with a small rongeur to expose a raw bony base in the center of the cartilage. The femoral shaft is exposed subperiosteally and osteotomized at the level of the head-neck fragment. It is usually impossible to distinguish between types A and B at birth. Types C and D have no acetabulum present by radiographic examination at birth. Amstutz believed that precise prognostication of the expected discrepancy in limb length was possible and that definitive treatment could be planned on these children as early as 2 years of age. the subtrochanteric valgus may increase to such magnitude that it will be difficult to correct it completely at a single stage. and trochanteric portion occur. there is a possibility that the capital fragment may fuse to the acetabulum. Correction of the deformity by subtrochanteric valgus osteotomy may be carried out. Lloyd-Roberts and Stone and Lange et al. The shaft fragment is now brought into opposition with the exposed neck by wide abduction and fixed to the neck fragment with Kirschner wires. In either case. and if a pseudoarthrosis. In the case of the older child in whom advanced http://www. The head and neck will be connected to the shaft fragment with a subtrochanteric varus deformity that may be progressive.org/alp/chap35-01. and then after 1 or 2 years the operation is repeated to complete the correction. This subtrochanteric varus may be associated with subtrochanteric pseudoarthrosis. In the first stage the deformity is partially corrected. which suggests that no femoral head will develop. The Hip Joint As described by Aitken classes A and B PFFD have an acetabulum present by radiographic examination at birth. the anatomic knee is flexed 90 degrees and the tibia functions as a femur. as well as a stretching and exercise program. ). No hip joint is present. and even though the discrepancy may be moderate at birth. King and Marks Hueter-Volkmann law. As with other limb deficiencies. then as an alternative an articulated extension prosthesis can be prescribed. A bone graft is desirable in an effort to obtain union. A treatment plan should be developed with the emphasis on early management for the prevention of deformity at the hip and the knee. If the parents are reluctant to accept ablation. but also the strength of the muscles about the hip. ). The weight-bearing line is therefore anterior and lateral to the weight-bearing line of the body. (2) femoral segment 20% to 70% of the normal side. ). Immobilization should be in a hip spica with wide abduction for a minimum of 8 to 12 weeks. http://www. acceptance of this recommendation can be expected. the anatomic knee extends to permit flexion of the prosthetic knee. may be considered Medium-Length Femoral Segments There are many options available in the treatment of patients with PFFD who have a femoral segment measuring 20% to 70% of the length of the normal femur.org/alp/chap35-01. this procedure offsets the weight-bearing line of the limb anteriorly and aggravates the hip limp in these patients. these patients manage very well. Recurrent flexion may later have attributed this reoccurrence to the appear through the epiphyses. or until good bony union is verified by radiographic examination. with success in four patients. the femoral segment is fused to the PFFD. Knee fusion. Steel et al. and these children do not do well. described below. a Coventry screw or small Smith-Petersen nail and plate may be used. King and Marks have pointed out that with knee fusion. Recurrent flexion deformity through the knee fusion should be corrected by osteotomy ( Fig 35A-34.asp[21/03/2013 21:58:08] . and (3) femoral segment greater than 70% of the normal side. After ankle disarticulation the transfemoral-type prosthetic knee is extended. and not only does the gait improve. pelvis with it parallel to the floor so that when the patient is standing.oandplibrary. the Van Nes rotation-plasty. Short Femoral Segments Patients with PFFD whose femoral segment is less than 20% of the length of the normal side are usually either in the Aitken class C or class D. they may be divided into three groups: (1) femoral segment less than 20% of the normal side. In our opinion. will establish a single skeletal lever. Definitive treatment in these patients will be disarticulation at the ankle level and prosthetic restoration ( Fig 35A-32. which should be carried out in full extension. The proximal fragment of the femoral shaft is now allowed to fall back into place and may be fixed with wire to the shaft at a more distal point. Although knee levels are unequal and therefore stride length is unequal. the child may be fitted with a platform orthosis or an extension prosthesis without amputation. Unilateral Partial Longitudinal Deficiency of the Femur (PFFD) Since length discrepancy is the major factor in patients with unilateral PFFD. the flexion-abductionexternal rotation deformity at the hip will spontaneously correct without surgical intervention. disarticulation at the ankle and prosthetic restoration with a Syme-type prosthesis are indicated ( Fig 35A-33. If the parents are resistant to surgical intervention or if surgical intervention is to be deferred beyond the time of expected ambulation.35A: Surgical Management | O&P Virtual Library ossification of the neck fragment is present. it will become progressive with growth. if the parents have been prepared and especially if they have attended a clinic and had the opportunity to observe other children with similar problems. The single skeletal lever then comes into the weight-bearing line. The wound closure is routine. This may be either a temporary measure or permanent if the parents so desire. have described fusing the femoral segment to the pelvis in classes C and D In their technique. When the femoral segment approaches 70% of the length of the femur on the normal side and full knee extension and quadriceps power have been maintained. As a further option. When the patient sits. Children with shorter femoral segments may have developed a flexion-external rotation deformity of the hip and associated knee flexion deformity. Orthoses may be prescribed. distal femoral epiphyseal arrest or shortening at the time of knee fusion may be desirable." Prior to making the decision for Van Nes rotation-plasty. Torode and Gillespie have performed rotation-plasty through the knee joint and.oandplibrary. The Van The Van Nes rotation-plasty may be considered in conjunction with knee fusion. Disarticulation at the ankle may leave the prosthetic knee center below that of the normal side. If acetabular dysplasia is present. If there is any question of circulatory impairment. Following solid healing. (2) growth arrest at the normal knee epiphyses. ). even though they are a manifestation of a deficiency in the proximal end of the femur. there must be a reasonable expectation that at the completion of growth the ankle joint will be approximately at the knee level of the sound side. Options to be considered include (1) lengthening of the short femur. If adequate bone has been resected.35A: Surgical Management | O&P Virtual Library Options in definitive treatment are disarticulation at the ankle with transfemoral prosthetic restoration or Van Nes rotation-plasty.5 cm more of the fibula. He does not include either of these conditions in the PFFD category. with no effort made to close the deep structures. Placement of the knee axis must be precise and the thigh corset constructed and padded to prevent pressure over the pretibial region. either additional tibia may be resected. Use of the Van Nes rotation-plasty provides the patient with a "knee joint" and a transtibial-type prosthesis ( Fig 35A-35. rotation of the distal segment 180 degrees poses no circulatory problem. with dor-siflexion of the ankle providing "knee flexion" and plantar flexion of the ankle providing "knee extension. Short segments of Kirschner wire may now be inserted into the proximal and distal ends of the tibia to be used as a reference point for rotation. 5 to 7. (3) shortening of the normal femur. depending on the age of the patient and the amount of shortening desired. The tourniquet is released and bleeding controlled. Long Femoral Segment Patients with femoral segments greater than 70% of the length of the normal side usually have a variation of coxa vara with bowing. According to the prior plan. The diaphysis of the tibia and fibula (when present) are exposed. valgus osteotomy is http://www. They stated that 5 girls with excellent results had no objection to cosmetic appearance. the tibia can be marked prior to resection for this purpose. or parallel Kirschner wires may be used above and below the osteotomy resection site for control of the fragments and the reserved fibula used as a central bone graft to prevent displacement. with weight bearing primarily on the heel and longitudinal arch of the foot. Again. These patients must be and as a rule they may be treated as having a observed and growth charts maintained. In this case. length discrepancy problem. disarticulation at the ankle and a Syme-type prosthesis are considered as a method of leg length equalization rather than resorting to excessive shortening of the patient's overall height.5 cm of tibia is resected and approximately 2. if 180 degrees of rotation was not obtained. development of the acetabulum must be carefully observed. and if satisfactory. Although patients with coxa vara and bowing of the femur or a congenitally short femur appear to benefit from subtrochanteric valgus osteotomy. The skin wound is closed. circulation of the foot is observed. Procedure for Van Nes Rotation-Plasty Tourniquet control is optional in the Van Nes rotation-plasty. the ankle joint can then be expected to function as a knee joint. or (4) a combination of lengthening and growth arrest. 6 of 12 unilateral patients had excellent results and 4 had good results. or if desired. Nes procedure requires resection of a segment of the tibia and fibula sufficient to permit rotation of the distal portion of the leg 180 degrees so that the foot then faces backward. or what Aitken terms a congenially short femur. the limb is immobilized in plaster. Fricia et al.asp[21/03/2013 21:58:08] . The fibula may be reserved to use as a central bone graft for added stability. an incision is made from the anteromedial proximal portion of the tibia slightly obliquely to the anterolateral aspect of the ankle level. If there is no reasonable hope for equalization of leg lengths.org/alp/chap35-01. After the usual preparation and draping. but preferred. reported on 13 patients with rotation osteotomy for PFFD and noted that 5 required repeat osteotomy. completed the rotation through the tibial osteotomy. The nonconventional prosthesis will have a socket modified to accept the foot as the shank portion. and fixation of the tibial fragments may be accomplished with a compression plate and screws. most of these patients with functional arms assume independent ambulation sometime between 2 and 3 years of age. disarticulation at the ankle joint on the short side is indicated. The short side is fitted with an articulated limb. whereas the long side is fitted with an extension prosthesis ( Fig 35A-37. and lifts should be prescribed as necessary to equalize leg lengths. Bilateral Partial Longitudinal Deficiency of the Femur (PFFD) Patients with bilateral PFFD may be divided into two groups : the symmetrical. It is interesting that these children spontaneously become hand walkers. The parents must recognize that weight control is very important and institute dietary control at home.41:1267-1285. When bilateral PFFD is associated with other lower-limb deficiencies such as fibular deficiency.org/alp/chap35-01. Since the combinations of deficiency may be varied. Prosthetic restoration is directed toward cosmetic rather than functional improvement. it may be necessary to consider surgical intervention and/or orthotic management to control the deformity." It is at the time of entering school that a child's deficiency in stature becomes important to him. provided that they have functional upper limbs. and the parents should be encouraged to permit the child maximum activity.35A: Surgical Management | O&P Virtual Library contraindicated. 61:133. When seen in infancy. 2. Aitken GT: Proximal femoral focal deficiency-definition. ). Although for those with severe upper-limb deficiencies walking may be deferred until as late as 7 or 8 years of age ( Fig 35A-36. Asymmetry may result from a difference in length of the remaining femoral segment or from a concomitant fibular or tibial deficiency on the short side.oandplibrary. Asymmetrical Patients with asymmetrical PFFD and one leg significantly longer than the other walk independently despite the severe deformity of both legs. It is therefore important to preserve the feet. an effort should be made to allow him to use "stilts. When seen in infancy. Achterman C. but what their ability will be at the age of 55 or 65 years we cannot say. weight is gained easily. Orthotic management will be necessary to maintain knee extension. Kalamchi A: Congenital deficiency of the fibula. Improvement in height by means of bilateral prosthetic restoration has been attempted in these children. References: 1. the treatment plan for each patient must be individualized. in which the length of the limbs is approximately equal. With development of good balance. It must be recognized that the energy consumption required for ambulation is great. the major effort should be directed toward preservation of joint function and prevention of deformity. in which there is a discrepancy in length between the two limbs so that to stand on the feet the patient is required to excessively flex one hip and knee while the other is extended. This group of patients should not be considered for amputation.asp[21/03/2013 21:58:08] . J Bone Joint Surg [Am] 1959. Children with bilateral upper-limb amelia and PFFD in the lower limbs prefer to have their feet free so that they may use the feet for prehensile activities. Provision of a Syme-type prosthesis will equalize length and give reasonable stature. We have observed patients continuously using their prostheses up to 35 years of age. Trunk-strengthening exercises should be instituted early in life. and since the child's activity level is usually reduced. the child ultimately can be fitted with articulated limbs without amputation to providing him with adequate height. Aitken GT: Amputation as a treatment for certain lower extremity congenital abnormalities. classification. 3. It is wise to use a helmet for head protection for children on stilt prostheses. When the child reaches 5 or 6 years of age. These activities should be encouraged and are of sufficient importance to contraindicate a prescription for prostheses. ). Symmetrical Patients with bilateral PFFD and approximately equal-length limbs ambulate despite the severity of their limb anomalies. and http://www. J Bone Joint Surg [Br] 1979. as occurs when the short side has an associated fibular deficiency. The feet and ankles should be preserved so that the patient remains independent without prostheses. particularly those with upper-limb deficiencies. they can begin a physical therapy program to maintain their musculature and prevent fixed deformity. When the discrepancy is great. and the asymmetrical. J Bone Joint Surg [Am] 1952. 65:1109-1115.28:175-178. J Bone Joint Surg [Br] 1985. Gillespie R. Torode IP: Classification and management of congenital abnormalities of the femur. Golyakhovsky V: The Ilizarov technique. Grissom LE. Gold S. 27. Eilert RE: Fibular transfer for congenital absence of the tibia. 71:1386-1392. 31. Mesgarzadeh M. Revesz G. Clin Orthop 1979. 33. Fixsen JA. J Bone Joint Surg [Am] 1962. Aparisi T: Missing cruciate ligament in congenital short femur. 29. 1971. in Aitken GT (ed): Selected Lower Limb Anomalies. 48:17-27. 13. 23. King RE: Some concepts of proximal femoral focal deficiency. Publication No. Inter-Clin Info Bull 1966. Bevan-Thomas WH. Kalamchi A. Washington. National Academy of Sciences. 17. Aitken GT: Tibial hemimelia. 34:941-955. Johnson EW Jr: Congenital absence of the fibula. Kim KI: Congenital deficiency of the femur. Dawe RV: Congenital deficiency of the tibia. Marks TW: Follow-up findings on the skeletal lever in the surgical http://www. DC. 52:394. in Proximal Femoral Focal deficiency: A Congenital Anomaly. Proximal femoral focal deficiency. Farmer AW. DC. National Academy of Sciences. 34. 34:349-371. 60:3139. publication no 1734. 32. Jones D. 18. Corner EM: The clinical picture of congenital absence of the fibula. Frankel VH. Clin Orthop 1990. 139:97. Washington. Barnes J.35A: Surgical Management | O&P Virtual Library 4. 42:1-12. Borggreve J: Kniegelenksersatz durch das in der Bein-langsachse um 180 gedrehte Fussgelenk. 57:262-264. 9. 15. Miller EA: A review of the proximal femoral focal deficiencies. Wilson PD Jr: Dysgenesis of the proximal femur (coxa vara) and its surgical management. 19. Amstutz HD: The morphology. in Proximal Femoral Focal Deficiency: A Congenital Anomaly. 14. Levinsohn EM. 6:23-28. Washington. Kalamchi A. 1969. O'Connor SJ. 67:581-587. 26. Lloyd-Roberts GC: Congenital aplasia and dysplasia of the tibia with intact fibula. DC. Harcke HT. 16. 12. J Bone Joint Surg [Am] 1965. 47:695-704.org/alp/chap35-01. management. Amstutz HD. J Bone Joint Surg [Am] 1983. A preliminary case report. Friscia DA. Hillmann JS. DC. Brown FW: Construction of a knee joint in congenital total absence of the tibia (paraxial hemimelia tibia): A preliminary report. Laruin CA: Congenital absence of the fibula. Br J Surg 1913. 5:221-225. 44:1-24. Johansson E. in Aitken GT (ed): Selected Lower Limb Anomalies. 65:557-568. Arch Orthop Chir 1930. Clin Orthop 1980. Birth Defects 1969. in Proximal Femoral Focal Deficiency-A Congenital Anomaly. et al: Proximal femoral focal deficiency: Radiologic analysis of 49 cases. Lloyd-Roberts GC: The natural history and early treatment of proximal femoral dysplasia. J Bone Joint Surg [Br] 1970. National Academy of Sciences. Kumar SJ: Sonography in the management of tibial hemimelia. J Bone Joint Surg [Am] I960. Packard DS Jr: Midline metatarsal dysplasia associated with absent fibula. Jayakumar SS. Cowell HR. 8. Classification and management. 20. King RE: Providing a single skeletal lever in proximal femoral focal deficiency. 30.asp[21/03/2013 21:58:08] . Moseley DF. Hootnick DR. J Pediatr Orthop 1985. McKusick VA: A seemingly unique Polydactyly-syndactyly syndrome in four persons in three generations. natural history and treatment of proximal femoral focal deficiencies. J Bone Joint Surg [Am] 1975. 1734. Kudner DF: Congenital ky-phoscoliotic tibia. J Bone Joint Surg [Br] 1983. 65:867-870. Brown FW: The Brown operation for total hemimelia tibia. Bohne WHO. 5:129-134. King RE. National Academy of Sciences. 7. 251:266-270. 1971. J Bone Joint Surg [Am] 1989. Epps CH Jr: Current concepts review. Washington. 22. J Bone Joint Surg [Br] 1978. 165:769-773. 1968. 150:203-206. 10. pp 50-76. Clin Or-thop 1977. In proceedings of the Australian Orthopaedic Association. 125:107-112. Radiology 1987.oandplibrary. DC. Badgley CE. Oppenheim WL: Rotational osteotomy for proximal femoral focal deficiency. 11. 56:86-95. J Bone Joint Surg [Am] 1952. 21. 5. 24. 49:1376-1388. 25. Eaton GO. J Bone Joint Surg [Am] 1983. National Academy of Sciences. 6. 1:203-206. Coventry MB. Washington. Doig WG: Proximal femoral phocomelia. J Bone Joint Surg [Br] 1974. Bull Hosp J Dis Orthop Inst 1988. J Bone Joint Surg [Am] 1967. Clark MW: Autosomal dominant inheritance of tibial meromelia. Root L: Hypoplasia of the fibula. 1969. 28. J Bone Joint Surg [Am] 1977. Warren FH: Management of proximal femoral focal deficiency. Orthop Trans 1979. 49:59-65. 59. et al: Iliofemoral fusion for proximal femoral focal deficiency. 63. O'Rahilly R: Morphological patterns in limb deficiencies and duplications. Capelli AM. SC. 58. J Bone Joint Surg [Am] 1984. J Bone Joint Surg [Am] 1977. Orthop Trans 1979. Kruger LM: Fibular Hemimelia: A symposium. 11:221-233. Int Surg 1930. Steel HH. p 49. Herring JA: Fibular transfer for congenital absence of the tibia: A reassessment. 50:42. Richardson EG.50:1549-1563. 38. Rogala EJ. Wynne-Davies R. 41. J Bone Joint Surg [Br] 1971. Johnston HA. InterClin Info Bull 1968. A follow-up study of fifty-one adults and thirty-two children. 53:495-599. National Academy of Science. Lange DR. 1979. Pediatrics 1954. 72:166-173. J Bone Joint Surg [Am] 1987. AJR 1978. Selected Lower-Limb Anomalies. Mosley CF: A straight-line graph for leg length discrepancies. 69:837-843. 43:625-642. Sciora J. Rambach B: Proximal femoral focal deficiency: A clinical appraisal. Kopits SE: Proximal femoral focal deficiency. 7:1-25. 55.35A: Surgical Management | O&P Virtual Library management of proximal femoral focal deficiency. Pellicore RJ. 45:557-560. Washington. 47. Warren FH: Proximal femoral focal deficiency: A 50-year experience. Schoenecker PL. Fraser FC. J Bone Joint Surg [Br] 1963. 64. 53. J Orthot Prosthet 1975. Kruger LM. J Bone Joint Surg [Am] 1989. Mazet R Jr: Syme's amputation. 46. J Med Genet 1974. Meyer LC. 52. Kostiuk JP. J Bone Joint Surg [Am] 1975. Hilton Head. 61. 42. J Bone Joint Surg [Br] 1967. Miccar EA. Baker CL: Proximal femoral focal deficiency. Inter Clin Info Bull 1974. Littlejohn A. 37. Gupta SK: Familial bilateral proximal femoral focal deficiency. Putti B: The treatment of congenital absence of the tibia and fibula (abstract). 36. Mclntyre JM. Mcintosh R. Polydactyly and absent thumb in father and daughter. Koman LA. 13:1-8. 45. Meyer LC. 3:45-60. 39. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies. Kruger LM: Classification and prosthetic management of limb-deficient children. J Bone Joint Surg [Am] 1961. 44. 11:1-4. 85:292. 65. Meyer LC: Proximal femoral focal deficiency. 131:289-295. Inter-Clin Info Bull 1973. 71:278-287. 62. et al: Bilateral aplasia of the tibia. Rossi TV: Proximal femoral focal deficiency and its treatment. Stevenson AC. Pappas AM: Congenital abnormalities of the femur and related lower extremity malformations: Classification and treatment.57:1039-1046. et al: Congenital limb anomalies: Frequency and aetiological factors. 60. September 1970. Schatz SL. 27:162. DC. 67. 48. 24:344-355. Lin PS. Marquardt E: Personal communication. et al: Congenital malformations. 12:7-15. et al: Incidence of bone overgrowth in the juvenile amputee population. Hall JE. et al: The incidence of congenital malformations. 29:37-57. 50. Schoenecker PL. et al: Congenital longitudinal deficiency of the tibia. Ogden W. Serafin JA: New operation for congenital absence of the fibula. Inter-Clin Info Bull 1971. 89:135-193. Presented at a meeting of the South Carolina Orthopaedic Association. Kritter AE: Tibial rotation plasty for proximal femoral focal deficiency. Koman LA. 1971. Richards MR. A report of a study of series of consecutive births in 24 centres. 56. 59:927-934. Clin Orthop 1978.asp[21/03/2013 21:58:08] . Pashayan H. 66:1470-1472. 59:174-179. 40. Ladder RF. Stone KH: Congenital hypoplasia of the upper femur. 43. Stewart MIP. 66. Betz RR. Lloyd-Roberts GC. Talbott RD: Amputation and prosthesis as definitive treatment in congenital absence of the fibula. http://www. 3:40. 54. 57. 51. Gillespie R.oandplibrary. Br J Surg 1939. Meyer LC: Current management of proximal femoral focal deficiency. Merritt KK. et al: Van Nes rotational osteotomy for treatment of proximal femoral focal deficiency and congenital short femur. J Bone Joint Surg [Am] 1968. 49. Kruger LM. Dev Med Child Neurol 1982. 14:505-522. S Med J 1979. Lambert CN.org/alp/chap35-01. 3:286. Langston HH: Congenital defect of the shaft of the femur. Sen Gupta DK. J Pediatr Orthop 1987. 35. 1:8. Bull World Health Organ 1966. Am J Anat 1951. J Pediatr Orthop 1983. 135:15-25. Clin Orthop 1972. Scheer GB: Treatment of proximal femoral focal deficiencies. Koman LA. 1969. Gunderson FO: Proximal femoral focal in deficiency-a review of treatment experiences. Arnold WD: Congenital absence of the fibula. Chapter 35A . and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 35A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community .org/alp/chap35-01. 74. Straub LR. J Bone Joint Surg [Br] 1983. 32:12-16. Thompson TC. 58:492-496. Washington.oandplibrary. J Bone Joint Surg [Am] 1965. Westin GW. Follow-up treatment by Syme amputation. J Bone Joint Surg [Am] 1957. Gillespie R: Rotation plasty of the lower limb for congenital defects of the femur. J Bone Joint Surg [Br] 1950. Zlotsky N. 68. J Pediatr Orthop 1983. Wood WL. 39:1229-1237. Torode IP. Wood WL: Congenital longitudinal deficiency of the fibula. Prosthetic. Van Nes CP: Rotation-plasty for congenital defects of the femur. 47:11591169. National Academy of Sciences. Inter-Clin Info Bull 1962. J Bone Joint Surg [Am] 1976. in Symposium on Proximal Femoral Focal Deficiency-A Congenital Anomaly. 70. Contact Us | Contribute http://www. Gillespie R: Anteroposterior instability of the knee: A sign of congenital limb deficiency. 73. 72. Torode IP. pp 100-105. Westin GW. DC. 3:467-470. Sakai DN. 65:569-573.asp[21/03/2013 21:58:08] .35A: Surgical Management | O&P Virtual Library 34(suppl):9-127. 75. Yelton CL: Certain congenital limb deficiencies occurring in twins and half-siblings. Westin GW: Congenital absence of the fibula: Treatment by Syme amputation: Indications and technique. 1:1-7. 71. 69.Atlas of Limb Prosthetics: Surgical. The emotional scars can be even more devastating than the physical loss. Rosemont. The optimum time to utilize a component for a specific child. A socket that allows for rapid linear growth 2. must be individually determined by the clinic team. Prosthetic.asp[21/03/2013 21:58:15] . Although sophisticated mechanisms have a role in prosthetics. Carmen Tablada. and very lightweight materials can be used.. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. In most cases the very young child has no awareness of being different from his peers.oandplibrary. Such fittings probably have more to do with the parents' or grandparents' idea of "body image" than the child's. Jr. The psychological impact on the parents and family must also be considered. Referral to a local support group can often help the family faced with the new challenge of limb deficiency. and Rehabilitation Principles. For the child with an acquired limb loss due to tumor or accident. 7 Months to 14 Months Most centers recommend fitting when the child is almost ready to pull to stand.org/alp/chap35-02. General guidelines based on experience with many children over time can be given for when to provide a particular level of complexity. reprinted 2002.P. Providing prosthetic and orthotic care for the limb-deficient child involves more than simply supplying the proper componentry. which varies among individuals. Oglesby. Only occasionally is referral to a professional for counseling necessary.P. The prosthetist's role is to help keep the child actively involved in normal daily activities. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. ©American Academy or Orthopedic Surgeons.Atlas of Limb Prosthetics: Surgical. the child must master sitting balance and other developmental tasks before standing and walking become realistic goals. Prosthetic. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). The major prosthetic considerations are as follows: 1. It is only from the reactions of his parents and others that he learns about his disability. Fitting and delivery of new devices must be timely to avoid adding to the child's feelings of being unable to keep up with his family and friends. The prosthetist is often able to help the family deal with these issues by discussing their concerns openly and calmly and by providing prosthetic care that encourages a normal developmental sequence for the child.O. Furthermore. On occasion. DEVELOPMENTAL STAGING OF COMPONENTRY The basic principle in pediatric prosthetics is to provide components that are appropriate to the child's developmental stage. Regular checkups to monitor growth and proper prosthetic length http://www. edition 2. 1992. children's devices usually emphasize simplicity and reliability. there may be the added factors of fear of death or guilt over the circumstances of the amputation. the family may insist on prosthetic fitting. and Rehabilitation Principles Lower-Limb Deficiencies: Prosthetic and Orthotic Management Daniel G. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. C. Prosthetic. Click for more information about this text. Reproduced with permission from Bowker HK.35B: Prosthetic and Orthotic Management | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 35B Chapter 35B . A suspension system that does not encumber the child 3. C. Birth to 6 Months Most centers do not provide lower-limb prostheses prior to 6 months of age because the child is growing so rapidly that it would be quickly outgrown. however. A well-fitted fully functional prosthesis can help keep the child and the family focused on constructive adaptation. IL. American Academy of Orthopedic Surgeons. the knee can be unlocked at home and later at preschool. Fit and function should be maintained by regular follow-up. As the preteen years approach. Endoskeletal designs can add longer tubes until the cosmetic cover no longer stretches any further. The solidankle. Endoskeletal construction is also possible. Most infants' prostheses are fashioned from one solid piece of balsa wood or rigid foam and covered with a lightweight plastic shell. When the parents purchase new shoes in a few months (without a lift attached). a hip joint permitting flexion is necessary to allow sitting.5 cm (½ in. Knee mechanisms are unnecessary for children of this age. manufactured components become available in simple and basic styles. the family may notice variations in the toe-in or toeout of the prosthesis. Function is similar regardless of the external configuration. Others prefer the ultimate durability of the exoskeletal type. one solid tube from socket to foot reduces weight by omitting the knee mechanism. Most prosthetists advise selecting the largest possible foot size for the initial fitting in anticipation of the child's future growth. Once again. Each new fitting offers the opportunity to vary componentry to address the increasing activities of this http://www. Many prosthetists fashion infants' feet from lightweight and flexible polyethylene foam material that provides good balance without stress on the residual limb or next proximal joint. When the infant with a hip disarticulation is fitted with a prosthesis. and the components generally fare well. Through careful prosthetic planning and follow-up adjustments. The child is so lightweight and the gait pattern so primitive that commercial feet are optional. children's prostheses are sometimes made 1. 7 to 12 Years The elementary school child goes through minor but continual growth changes. Endoskeletal designs are readily available. often with a manual locking option initially.) longer than is correct with an equivalent buildup on the opposite shoe to level the pelvis. dynamic-response alternatives have recently become available.asp[21/03/2013 21:58:15] . this is seldom significant for the growing child. Almost all pediatric designs use nonarticulated feet. Commercially available feet are preferable starting at this age. arts. cushion-heel (SACH) design is inexpensive and reliable. and social activities such as dancing. 37 to 72 Months During the child's preschool years. eventually. the high-level or bilateral case is the possible exception. The preschooler's active lifestyle commonly results in lost or tattered clothing after a hard day at play. The youth's interests begin to have an impact on the prosthetic design as limitations of the previous artificial limb become apparent. it is common for pediatric prostheses to remain serviceable for a full year or more despite the rapid growth that is anticipated. at least quarterly. the covers are another matter. and repairable. and the foot is often formed of lightweight foam materials. An extension assist aids knee stability but may need repairs from time to time.oandplibrary. 15 to 36 Months During the period from 1 to 3 years of age. rugged. the effective length of the prosthesis is increased. This seldom affects the child's gait significantly and can be simply observed. Some parents gladly accept the need to replace the outside covers at intervals and eagerly embrace endoskeletal prostheses. it may be necessary to cut the prosthesis in half and add material to the shin plus relaminate. There are several ways to accommodate the need for a longer prosthesis. limb growth is the most evident change. from ages 3 to 6 years. Although foot size will seem to lag behind as the uninvolved foot grows. A few families will accept an endoskeletal device without the covering during the more destructive phases of childhood. It is also possible to place spacer blocks between the ankle and foot mechanism up to a point. both boys and girls develop interests in new "outside" activities including sports. Initial results suggest enthusiastic acceptance of the more responsive designs by both children and parents. although the functional differences for children are as yet undocumented. As the child masters the prosthesis.35B: Prosthetic and Orthotic Management | O&P Virtual Library The chief biomechanical function of the foot at this age is to fill the shoe. the knee joint is customarily omitted. As the musculoskeletal system matures.org/alp/chap35-02. The prosthesis is subjected to similar rigors and must therefore be simple. A functional knee is commonly introduced at this age. At the time of initial delivery. Only rarely will it be necessary to realign the prosthesis due to significant postural or structural changes in the maturing child. Transtibial (Below Knee) Foot components are selected according to the function desired. Beyond that. from abrupt changes in fashion (e. and the modified ankle-foot Another approach is to provide a flexible laminated rubber orthosis (AFO) is one solution. SACH remains but dynamic-response designs. the discrepancy usually increases as the child matures due to more rapid growth on the uninvolved side." simplicity and repairability may be prime requirements. Epiphysiodesis just prior to the cessation of growth is always an option. much more sophisticated prostheses are increasingly common.oandplibrary. Cosmetic appearance naturally becomes an This is also a time of transition for the increasing concern for both boys and girls.for amputee and nonamputee alike.35B: Prosthetic and Orthotic Management | O&P Virtual Library age group. "boot" for both function and better cosmetic appearance. During the "sandbox years. while others will insist on a garish neon color lamination as a statement of personal expression. Since children are lightweight and typically have excellent vascularity. such belts are http://www. 13 to 18 Years During the preteen and particularly the teen years. Unlike the case with adults. particularly for the older child. the primary factor in selection of prosthetic componentry is developmental readiness. The SACH foot has been the only option until Dynamic-response feet have been well received by adults. Once the proximal third of the foot is involved. Cuff suspension alone may stress the ligaments if not reattached regularly as the child grows. When only loss of the toes is involved.g.org/alp/chap35-02. CONSIDERATIONS BY LEVEL OF AMPUTATION As has been discussed. physiologic and psychological changes are intensified. The ability to conform by being a nonconformist can become a prosthetic factor too.asp[21/03/2013 21:58:15] . Furthermore. most children with Syme or Boyd amputations can ambulate short distances without any prosthesis. the prosthetic componentry and suspension will become increasingly sophisticated as the teen approaches adulthood. By the time the youth is 18 years old. and some types are recently. Partial Foot Treatment for the partial-foot amputee varies according to the degree of loss. beginning to appear in pediatric sizes. This is fortunate because shoe modifications would quickly become expensive for the rapidly growing child. The need to provide some means of protection from the stresses of competitive sports activities is common.. Syme Ankle Disarticulation The Syme and similar levels play an important role in pediatric amputations since the growth plates are preserved (when compared with a transtibial level) and the risk of bony overgrowth is avoided. Forefoot to midfoot amputations often do well with a modified University of California Biomechanics Laboratory (UCBL)-type insert that incorporates a toe filler. it is seldom necessary to modify the shoes themselves. suspension becomes a problem. a simple foam filler is usually all that is required. have also most common. During this period any number of considerations will arise. prosthetist inasmuch as he must recognize the increasing independence of the maturing amputee and develop a good working relationship that will last on into adulthood. been well received. they often do very well with partialfoot amputation. heel heights) to pregnancy. Some will demand that the prosthesis be inconspicuous and blend into the background. Although a loose cuff or fork strap attached to a waist belt is more forgiving. as in adults. durability and function become significant considerations. For the very young child there is often insufficient discrepancy to provide a commercial foot mechanism. As a general rule. as adulthood approaches. adult componentry and fitting principles are fully applicable. Many methods of suspension are suitable for this population. and each must be handled with the seriousness they deserve. Rarely. For those with telescoping hip joints. Most centers are experimenting with thermoplastics and more flexible socket designs for all levels of amputation. particularly those who need a little extra mediolateral stability at the knee.35B: Prosthetic and Orthotic Management | O&P Virtual Library seldom necessary and encumber the children. Knee criteria have been previously discussed. and further investigation is warranted. and surgical intervention is generally avoided. Hip Disarticulation One key factor for the hip disarticulation fitting is to plan ahead to accommodate circumferential growth of the pelvis. Not only is there a significant limb length discrepancy. Knee sleeves and the silicone suction socket (3S) design both provide suction suspension. maximum elongation during casting improves ischial weight bearing during stance. Prosthetic restoration is geared to minimize the excessive trunk bending and internal rotation of the hip that typify proximal femoral focal deficiency (PFFD) gait.org/alp/chap35-02. it must be molded in a plantar-flexed position that allows good cosmesis yet permits some weight bearing on the sole of the foot.oandplibrary. Dynamic alignment is individualized but must take into account the child's age. Once the child has grown somewhat. the clinic may elect to initially fit the young child with shoe buildups and/or an AFO. but hip joint involvement is also common. Definitive treatment with orthotic devices or with extension prostheses may be offered. The knee is often All those unstable and may be difficult to palpate within the short. fleshy thigh tissues. the pediatric hip disarticulate typically does very well with a prosthesis. Joints and corsets are rarely seen. Many prosthetists elect to use an individualized shape for growing children that is based on the cast impression of their residual limb. The knee joint is usually omitted until the child is near school age.asp[21/03/2013 21:58:15] . being reserved primarily for the child with marked ligamentous damage to the knee. factors complicate prosthetic management. Remodification of the positive model and fitting with a revised test socket is often required. As the child with bilateral PFFD grows and the extension devices become longer. In cases where the foot remains. to permit sitting down. Transfemoral (Above Knee) The same controversies that exist regarding adult sockets apply to pediatric designs. physical findings. Presumably this is due to his small stature (short lever arms) and high energy level. Despite the simple componentry. The presence of significant body fat or the use of bulky diapers dictates a unique shape for the small child's socket. Van Nes rotation-plasty may be performed and the child is fitted with a modified transtibial prosthesis. Bilateral PFFD is a special circumstance. Careful molding is necessary to achieve good ischial weight bearing rather than posterior-thigh weight bearing. and any additional abnormalities. the socket brim may be utilized as a control cable anchor point. Hip abduction and flexion contractures are common. Results to date look very encouraging. The hip joint is provided at the outset. however. fitting with an extension prosthesis or ablation of the foot and fitting with a modified knee disarticulation prosthesis may be undertaken. a free knee is unnecessary for the very young child. Many pediatric amputees do quite well with supracondylar suspension. Many abandon external devices as they approach adulthood and choose to ambulate unencumbered. This does not necessarily mean that he is http://www. Transparent test sockets are invaluable in evaluating the above factors. In some cases. This is accomplished by meticulous casting of the affected leg and pelvis while maintaining the proper rotation and hanging angle. A SACH foot completes the prosthesis. endurance and balance are reduced. For those with concomitant upper-limb involvement. Ischial containment and quadrilateral contours have both worked well with this age group. Many progress to become excellent hands-free ambulators even as adults. SUMMARY The young person with an amputation or limb deficiency will find that his life will be different in some ways from the lives of his playmates. Proximal Focal Femoral Deficiency This limb deficiency warrants individual discussion because of the complex clinical picture it presents. Orthop Prosthet Appliance J 1962. Chapter 35B . 10. Setoguchi Y: Some nonstandard prostheses for children. Prosthetic restoration may enhance or detract from the amputees independence. and faithful follow-up are the cornerstones of successful pediatric prosthetics. Springfield. 16:144-147. 29:1118. sockets. National Academy of Sciences. 5. Setoguchi Y: The Limb Deficient Child. 1982. Orthop Prosthet Appliance J 1961. Prosthetic.oandplibrary. 15:27-45.35B: Prosthetic and Orthotic Management | O&P Virtual Library limited. Imler CD: Imler partial foot prosthesis IPFP-"The Chicago Boot. 6. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 35B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Dorsch B: Developmental factors in the case of the adolescent amputee. 34:3-12. Leimkuehler J: Syme's prosthesis-A brief review and a new fabrication technique.asp[21/03/2013 21:58:15] . 12. 1969. Orthot Prosthet 1975. Aitken GT: Proximal Femoral Focal Deficiency-A Congenital Anomaly. developmentally appropriate complexity. 2. Washington. Clin Prosthet Orthot 1981. 9:4-30. 9.org/alp/chap35-02. Ill. 39:53-56. Publishers. Pritham CH (ed): New concepts in A. Tablada C: A technique for fitting converted proximal femoral focal deficiencies. Brodsky R. 3." Orthot Prosthet 1985. Orthot Prosthet 1980. 7. Contact Us | Contribute http://www. Orthot Prosthet 1980. 8. Careful attention to detail. Charles C Thomas. 11.K. he will be as functional as society and circumstances allow. Orthot Prosthet 1972. Dorsch MS: Prosthetics considerations for the female. Curry RN.Atlas of Limb Prosthetics: Surgical. Artif Limbs 1971. 16:148-150. 4. Beal LL: The impact of an anomalous child on those concerned with his welfare. References: 1. DC. Orthop Prosthet Appliance J 1962. 35:17-21. Ogg HL: Physical therapy for the preschool child amputee. Kay W: The use of the SACH foot with children. depending upon the quality of fit and function provided. 15:261-264. 26:3-5. THE BEGINNING OF MODERN PROSTHETICS The 1950s proved to be an exciting and revolutionary time for children's prosthetics in Germany. Prosthetic. however. and Rehabilitation Principles Special Considerations: The Multiple-Limb-Deficient Child Ernst Marquardt. The second was the international cooperation that developed with Kessler of New Jersey. and each center developed its own ideas without exchange of ideas with others in the same field. Three factors were central to the changes that occurred in the field. The first of these was the visit of the German Study Group to the United States in 1952 and the outpouring of new ideas resulting from this stimulation. on the other side. for children. Heidelberg. There was no special education or organized interchange of ideas. In some of these hospitals. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). It was widely assumed that children with transverse deficiencies of the upper limbs or children with traumatic amputations should be fitted with prostheses only after they had completed their growth.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 36A Chapter 36A . edition 2. Prior to the 1950s adult prosthetics in Germany ranged from good to excellent in both the quality of the prosthesis and medical care. IL. each prosthetist had to build on his own personal experiences. The third event was the thalidomide catastrophe.Atlas of Limb Prosthetics: Surgical. Patients with congenital limb deficiencies were treated on an individual basis in the regular orthopaedic hospitals. Click for more information about this text. forks. They were generally fitted with the most simple walking devices that could be constructed. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. However. No center was able to claim the presence of a complete clinic team. experience in certain limb deficiencies existed in the orthopaedic and prosthetic services. Prosthetic. pencils.asp[21/03/2013 21:58:20] . ©American Academy or Orthopedic Surgeons. On one side. Prosthetic. 1992. There was no systematic treatment of the limb-deficient child. However. In 1952. Biesalski demonstrated a 9-year-old boy with new bilateral terminal devices. practices.oandplibrary. Michigan. There were no special devices or equipment for children's prosthetics. such as that started in Grand Rapids. these terminal devices were not widely used and were soon forgotten. Many of these were stirrups fixed by splints or leather sockets that functioned as extensions. the Heidelberg pneumatic prosthesis gave additional independence for some individuals but did not have a wide sphere of influence. In the following years. For the very high upper-limb amputee. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. who provided advice and stimulation to his German colleagues in the development of comprehensive clinic programs. nor were there organized limb deficiency clinics or child amputee clinics. With this procedure. the bilateral amputee was able to achieve independence in many of the activities of daily living. Because of this philosophy. or other items could be attached directly to the prosthesis. Lower-limb prostheses for children were even more provincial and personalized. This boy was able to demonstrate that both of these were as practical as the hook. Miinster. Rosemont. In 1917. Hepp http://www. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. it is understandable that the Krukenberg procedure had greater acceptance in Germany than in the United States. Soft leather sockets for transradial amputees had adaptors so that spoons. and Volmarstein. American Academy of Orthopedic Surgeons. and experiences among workers with child amputees. they did not work together as a full team. The philosophy of upper-limb devices centered on the development of technical aids for limbdeficient persons. the German orthopaedic surgeon Hepp and a group of experts in prosthetics came to the United States to review the progress and problems encountered in the prosthetic centers and his coworker Kuhn developed special in that country. reprinted 2002. Hannover. the boy had the "Finger-Klaue" and. the "Spann-Klaue. such as in Berlin.D. Reproduced with permission from Bowker HK." both developed by Fischer in Berlin. M. or other similar teams in the United States. and Rehabilitation Principles.org/alp/chap36-01. the head must be protected from bruising as the child starts to walk. the Pavlik harness or similar treatment is recommended.oandplibrary.). if one side is functionally behind the other and cannot be used in bimanual activity. However. and a generous exchange of information resulted. If the child can eat and play. which allowed us to give them simple grasp at an early age. should be conducted in the home. In view of these numbers it is understandable that a major investment in time. even deformed hands are better than a prosthesis. I also made contact with numerous other prosthetic clinic teams in the United States. 5. If there are small digits or hands off the shoulder they should be trained to appreciate touch and grasp. All instruction should be channeled through her. which proved to be the most universal and most functional of all terminal devices.). The The treatment of a limb-deficient child is centered in the family. It is important that all possible sensory contact with the feet be stimulated. better results than had previously been thought possible were obtained. the prosthesis should be accepted without difficulty. there was an enormous increase in newborn children with multiple. first in Kiel and later in Miinster. Whenever possible. In the upper limbs. While observing Kessler's patients with kineplasty and body-powered as well as pneumatic prostheses. If there is hip dysplasia. a prosthesis is necessary. These abnormalities were later shown to be associated with maternal ingestion of thalidomide early in pregnancy. They introduced the active hook. What was new was the enormous number that seemed to be almost an epidemic of multiplelimb-deficient children. the training. http://www.org/alp/chap36-01. despite these advances. By watching the children with and without their prostheses. after the withdrawal of thalidomide from the market. The infant should be permitted to see his feet uncovered and encouraged to play with them ( Fig 36A-3. it is expected the infant will incorporate the prosthesis into its body image. only 10 children were seen with this type of limb deficiency. or both. However. which will need the most acute sensory input. there were still no special units for children in all of Germany. a whole philosophy of care developed in our center. Their work in research and development was made easier by the German federal government providing money for prosthetic centers. PHILOSOPHY OF TREATMENT-1960s The simple fitting of a prosthesis or multiple prostheses for these children is not adequate.asp[21/03/2013 21:58:20] . At this age. As we struggled to make them as independent as possible. since the feet will be allowed full freedom. I learned of enormous possibilities inherent in the body's own compensatory functions and of the limited value of artificial limbs for congenitally armless persons. from 1959 through 1962. and ingenuity was directed to the multiple-limb-deficient child. whether the child uses the prosthesis or not. Cake prosthesis for armless babies. A helmet or a ring of sponge rubber or other material can provide such protection until stability of walking has been achieved ( Fig 36A-4. this was combined with lower-limb deficiencies in either the tibia. longitudinal limb deficiencies. This is now well known as the Minister socket ( Fig 36A-1. If there are no arms. eventually they may have important prosthesis control functions. combined with prosthetic training that emphasized motivation and play. 37 children were seen in the orthopaedic hospital at the University of Heidelberg. However. Even if they seem functionless.).36A: The Multiple-Limb-Deficient Child | O&P Virtual Library casting techniques for the upper limb and the fabrication of a new plastic socket. not in the hospital. we developed the Pat-Adevelops activities of daily living. or both. femur. During the years 1958 to 1962. the father. between 1953 and 1958. Prior to the thalidomide episode.] These limb deficiencies were often associated with abnormalities of the spine and potentially with every other body system. In the following 2 years.294 upper limbs of 2. there was a predominant reduction on the radial side of the hand and forearm. research. my colleagues and I realized the need to improve all of the body's own compensatory functions as the child Following these experiences. mother is the child's best therapist under the supervision of the clinic team-physician. and physical therapist ( Fig 36A-2. When these were fitted early.). symmetrical. 216 children had multiple-limb deficiencies. occupational therapist.[†In November 1978. The second of these major factors was my visit to the Kessler Institute for Rehabilitation in New Jersey and the development of a close friendship with Kessler. If it allows for increased function and activity. These types of longitudinal deficiencies were not new and had been reported since antiquity.647 thalidomide victims were reviewed and registered by the "Stiftung Hilfswerk fur behinderte Kinder" Bonn-Bad Godesberg. The infant at 8 months of age can be successfully fitted with a passive prosthesis allowing gross grasp. and this. by both in hybrid systems ( Fig 36A-5. coupled with high cost and discomfort of wearing. some after years of wearing and with excellent prosthetic accomplishment. which is provided by the prosthetic team. This is at best a compromise and provides the best possible appearance.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library The provision of an actively powered prosthesis starts about the beginning of the second year Shoulder movements or.asp[21/03/2013 21:58:20] . powered by carbon dioxide. Training of the child with the prosthesis is adapted for the stage of development present at that time. My Horowitz lecture in 1968. Of major importance is the recognition of the fact that the prosthesis should never impede the child's function. Annual workshops and meetings were organized. Prostheses for amelic and phocomelic children are still in the experimental state. Programs for research and development of prosthetic devices as well as the testing of prostheses and technical aides for limb-deficient children were developed. For the phocomelic child. conventional body-powered prostheses for amelic and phocomelic children provide so little function that they are likely to be rejected. and in 1964. the prosthesis should be removed in favor of such function as was present without it. The active prosthesis for children over the age of 4 years has an active grasping function with active wrist rotation and an active elbow joint with automatic locking. Both are fixed on a Simpson frame. but the weight and complexity of the mechanism have precluded its general acceptance.). Only 2 of these 67 continued to wear externally powered arm prostheses ( Fig 36A-6. such a philosophy was developed at Heidelberg and in the other centers. small digits emanating directly from the of life. When amelic or phocomelic individuals request an arm prosthesis at or after the age of puberty. and some function ( Fig 36A-6. "The Total Treatment of the Limb Deficient Child. along with a discussion of all pros and cons. if present. they must be supplemented cleverly by individual pedagogic and psychological guidance of the children and their parents. By the same token. The major problem is in positioning the terminal device in space and not so much the terminal device itself. 65 of 67 children fitted with different types of pneumatically powered prostheses have ultimately rejected them. For the upper-limb amelic child. Nevertheless. In 1962 and 1963. should be used to compensate for loss of normal function. On the other hand." and the publication in 1974 of "10 Jahre Entwicklung und Erprobung von Hilfen und Hilfsmitteln fur behinderte Kinder" concisely spelled out the development of prosthetics and technical aids and training for limb-deficient children. particularly by those who are able to use their feet as hands. In the years following the thalidomide episode. externally powered prostheses are too heavy and complicated.000 of http://www. which I believe should be integrated into the total philosophy of care.500 children were victimized in the Federal Republic of Germany.org/alp/chap36-01. in which some 2. the Federal Republic of Germany opened special units for "Dysmeliekinder" in eight other centers. causes rejection. In addition to developing new bodypowered and externally powered prostheses for the upper limbs. In general. The Heidelberg philosophy may then be summarized as follows: 1. the feet and not the arm prostheses will provide maximum function.oandplibrary. both upper and lower. The actual technical provision of the prostheses and exercise within a therapy setting are insufficient. shoulders can be used to control externally powered prostheses in the sixties. This was espoused and financed by the government and especially by the Social Security System for the benefit of these victims. in addition to those clinics that already existed in Miinster and Heidelberg. in the eighties and nineties by batteries. They provide too little effective function for the patients need. the lightest weight. Simpson has developed a brilliant technical solution to this problem. a new electrically driven vehicle was developed in Miinster by Kuhn.). 3. If these prostheses are to become functional. When a decision is made to prescribe prostheses for these individuals. all digits. in the seventies. When it is recognized that wearing a prosthetic device diminishes important functions.). 2. Practically all of these individuals continue to use the feet as hands. it is our policy to prescribe one functional externally powered prosthesis for the dominant side and a cosmetic arm with the power pack in it for the nondom-inant side. 4. I made my first statement about the development of compensatory functions of the clubhand by the patient and warned against early operative intervention. this request is considered and discussed with the patient. the success of bilateral arm amputees fitted with pneumatic prostheses cannot be reached by amelic and phocomelic children. On the basis of evaluation of 2. If the condition of distal skin permits. in instances. In 1972. taken the form of either resection of the overlying bursa and shortening of the bony stump or. Buchtiarow attempted stump capping by using a bone and cartilage transplant for transfemo-ral stumps.500 children.asp[21/03/2013 21:58:20] .). In the case of a transtibial stump. Swanson reported the development of a silicone rubber implant for capping a transtib-ial amputation stump. various reconstructive procedures on other parts may make a transplant source readily available . in fact. it is desirable to procure a transplant with an epiphyseal plate to obtain additional length. etc. enhance function of transhum-eral prosthetic use. when knee arthrodesis is planned. a formal reamputation at a higher level. When the procedure is done for overgrowth of the humerus. In the humerus it seems preferable to use a cartilagebone transplant without a growth plate. and provide surgically assisted prehension in a forearm stump as well as considerations in the positioning of residual prehensile members are reviewed in some detail. Secondary damage such as arthropathy or osteoarthritis to the hip joints. but in the quadrimembraldeficient child. an effort is also made to attain optimal growth. The conventional practice in treating bony overgrowth has. conversion of a transhumeral or transtibial amputation into a stump resembling that seen in a disarticulation ( Fig 36A-7. bony overgrowth has. an epiphysis from the amputated limb may be used. Stimulated by these experiences. the easiest available transplant is the head of the fibula and. I have developed a technique for capping stumps with The goal is osseous overgrowth that uses autogenous cartilage-bone transplants. procedures that are designed to provide even limited improvement in function are more frequently indicated. in the case of a humeral stump. He also used this silicone cap for revising amputation stumps in which bony overgrowth had occurred. Stump Capping Contrary to a generally held opinion of a few years ago. of course. This overgrowth and its concomitant stump attenuation is particularly troublesome when it occurs in a weight-bearing segment such as the tibia and is. It can eventuate in catastrophe should it occur in a bilateral short transhumeral stump and necessitate revision to a higher level such that the prosthesis would be of the shoulder disarticulation type rather than the transhumeral type. in the past. Bony overgrowth of a transhumeral deficiency may be equally disabling. In the same condition. the spina iliaca posterior. SPECIAL SURGICAL PROCEDURE FOR THE MULTIPLELIMB-DEFICIENT CHILD A number of surgical procedures have been used to advantage in children with multimembral deficiencies and might have application only occasionally in selected cases of single-limb deficiency. Because of the degree of functional disability in patients with multiple deficiencies. the articular surface of the distal portion of the femur may be salvaged for transplant. Several procedures that have been used to treat bony overgrowth. the wide excision of the scars followed by the stump-capping procedure and by a musculocutaneous latissimus dorsi island flap with its intact neurovascular supply is recommended. The care of these patients continues. the latter is contraindicated in persons who need crutches or canes. transplantation of a growth plate here may be carried out. knee joints. In most instances weight-bearing training will stimulate continued growth in the proximal humeral growth plate. the cartilaginous and bony cap from the femur may be used. on the other hand.oandplibrary. http://www. for instance. as well as to the spine.org/alp/chap36-01.. most disabling when the opposite limb is also the site of a deficiency. In the weight-bearing bones. been observed in transverse diaphyseal deficiencies. in some cases. When a proximal femoral focal deficiency (PFFD). are increasing problems for future years. is present. In those cases where amputation is carried out for trauma.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library these 2. to change. For cases with severe scars at the end of the humeral stump(s). my conclusions on the treatment and rehabilitation program have continued to develop and. The operation may be used in cases of overgrowth in congenital deficiencies of the humerus or in treatment of the condition in a transfemoral or transtibial amputation. unless there is good-quality soft tissue overlying the end of the stump or the patient has bilateral short transhumeral stumps. she was fitted with cable-controlled transradial prostheses and transtibial prostheses with a thigh corset.C). The defect between the split ends of the long bone is packed with additional autogenous cancellous bone ( Fig 36A-9. A medial or lateral longitudinal incision is made. 2 or 3 kg of pressure is used and gradually increased until the patient is able to take at least 50% of his body weight directly over the stump end. During this period of time the healing and conditioning of the stump should be evaluated and the decision made as to the time for prosthetic prescription and training. and by October 1972. At the time of birth it was noted that the child had transverse deficiencies of all four limbs. and in lower-limb stumps. she was fitted with a transtibial prosthesis for the left leg with supracondylar wedge suspension. Case Report The child in Fig 36A-10 (a-c). 1965..oandplibrary. The di-aphysis of the bone is then split longitudinally for a distance of at least 3 to 4 cm proximally from its tip ( Fig 36A-8. This training is conducted in coordination with the other daily exercises necessary for rehabilitation. During this training an effort should be made to apply pressure to different surface areas of the stump so that the loading will ultimately be distributed over the entire stump end. By December 1970. this had increased even though she had received treatment of skin traction and "extension therapy" of the skinmanual stretching by the mother. Additionally the child had micrognathia and dysplasia of the tongue. . Immediately after the end-bearing training session the therapist should also show the patient and the parent the technique of stretching the skin distally over the stump to prevent contracture or tightening of the skin over the reconstructed end. 1966." is commenced.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library Surgical Procedure The incision is planned to avoid scarring in the skin of the end-bearing area. In the early pregnancy. The periosteal-muscular flaps are then reattached to the transplant with sutures passed through small drill holes in the graft. The bursal sac is opened. On the right side. with the forearm deficient in the upper third bilaterally and the leg similarly deficient in the upper third bilaterally. There was no history of congenital limb deficiency in the family. osseous overgrowth of the left transtibial stump was noted. In the weight-bearing limbs the prosthesis should be designed to use the end-bearing capacity of the stump to ensure continued hypertrophy and tolerance. The therapist teaches the patient to apply weight to the reconstructed stump. New sockets were prescribed. Fig 36A-10 (d-f). the mother had had considerable illness and taken numerous medications. but no knee joints were prescribed. the first child of healthy parents with two normal siblings. She was first seen in my outpatient clinic on May 2.. so the limb-deficient child requires an ongoing training program. Just as the normal individual or the athlete requires constant conditioning to maintain maximum muscle strength and joint motion. and she walked independently with these prostheses. as well as on acceptance and use of a carefully designed prosthesis. In 1968. she was fitted with a bent-knee prosthesis. starting a few centimeters proximal to the end of the stump ( Fig 36A-8.. and Fig 36A-10 (g-j). however.D). a rigid plaster dressing is used. nor were there other congenital anomalies. the conditioning. Approximately 3 months after the stump-capping surgery. In transhumeral stumps a soft compression dressing is preferred. and in August her first stubby prostheses were fitted to her lower limbs. and the bony overgrowth is transected at its entry into the bursa and removed. The cartilage and bone transplant is prepared with two grooves fashioned on either side of the bony portion to accept each of the arms of the split long bone ( Fig 36A-8. with care taken to prevent fracturing. she received two new transradial prostheses with Miinster sockets and Dorrance hooks. as well as two new lower-limb prostheses. These children should be maintained on a daily physical therapy program throughout growth. End-bearing training should be repeated at intervals throughout the day. with the knee flexed at 90 degrees. was born on July 12. Fixation of the transplant may be accomplished with two crossed Kirschner wires or with a centrally placed long intramedullary screw. which is called for emphasis "end-bearing training.org/alp/chap36-01.asp[21/03/2013 21:58:20] . The split ends are gently spread apart. Two or three periosteal and muscular flaps are then developed on the sides of the diaphysis and are reflected proximally. because of the extreme short transtibial stump. The wound is repaired so as to avoid skin tension. . In January 1967.B). Postoperative Care It is important to recognize that the success of this procedure depends not only on the surgical technique but also on the postoperative physical therapy training program. as well as aplasia of the fibula. Initially. In June 1969. In October 1975.). there was http://www. Three months after surgery. however. however.org/alp/chap36-01. end-bearing training was instituted. as little as 3 cm for the angulated distal fragment may be acceptable. an open-socket prosthesis suspended only by two straps may be used.oandplibrary. The angulation osteotomy should be used primarily for the bilateral long transhumeral amputee as well as for the elbow disarticulation stump with hypoplastic humeral condyles. The left transtibial stump remained healthy. In a long slender stump. I have developed a technique of Following this osteotomy of the distal portion of angulation osteotomy of the humeral stump. she had a painful bursa about the area of spiking at the distal end of the tibia of the left transtibial stump. the osteotomy must be started 4 cm above the distal end of the stump. the humeral rotation can also transmit a useful amount of pronation and supination at the terminal device. and there was a varus deviation of the tibia despite the fact that the fibula was absent. With the conventional fitting. nonetheless. the important and useful function of active pronation and supination of the forearm is absent. Surgical Procedure For planning of angulation osteotomy. In the case of middle-length stumps. This may be provided by passive rotation of the terminal device at the wrist. In December 1976. mediolateral positioning of the forearm segment and terminal device through humeral rotation is usually deficient in strength and range. the same procedure was carried out on the right tibia. particularly. Although most amputees with long or middle-length stumps have essentially normal shoulder function and strength. In a large. Passive rotation through a turntable elbow unit or the use of an externally powered rotation unit has never been completely satisfactory. In addition. flabby stump. the length of the remaining humeral segment should be carefully measured. When the forearm is in a moderately extended position. The planned length of the distal osteotomy fragment will depend on the volume of the stump.asp[21/03/2013 21:58:20] . In the middle-length stump the distal angulated humeral segment is maintained by one or two straps. however. a stumpcapping procedure of the left transtibial stump was carried out with a homologous cartilage bone transplant to the cap supplemented by autogenous cancellous bone to fill the gap between the two branches of the split tibia. however. the right showed reduction of the transplant and increased pain. External locking hinges are used. The flanges necessary for stability in the conventional prosthesis are eliminated. It required revision in March 1978. More important. This is particularly difficult for the bilateral transhumeral amputee to accomplish.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library increased spiking at the distal end of the tibia. To accomplish this. the artificial elbow joint is set somewhat proximal to the distal end. as well as allows full internal and external rotation to be transmitted to the prosthesis. full shoulder rotation cannot be transmitted through the stump-socket interface to the terminal device with the conventional transhumeral fitting. it is necessary to have at least 5 cm of bone in the angulated segment to provide adequate suspension for the socket. http://www. she is completely independent in all activities of daily living. and the left side did well. She wore her forearm prostheses only part-time. this patient is wearing a transfemoral knee prosthesis on the right side with 90degree knee flexion and a transtibial prosthesis on the left for 12 to 13 hours a day. Presently. The angulation osteotomy is contraindicated if the stumps would be unable to touch each other in front of the chest after surgery or additional stump lengthening would be indicated. the humerus. By June 1976. full abduction and. In the long transhumeral amputee the dorsal end of the stump may be left exposed for tactile sensation. Angulation Osteotomy of the Humerus An amputee with a long transhumeral deficiency can use a body-powered prosthesis quite effectively. the shortening of the humerus conditioned by the length of the angulated humeral segment should be measured before surgery by help of a radiographic sketch. however. but must be preset by the patient. and rotational stability and motion are provided by the angulated distal end of the stump in the socket. which was now being handled with liners in the plastic sockets of her prosthesis. With this fitting. In July 1976. An anterior angulation of the distal end in the sagittal plane of from 70 to 90 degrees in the neutral-zero method of measurement is planned. This strap suspension is easy for the bilateral amputee to apply himself. In an effort to provide the transhumeral amputee with a simpler and more effective prosthetic device that might help to provide these additional functions. is that it frees the shoulder for full abduction and elevation. but in Germany and elsewhere it is quite widely used.oandplibrary.asp[21/03/2013 21:58:20] . A compression dressing is applied.5 degrees for every month of growth. bathing." The Krukenberg Procedure In 1917.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library The incision should be planned to extend no further distally than the lower level of the osteotomy site. during and after World War http://www. Patients with a shorter transhumeral stump may be treated by exposing the bone on its posterior side to carry out the posterior angulation osteotomy. To diminish bulk. during the attempt to bend the posterior cortex. The periosteum is then repaired. It is important to prevent any damage to the blood supply of the distal fragment. Suction tubes may be removed in 48 hours. The Kirschner wires may be removed at this time. Bauer. The osteotomy is then fixed with a single Kirschner wire. . and the wound is closed in layers. The periosteum is incised longitudinally directly over the area from which the wedge of bone is to be removed. eating and toilet activities. No stripping of the periosteum of this distal segment is carried out. An incision 5 to 7 cm long is made from the distal level of the planned osteotomy site proximally. a second Kirschner wire passed parallel to the first but crossing the osteotomy should provide adequate fixation ( Fig 36A-12. Kreuz. The posterior cortex. Proximally and distally the open cortex may be notched with a fine rongeur so that when the angulation osteotomy is closed. If there is any separation at the osteotomy site. described a similar incision but distal part of the forearm were excised. this can be most easily done with a bone-cutting forceps or rongeur. but quicker after end-bearing training only and slower after daily traction exercises corresponding to the Bavarian "Fingerhakelu. In the child. but no plaster of paris cast is necessary. fracturing occurs and inherent stability is lost. Suction drainage is instituted. Children with mul-timembral deficiencies.3 to 1. the notches will interdigitate to provide some stability and good bone apposition ( Fig 36A-11.org/alp/chap36-01. The periosteum is carefully dissected from the area of wedge removal and further periosteal dissection carried only proximally to avoid denuding the distal fragment. ). employed radical excision of all distal muscles except the brachioradialis. Swanson reports on excellent results in children and extends the indication "for patients living in areas where prosthetic services are unavailable. . the defect may be packed with cancellous bone from the removed wedge. As with the stump-capping procedure. The fitting with the new prosthesis may proceed at approximately 6 to 8 weeks after the operation ( Fig 36A-13. Approximately three quarters of the thickness of the diameter of the bone is then removed in the shape of a trapezoid wedge. probably due to cosmetic objections. usually anteriorly. is now bent into the planned angulation. ). If. It has been generally accepted that the prime indication for the Krukenberg procedure is the bilateral transradial amputee who is blind and absolutely requires tactile sensation for independence. based proximally. pronator teres. has not received wide acceptance in the United States. A large free-skin graft was necessary to cover the grasping surface of the ulnar half of the forearm. Postoperative Care At 6 to 8 weeks after angulation osteotomy the radiographs should demonstrate secure union. to cover the proximal portion of the cleft of the split forearm. who have bilateral long or medium-length transradial stumps should also be considered for this procedure. Hermann Krukenberg developed an operative procedure to convert a long transradial This operation amputation stump into a pincer-like grasping organ with tactile sensation. Krukenberg used a simple U-shaped incision and bisected the forearm with either one or two V-shaped flaps. supported by its intact periosteum." Surgical Procedure In his original technique. This is intended to condition and prepare the stump for prosthetic use and over the long term to stimulate growth of bone in both size and length. which passes obliquely across the angulated bone at an angle of 45 degrees from the distal fragment through the proximal fragment and penetrates both cortices of each fragment. In a young child it may be expected that the given angle will diminish approximately 1. In the younger child this produces a fairly stable "greenstick" fracture but maintains stability. and supinator to allow primary skin closure without grafting. however. . end-bearing training as well as gentle traction on the osteotomy site with the parent's finger should be instituted as soon as bony healing is secure. some of the muscles of the in 1949. ).The advantages of readily available prehension with sensation are significant. especially in dressing. During the training period the patient must be taught to properly use and balance these muscles to gain this function. The interosseous membrane is divided throughout its length along its ulnar periosteal attachment to avoid damage to the interosseous vessels and nerves ( Fig 36A-16. the forearm muscles are carefully dissected into radial and ulnar groups.D). A). These are covered with splint-thickness or free full-thickness skin grafts taken from the groin. proximal transposition of the radial insertion of the pronator teres may be advisable to gain additional opening space and span. abducts the radius away from the ulna. .oandplibrary. like Tubiana. physical and occupational therapy may be started. Between training sessions the patient should be provided with a well-shaped wedge to maintain maximum opening and prevent contracture.B and C). Shorter stumps may have less opening. It is important that the surgeon review the anatomy of the cutaneous nerves of the forearm ( Fig 36A-15. Skin grafts are applied to the outer surfaces of the digits where sensation is less important. actions to be exploited are pronation and supination. but useful function and power can be expected. Following closure. The supinator will become the major adductor. Interdigitating V-flaps. The two L-shaped flaps are rotated so as to cover the grasping surfaces and sutured to the skin over the tips of each digit. ) so that these are not transected in the incisions used for creating the flaps. the volar flap is advanced or rotated over the grasping surface of the ulna and the dorsal flap over that of the radius so that the opposing tactile surfaces will be covered with skin having normal tactile sensation. For some period of each day. After developing the skin and fascial flaps. ). closure is carried out. required on the grasping surface of the ulna. gentle separation of the radius and ulna is carried out to create an angle of 25 to 30 degrees. Closure is completed with care to avoid undue tension ( Fig 36A-16.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library II. He did not excise muscle in the belief that a better blood supply was thus preserved and a better grasping surface and proprioception created. Skin defects will be present on the outer side of each forearm branch. . It is advisable to thoroughly wet the dressings down so that they can be removed easily without damaging the skin grafts.asp[21/03/2013 21:58:20] .to 14-year-old-the length of the opening V of the digits will be approximately 12 cm and the opening span between the tips approximately 8 cm. . teres muscle is part abductor and part adductor. however. Large skin grafts were. Pronation has been converted into an opening motion as the pronator teres. The musculature that will motor the forceps action of the reconstructed limb must be carefully The pronator dissected and preserved. After division of the muscle groups. the wedge is removed and a circumferential bandage applied to maintain the fully closed http://www. In the very short stump. The voluntary If healing is satisfactory. which is stabilized by the triceps. the two branches are separated to a little less than maximum opening position and sterile dressings applied with a wedge of soft material to maintain the open position ( Fig 36A-16. In closure. When the dissection is completed and the radius and ulna spread to a maximum without damaging muscle. Supination has been converted to a closing action since the supinator adducts the radius against the ulna. The V-flaps are sutured in an interdigitating fashion to cover the cleft between the separated radius and ulna. The brachioradialis will open the digits. based proximally. I use. however. Postoperative Care The suction drainage tubes are removed 2 days after the operation without disturbing the other dressing. are used to cover the proximal web of the cleft.org/alp/chap36-01. In an attempt to combine the advantages of the Kreuz and Bauer modifications and avoid the necessity of excising muscles for closure. an incision with two Lshaped flaps rather than the simple bisecting U-shaped incision ( Fig 36A-14. Suction drainage is placed between the V-flaps in the cleft. acting with the biceps and with the brachioradia-lis. performed approximately 700 Krukenberg operations. If the radius is approximately 22 cm in length-an average normal for a 12. All wounds are dressed at a minimum of 10 to 14 days aftersurgery. The distal fibers of the supinator must be carefully observed during this part of the procedure since overstretching or tearing of its muscle fibers must be avoided. prostheses that will provide some function but are primarily desired for aesthetic reasons. he studied law and is now a judge. the hands and fingers should be free for play. Radial abduction combined with volar flexion is often used for grasping. when there is a hypoplastic or absent thumb. At birth it was recognized that the child had bilateral total carpal transverse deficiencies of both upper limbs. elbow. as parents often are wont to do. In watching and assessing the developing function in these children the careful observer will note important compensatory functions that depend on the radial positioning of the hand. particularly the metacarpophalangeal joints. used the right open-end prosthesis in association with his "Krukenberg. Most important is the physical therapy program to emphasize maximum mobility of all joints. It has already been emphasized that in the infant and small child the shortened arm must be left exposed and not covered or concealed by clothing. Splints to maintain the corrected position are used. Case Report The child in Fig 36A-18. but there had been a threatened abortion in the third month. a Krukenberg operation of the left upper limb was carried out. The child was first seen in March 1965. These patients refer to the prostheses as their "Sunday hands. In addition to these special devices. consideration of the contraindications to surgery deserve more emphasis than do the indications. Surgical Considerations in the Radial Clubhand The implication of radial clubhand as a component of multiple deficiencies is quite different from when it occurs as an isolated anomaly. even the myoelectric system. The decision to operate on the left side rather than the right was based on a subluxation of the proximal end of the radius on the right side and a tendency to dysplasia in this limb. In the child with multi-membral anomalies in which longitudinal deficiency of the radius (radial clubhand) is present. Postoperatively he became an excellent Krukenberg user and at first. After high school. corrections with traction. especially on the right side. Hypermobility of the wrist and metacarpals substitutes for lost pronation and supination ( Fig 36A-19. which should not be sacrificed in attempts at cosmesis. The position of uncorrected deformity in the bilateral case may have very significant functional advantages. on June 15.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library position. and greatly enhances dexterity. 1978. http://www. at which time openend prostheses were prescribed. As the patient gains the primary function and strength in the forceps action of the stump. He is completely independent in activities of daily living and in his profession and uses the Krukenberg limb in cooperation with the right forearm stump. additional devices such as wedges or clip-ons are fabricated to hold particular instruments for writing or eating.org/alp/chap36-01. especially on the ulnar side. of healthy parents with two normal siblings. so that the child will develop maximum function of the fingers. These assistive devices increase the versatility of the stump and allow the patient to perform specially needed tasks more easily. In many of these children the power of the hook created by radial deviation of the hand is the only power grasping action. In 1970.oandplibrary. 1963. experience has shown that those patients who have good vision want. There was no history of drug ingestion. was born Dec 20. ). In addition. Many of these patients have limited elbow flexion.asp[21/03/2013 21:58:20] . and shoulder. if at all. A powered electric system is also possible in which the microswitches are placed so as to activate terminal device opening by supination and closing by pronation ( Fig 36A-17. only at night. In this way maximum mobility of the joint is maintained and the contractures prevented. They will develop fine grasp between the fingers. in addition to their Krukenberg stump. In the radial clubhand the fifth finger is much more often used for fine pinch than is the index finger. shown and controlled by the physical therapist." Then he rejected every prosthesis. During the day. ). is important in assessing function." For this purpose a conventional body-powered prosthesis in which the socket is modified to accept the Krukenberg stump is usually prescribed. 10X Dorrance hooks were substituted for his earlier terminal devices and. He was admitted for training in the use of the prostheses but preferred the tactile contact with the stumps. The range of motion of finger joints. and may be more suitable for pollicization than the index in terms of useful function. should be done by the mother or father every day several times to minimize the contracture. and radial abduction of the wrist is an important substitution to bring the hand to the mouth or face. asp[21/03/2013 21:58:20] . When good function of the digits and of the elbow joint is present. In some instances. with centralization of the hand. the lunate may be excised completely and the bed for the reception of the ulna excavated in the capitate bone or in the distal portion of the synostotic carpal block. this procedure is a preliminary release of the shortened radial structures to permit bony centralization of the hand on the ulna with a minimum of shortening of the bony elements. and tendons lengthened as necessary. The second stage is accomplished after the conclusion of growth and after thorough healing of the first stage through an S-shaped dorsal incision beginning on the ulnar side of the distal forearm. The carpal bones are seldom normal. These structures are then elevated from the underlying ulna and dorsal carpal ligaments as an intact soft-tissue bridge beneath which the procedure is completed. provides for lifting capacity with strength not available with a weakened finger grasp. in spite of conscientious examination and observation.. These two bones together have a larger base and with it a better resistance against recurrent deformity than does the lunate bone alone. The first. and then turning distally to the base of the second metacarpal. however. For the most part the carpal bones on the radial side of the wrist are extremely hypoplastic or absent. limit the extent of correction at this first stage. If there is insufficient shortening to permit centralization without excessive soft-tissue tension or if the lunate bone is too dysplastic. or better. and we should save mobility and function for the multimem-bral-deficient person as much as possible without increasing the risk of recurrent deformity. The ulna is shortened sufficiently to obtain full correction of the clubhand. The excellent mobility of the joints distal to these bones with regard to dorsi-flexion and volar flexion will be preserved. especially in patients with acutely angulated radial abduction who require the function of the clubhand position. Frequently there are various degrees of synostosis of the carpal bones. In the quadrimembralto do these surgical procedures only deficient child. ). which. The region of the lunate bone in the synostosis is excavated to form a bed for reception of the shortened ulna. ). is primarily a procedure in the form of a Z-plasty of the skin on the radial side of the wrist with After developing the skin flaps. In other instances. followed by pollicization of the index. The transverse portion of the incision is superficial. this procedure is adequate to obtain enough correction to increase the range of movement without losing this functional need. Postoperative therapy emphasizes function and motion of the fingers. which may. limited elbow flexion. transversely crossing the proximal wrist. This function may be necessary in using a rail for stair climbing. I still prefer. but this should be carried out only by a hand surgeon well experienced in congenital malformations.oandplibrary. surgical correction of the radially deviated hand for centralization is carried out in two stages. only for cases without the possibility of passive correction. With the desired correction attained. The dorsal capsule is then elevated from the ulna and dissected distally to expose the carpus. as well as the extensor tendons. Other hand surgical techniques for correction of the radial clubhand have been described by Blauth and Schneider-Sickert and by Buck-Gramcko. the flaps of the Z-plasty are reversed and the wound closed. The hand is positioned to avoid tension on skin sutures. As the hand is deviated in an ulnar direction. Surgical Procedure (Centralization of the Hand) Where indicated. as do Witt et al. In this process care must be taken in the volar dissection to identify and protect the radially displaced median nerve. after the completion of growth provided that.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library These children must be carefully evaluated by both the surgeon and therapist before surgical treatment is planned to be sure that no important functions will be lost by centralization of the The most important is hand ( Fig 36A-20. I propose excavating both of them while carefully protecting their distal joints to prevent displacing them. This may be adequate to allow correction of the radial deviation. often in combination with volar flexion. If the lunate and triquetral bones are separate. his radicalization procedure after an optimal conservative correction within the first year of life. as well as by Lamb et al.org/alp/chap36-01. the fascial contractures are released soft-tissue release. The contraindications should be recognized. It should be recognized that the radially deviated hand. in "Suggested http://www. throat. curving around the styloid of the ulna. Buck-Gramcko recommends centralization. will prevent the individual from using it for any activity approaching the neck. in fact. but in severe deformity it may be necessary to open the radial side of the wrist joint capsule. there are no major contraindications ( Fig 36A-21. face. it may indicate early surgical correction. care must be exercised to avoid stretching the nerve. remain intact and protected. or mouth. and the large dorsal veins and cutaneous nerves. and the correction is maintained in a plaster of paris dressing. on occasion. instead of the described shortening of the ulna plus wedge resection. fixation is accomplished by two crossed Kirschner wires. The correction with shortening of the bones. no attempt should be made to perform arthrodesis to the wrist. Plaster is changed and sutures removed at about 14 days postoperatively. ). bowing of the tibias bilaterally. show the firstborn of a 39-yearold mother. This is true during the whole period of lengthening and underlines the need for careful observation and daily medical examinations. the tourniquet is released and circulation in hand and fingers observed. Postoperative Care Suction drainage is removed at 48 hours. Too much tension on the tendons may have fateful consequences for the future function of the hand. If circulation is satisfactory and bleeding controlled. complete bilateral longitudinal deficiencies of the fibula. The ulna should be shortened to a level of about 1 mm proximal to the distal end of the radius. followed by elevation of a capsular flap and shortening by removal of a segment of the ulna while preserving approximately 2 cm of its distal end. In reducing the shortened ulna. after this procedure should be maintained a minimum of 3 months and. Immobilization is applied with sterile dressings and plaster of paris extending from above the elbow to the proximal interphalangeal joints of the fingers. Circulation must be checked prior to internal fixation with crossed Kirschner wires. Orthoprostheses were prescribed for the lower limbs. In this procedure an additional technical detail should be noted. reduction of the hand around the shortened ulna should be carried out gently and gradually and the tension on nerves and vessels carefully observed.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library Readings. would be possible. and the tendon of the ulnar extensor muscle of the wrist will be shortened. 1971. Before the wound is closed.. even if blood supply and sensation are intact.asp[21/03/2013 21:58:20] . Procedure With a Hypoplastic Radius (After the Growth Period) For those patients in whom the radius is hypoplastic rather than absent and radial deviation of the hand is present. This tendon should be shortened proximal to the ulnar styloid process under sufficient tension so that it prevents passive radial deviation of the wrist.. The child was born on June 15. repair of the wrist joint capsule is carried out. Suction drainage tubes are inserted and the wound closed.org/alp/chap36-01. When bony fusion of the ulna to the carpus is complete. If immobilization is extended beyond 3 months. in particular. and Fig 36A-23 (h-k). A wedge of bone with its base ulnarward and dorsalward is removed from the distal carpal row. As with the other procedures. The procedure should be a release of the contracted structures on the radial side of the wrist. up to 6 months to ensure stability. Immobilization. Immobilization and aftercare are similar to the procedure previously described.Fig 36A-23 (c-g). all finger joints should be freed. There were numerous lesser deformities. centralization and correction of the deformity is obtained ( Fig 36A-22. Night splints maintaining full correction of the hand are employed for at least a year postoperatively. however. including some hypoplasia of the right femur and. care must be taken to not place the neurovascular structures under tension. When the wedge defect is closed. however. a thigh corset and knee joint http://www. by cae-sarean section with total bilateral transverse deficiencies of the forearms. the tendons of the radial flexor and extensors of the wrist will be transposed to a dorsal-ulnar position." As in the soft-tissue release. Nowadays the lengthening of the radius. the Kirschner wires may be removed and a full physical therapy program begun. The metacarpophalangeal joints are maintained in slight flexion. CASE REPORTS Retention of Feet When Hands Are Missing Fig 36A-23 (a-b). In addition. and fifth metatarsophalangeal deficiencies also present. and physical therapy for finger motion should be instituted. is less risky with regard to function of the fingers. the distal fragment should be externally rotated slightly so that the line of pull of the extensor carpi ulnaris within its groove is partly changed to that of ulnar abductor. With correction obtained and centralization acceptable. She was first seen in the outpatient clinic in October 1972 at the age of 16 months.oandplibrary. 1990). Following this surgery. she asked for amputation. when it was recognized that she had a small rudimentary ulnar fragment present on the right. In February 1977. New orthoprostheses were prescribed. She has friends and is a pleased and happy person. There was no history of unusual medication during the pregnancy. Fig 36A-23 (c-g). completely independent in the activities of daily living as well as fully ambulatory with her lower-limb prostheses. a partial tarsal. ). Knee disarticulation was contraindicated because of the hypoplasia of both femora and also to preserve his independence. In October 1975. was born Sept 17. New limbs were prescribed in February 1979.. By December of the same year. The child's twin was born with bilateral lower-limb deficiencies ( Fig 36A-25 (a-d). his training with the upper-limb prostheses was quite satisfactory. and Fig 36A-25 (e-i). as well as a flexion deformity at the radiohumeral joint. In December 1972. she was independent in the activities of daily living and used her forearm stumps but not her prostheses. He used his upper limbs approximately 8 hours a day for years. Bilateral pneumatic upper limbs were prescribed for the child and reconstruction of the knees and feet undertaken. to healthy parents with a 3-year-old normal sibling. the bowing of the right tibia had increased enormously so that alignment and maintenance of appearance of this orthoprosthesis were difficult.oandplibrary. 1968. followed by an optimal prosthetic fitting (published with different figures in Seminars in Orthopaedics. She did use her upper-limb prostheses when she went to a restaurant. In 1987.. There was. partial carpal deficiency. with arthrodesis of both knees. the child was ambulatory.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library on the right side.asp[21/03/2013 21:58:20] . cushion-heel (SACH) feet. wears his lower limbs full-time. These were replaced by orthoprostheses with stiff knees and SACH feet ( Fig 36A-24 (a-d). At the time of birth. pp. No upper-limb prostheses were prescribed. new lowerlimb orthoprostheses were prescribed ( Fig 36A-23 (a-b). She was not seen again until April 1975. the child was not seen. At this time Syme ankle disarticulations for the lower limbs were considered. and articulated feet. ). and we constructed an endbearing modified Pirogoff stump. and only further correction of the tibial deformity was carried out. and is independent in eating and drinking. partial-foot amputation. Again. and Fig 36A-23 (h-k). writing. the infant was noted to have bilateral upper-limb deficiencies consisting of total longitudinal deficiency of the ulna.org/alp/chap36-01. The patient is fully ambulatory. There was also a left coxa vara with bowing and hypoplasia of the femur. he became ambulatory and independent in donning and doffing his four prostheses. 5. 44-45. In August 1972. attended regular school and high school.E and F). Reconstruction and Prosthetic Fittings for Multiple-Limb Deficiency The child in Fig 36A-24 (a-d). The initial fitting was temporary plaster of paris sockets with solidankle. Her parents would only consider functional hands and rejected the use of a hook. and Fig 36A-25 (e-i). and a total metacarpophalangeal deficiency of digits 2 through 5. The patient was first seen in April 1972. There was an additional history of the father's sister having given birth to twins who died at birth with unknown limb deficiencies. and he was able to feed himself as well as play by using the artificial limbs. but after consultation with the parents.. a significant family history in that he was born with a twin who had limb deficiencies as well ( Fig 36A-25 (a-d). There was additionally hypoplasia of both the radius and humerus. and stabilization of the astragalus to the fibula bilaterally ( Fig 36A-24 (e-h). Further efforts at reconstruction concluded in June 1977. Use of transfemoral prostheses would have required the help of others to don them. however. The patient continues to use her forearm stumps for all activities. Between 1975 and 1977. Meanwhile. and other activities of daily http://www. the child was fitted with new orthoprostheses. at which time training in the activities of daily living was immediately instituted. Vol. At this time upper-limb prostheses were prescribed. the decision was made against this. and more of an orthopaedic shoe on the left side. she finished high school with excellent results and began her years of university study in 1990. During this period she rejected her prostheses and resumed ambulation on her own feet but with gradually increasing deformities so that when she was again seen in October 1977..D). ). The combination of total ulna and tibia longitudinal deficiencies is extraordinary. Bilateral transradial cable-controlled prostheses were prescribed. the child was beginning to take her first steps in a walker. knee joints with Swiss locks. he was fitted with his first lower-limb prostheses. and total metatarsophalangeal deficiencies of digits 1 through 3. The child had bilateral longitudinal deficiencies of the lower limbs consisting of a total tibia. surgical intervention in the form of osteotomy of the tibia and fixation of a digital transplant from the great toe of this foot to the left ulnar fragment to create a better transradial stump was carried out. The prescription included plastic transfemoral sockets with windows and Velcro suspension. but at home he likes to walk on his stumps. and Fig 36A-24 (e-h). and is able to play soccer while wearing them. The lower limbs showed a left partial longitudinal deficiency of the femur (intermediate-the equivalent of an Aitken class A PFFD). He is now a philosophy student. In 1967. and 6 weeks later the patient was fitted with a new orthoprosthesis. In 1974. was born on June 9. Shortly thereafter.). 1962.asp[21/03/2013 21:58:20] . the father and mother are both entirely normal. as well as correction of the severe hip flexion deformity. She is working full-time in an office on behalf of disabled children and is happy and feeling fine except that she now observes a flexion contracture of the left hip and low back pain. At this time a left upper-limb prosthesis was prescribed. In August 1964. got troublesome to him. and a pyloric stenosis corrected by surgery on the second day of life. the child was admitted to the hospital for self-care training. and he began a physical http://www. he felt more comfortable without and rejected them completely without any diminution in activities of daily living or in his psychological stability. and has her own apartment. There was no family history of limb deficiency or other congenital deformity. centralization of the fibula under the femur and of astralgus under the fibula was carried out at Tubingen for stiffness on the right. on the right. 1961. a history of the mother having ingested thalidomide in early pregnancy. the left subtrochanteric pseudoarthrosis was resected and the first stage of correction of the severe varus deformity undertaken. the second stage for correction of the varus deformity was carried out. the mother of the patient ingested thalidomide for a period of 3 days for surgery. In the lower limbs there was bilateral total longitudinal deficiency of the tibia. especially in the technique of using the feet as well as the vestigial hands for activities of daily living. reveals that at approximately 6 weeks after her last menstrual period. At this time the trochanter was also transplanted distally. completely independent in activities of daily living.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library living. however. This was a ball bearing-supported elongation of the left upper limb with a pneumatic hook and a pneumatic wrist rotation unit operated by the left phocomelic hand (see Fig 36A-5. Hip Reconstruction for Proximal Femoral Focal Deficiency With Multimembral Deficiency The child in Fig 36A-26 (a-d). she is a young woman.). whereas on the left. The history. In 1967. good humored. physical therapy is planned on an inpatient basis in a rehabilitation hospital and should continue at yearly intervals to preserve mobility and independence and to postpone total hip replacement. Other congenital anomalies included a mild scoliosis. orthoprostheses as well as a night splint were provided. The child was first seen in September 1962. Reconstructive Surgery in Upper and Lower Limbs Prior to Prosthetic Fitting The child in Fig 36A-27 (a-d). metacarpophalangeal 1 was totally absent. a valgus osteotomy of the right femur was carried out. His upper-limb prostheses. The pregnancy was uneventful with a normal birth. For the present. and gifted. a longitudinal deficiency of the radius. she was enrolled in a special preschool for the physically handicapped. There was. and attended school in her own village. free knee joint. the hardware was removed and a Chiari osteotomy carried out to provide increased coverage of the femoral head. In 1968. The child had the following limb deficiencies: upper limbs showed bilateral hypoplasia of the radius with partial carpal absence and. After healing of this surgery a new orthoprosthesis was prescribed with a left thigh corset. . strabismus. Fig 36A-26 (f-i). used her toes as well as her vestigial hands for self-care. The child became fully and independently ambulatory. was born of healthy parents on May 15. . In 1975. after a full-term pregnancy. and in September 1964. On the right side there was coxa vara with bowing. and Fig 36A-26j. and total metacarpophalangeal 1 and 2 deficiency.. his upper-limb prostheses had been of importance for him as well as for his parents. In 1969. with coxa vara of the femur on the right and a longitudinal deficiency of the proximal portion of the femur on the left (Aitken class A) and subtrochanteric pseudarthrosis. The patient was first seen in 1964. The child was born with bilateral pho-comelic upper limbs consisting of hypoplastic rudimentary humeral segments synostosed with the ulna.oandplibrary. however. at which time a physical therapy program was instituted as well as extension splinting of the lower limbs. In 1976. For many years. she was supplied with an orthoprosthesis for the left lower limb with a stiff knee and SACH foot (see Fig 36A-4. Fig 36A-26e. Years later. prior to which he had been fitted with stubby prostheses at the University of Tubingen. she was supplied with an extension orthosis for the left leg. however. A full physical therapy program to maintain functional mobility of the spine was likewise undertaken.org/alp/chap36-01. with hypoplasia of the remaining digits. and Fig 36A-27 (e-h). By the following year the child had rejected the pneumatic prosthesis. and SACH foot. partial absence of metacarpophalangeal 1. as were three older siblings. however. New orthoprostheses were prescribed. He was also able to sit and stand independently. and Fig 36A-28 (d-h).4 days of hospitalization. especially the use of the foot for prehension by the armless child. proximal third (with a very short ulna segment remaining). and in 1970. 22. In 1968. even manage stairs. and after 4 weeks of training he was able to ambulate on a level surface and. with considerable effort. Parallel to his increased walking and grasping abilities. extended the hospital school. In 1978.). he is independent in activities of daily living. his upper-limb prosthesis was changed to a cable-controlled Hosmer outside-locking elbow with a Dorrance 10X hook interchangeable with an Otto Bock hand. and reduced the period of hospitalization (average period in the dysmelia department: 1970. Stairs were particularly important because without this ability. he would not be permitted to attend high school at home but would have to attend a special school. polliciza-tion of the right index finger was carried out in Heidelberg. This patient demonstrates the importance of reconstructive surgery in both the upper and lower limb prior to prosthetic fitting. and most recently in 1979 to extend the socket somewhat proximally to act as a support for his progressive scoliosis. Hip Disarticulation Prostheses for Bilateral Lower-Limb Deficiency This child was born Nov 4. These prostheses were first applied July 1973. including vestigial digits on deficient upper limbs. He had other congenital anomalies.5 days of hospitalization. In addition to all of his physical problems. drives his own car. Finally. this child's schooling had been much delayed by these multiple surgical procedures.6 days of hospitalization. and a transverse deficiency of the forearm. Reconstructive procedures that have special benefits for the multimembral-deficient child as opposed to the unimembral-deficient child are discussed. His lower-limb socket had to be changed in 1976. Particular emphasis is placed on using all function in tactile areas. 1962 ( Fig 36A-28 (a-c). In 1974. he is independently ambulatory. He was additionally supplied with a cosmetic forearm prosthesis for swimming. and his pollicized index fingers function quite well as thumbs. but he also demonstrates the need for a better consideration of the child's psychological development if orthopaedic surgery and hospitalization are indicated. Bilateral lower-limb prostheses were prescribed with automatic knee locks in the stance phase and automatic combined hip and knee flexion for sitting. There was no family history of limb deficiencies. as indicated in Fig 36A-27 (a-d). The child was born with bilateral transverse lower-limb deficiencies. 1985. the last year of my full professional life.. the left subtrochanteric pseudarthrosis was resected and the varus deformity corrected. his cognitive skills improved. case studies are used to illustrate the complexity of the problems involved with the quadrimembral-defi-cient child. and is accepted and accepts himself as he is. deficiency of the upper third of the thigh. and he is now in a fulltime job as an office worker.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library therapy and occupational therapy program. and 1988. at which time he was using primarily a wheelchair but was able to get around on the floor by using his hands. 1980. and Fig 36A-27 (e-h). http://www. improved cooperation with the parents. In 1969. and in 1974. Substitution patterns are discussed. 14. and his two siblings were normal. A left transhumeral prosthesis was constructed with a crutch attached to the functional hand for ambulation. Harrington instrumentation should not be considered. CONCLUSION An effort has been made to document a philosophy for management of the multimembraldeficient child.org/alp/chap36-01. subsequent to which new prostheses were prescribed. 43. it had been 13. He was also noted to have a scoliosis. Prosthetic solutions are presented for both upperand lower-limb deficiencies. The child was first evaluated in November 1972. the left index finger was pollicized. In following years we established the rooming-in system for preschool children with their mothers in the hospital. It is important to recognize that in no way could such a chapter as this cover all combinations of deficiencies and that this is an effort to present the problems in general with some particular solutions. arthrodesis of the right knee was carried out. in the early life of these children.8 days). developed the efficiency of the outpatient clinic. arthrodesis of this knee was carried out. Stress is placed on the limitation of functional value and particularly on the excess of the weight of currently available externally powered upper-limb devices. There was no history of ingestion of any medication during the pregnancy. Nonetheless. new orthoprostheses were prescribed for the lower limbs. In 1971. It was believed that because of his problems in ambulation with bilateral hip disarticulation-type prostheses.asp[21/03/2013 21:58:20] .oandplibrary. again in 1978. because of increasing flexion adduction deformity in the left knee. Ruge and W. July 28.Atlas ihrer operativen Behandlung. 60:30-39. Jones D. Lamb DW: Radial club hand. Berlin. 1916. Blauth W. Hepp O: Dies Haufung der angeborenen Defektmidbil-dungen der oberen. Charles C Thomas Publishers. 1981. Hafher O: Die pneumatisch bewegte Prothese. Extremitaten in der Bundesrepublik Deutschland. Willert HG. 12:229-233. 828291. 37:228-247. Henkel HL: Klinik und Pathologie der Dysme-lie. 1974. 1969. Julius Springer Verlag. Heyne S: Ergotherapie bei blinden Ohnhandern mit Krukenberg-Plastik. 36:51-53. Berlin. Springer-Verlag. in Handchirurgie. a modified technique avoiding skin grafts. Verh Dtsch Orthop Ges 1949. in Hoffa A (ed): Orthopddische Chirurgie. J Bone joint Surg [Br] 1978. Kessler HH: Cineplasty. Buck-Gramcko D: Angeborene Fehlbildiingen der Hand. 3. Thomsen W: Diskussionsbeitrag zum Thema Krukenberg-Plastik. Kallio KE: Recent advances in Krukenberg's operation. Clin Orthop 1974. Germany Ferdinand Enke Verlag. pp 780-824. 1960. Hackenbrock K. Acta Chir Scand 1948. Berlin. 57:419-426. Kelikian H: Congenital Deformities of the Hand and Forearm. 1949. pp 1-115. Nguyen BT: The Krukenberg operation. 1963. Deutsche Vereiningung fur die Rehabilitation Behinderter. 6:423-433. Gocht H: Atiologie. Barnes J. WB Saunders Co.oandplibrary. Med Klin 1962. Neff G: The angulation osteotomy of above-elbow stumps. West Germany. 6. Stuttgart. 1925. Stuttgart. Eine Anleitung fur Chirurgen and Techniker mit anato-mischen Beitnigen von G. Felix unter Mitwirkung von A. et al: Centralization of the radial clubhand: An ulnar surgical approach. 7. Georg Thieme Verlag. Pathogenese und Therapie der Deformi-tiiten im allgemeinen. West Germany. Sauerbruch F: Die willkiirlich bewegbare kiinstliche Hand. http://www. Lloyd-Roberts GC: Congenital aplasia and dysplasia of the tibia with intact fibula: Classification and management. Martini AK: Klumphandkorrektiir nach Wachstumsabschliits. 8.org/alp/chap36-01. Hepp O: Prothesen der oberen Extremitat. Handchirurgie 1980. J Bone Joint Surg [Am] 1977. vol 1. References: 1. Verh Dtsch Orthop Ges 1949. 4. Philadelphia. Springer-Verlag. insbesondere des Krukenberg-Armes. in Hohmann G. vol 26. Heidelberg. 104:232-238. 9. West Germany. J Hand Surg 1977. Stuttgart. 2. Stuttgart. Manske PR. Biesalski K: Die Kunstglieder der Versuchsund Lehr-werk-statte des Oskar-HeleneHeims. 1957. J Hand Surg 1981. 36:60-61. Lindemann L (eds): Handbuch der Orthopadie. 5. Bauer KH: Zum Problem der Ohnhanderversorgung und zur Frage der operativen Behandlung. Die Fehlbildungen an den oberen Extremitaten bei der Thalidomidembryopathie. Stadler. Kuhn GG: Neue technische Hilfen fur schwer Korperbe-hinderte kinder. FK Schattauer Verlag. Georg Thieme Verlag. 1976. 111. 59:1-13. 97:165. Pat-entschrift des Patents der Bundesrepublik Deutschland. 2:127-130. Nathan PA. Z Orthop 1917. Ferdinand Enke Verlag. 1. 37:174-278. 1947. West Germany. Hepp O: Information on Measures for Habilitation for Children With Dysmelia. in Experimentelle Medizin. Schneider-Sickert F: Handfehlbildungen .36A: The Multiple-Limb-Deficient Child | O&P Virtual Library SUGGESTED READINGS Boos O: Die Versorgung von Ohnhandern.asp[21/03/2013 21:58:20] . in Baumgartner R (ed): Amputation und Prothesenversorgung beim Kind. 1977. Stuttgart. Springfield. Marquardt E. Vol. No. Pathologie und Klinik. 1916. Fischer: Z Orthop 1917. 1956. Rehabilitation Monograph 44. McBride WG: Thalidomide and congenital abnormalities. 2:689-693. Dtsch Med Wochenschr 1962. Heidelberg. Marquardt E: Provision with active prostheses of armless babies in the second year of life. Lenz W: Missbildungen nach Medikamenteneinnahme wiihrend der Graviditat. Deutsche Vereinigung fur die Rehabilitation Behinderter.oandplibrary. 18. Deutsche Vereinigung fur die Rehabilitation Behinderter. 17. The Horowitz Lectures. Kreuz L: Die Herrichtung des Unterarmstumpfes zum natiirlichen Greifarm nach dem Verfahren von Kruken-berg. 14. in Witt AN. J Bone Joint Surg [Br] 1965. 1969. 1963. pp 42-51. pp 363-378. 30. von Privatdozent Dr. Springfield. 34. 16. in Baumgartner R (ed) : Amputation und Proth-esenversorgung beim Kind. West Germany. Rehabilitation 1972. Med] Aust 1963. Marquardt E: Indications for an early treatment of children with dysmelia. 1968. Haefner O: Technical adequacy and practical application of the Heidelberg pneumatic prosthesis. Marquardt E: Steigerung der Effektivitat von Oberarm-prothesen nach Winkelosteotomie. Marquardt E: Angeborene Extremitatenmissbildungen. Pfeiffer RA. 27.org/alp/chap36-01. Ferdinand Enke Verlag. Charles C Thomas Publishers. Heidelberg. 12. 10. 17:221-225. Heidelberg. Roesler H: Prothesen und Prothesenver-sorgungen der oberen Extremitat.11. Marquardt E: Plastische Operationen bei drohender Knochendurchspiessung am kindlichen Oberarmstumpf. et al (eds): Orthopadie in Praxis und Klinik. West Germany. 114:711-714. Marquardt E: Einleitung der Diskussion uber die Thera-pie der radialen Klumphand. 36:61-64. 1978. McBride WG: Thalidomide and congenital abnormalities. 11. in Information on Measures for Habilitation of Children With Dysmelia. Verh Dtsch Orthop Ges 1949. 1975. Warsaw. 35. Georg Thieme Verlag. W.A. 2:1358. in Information on Measures for Habilitation of Children With Dysmelia. 1968. Marquardt E: Die Krukenberg-Plastik. 32. 1968. Arch Orthop Unfallchir 1956. 20. New York. Neff G. Marquardt E: Erfahrungen mit pneumatischen prothesen. am 19. 17:221-225. 31. Stuttgart. Georg Thieme Verlag. 1963. 1:45. in Limb Development and Deformity: Problems of Evaluation and Rehabilitation. Stuttgart. Marquardt E: The Heidelberg pneumatic arm prosthesis. Bundesminister fur Gesundheitswesen. Marquardt E: The radial club hand: The case for conservative therapy. Verh Dtsch Orthop Ges 1966. Zentralbl Chir 1944. pp 34-41. 19. Hamburg. Lancet 1962. pp 37-50. Marquardt E: Osteotomia katowa kikuta ramienia. 25. 1963. Deutsche Vereinigung fur die Rehabilitation Behinderter. 1981. Kosenow: Zur Frage der oxogenen Entstehung schwerer Extremitaten-Missbildungen. Originalmethode und Modifikationen fur blinde Ohnhander. 52:346-352. Bartmann. 1917. Marquardt E: The total treatment of the limb deficient child. in Monographic uber die Rehabilitation der Dysmeliekinder. Lancet 1961. Marquardt E: Pneumatic arm prostheses for children. Krukenberg H: Uber die plastische Umwertung von Ar-mamputationstumpfen. Schlegel FK. Ill. Z Orthop 1976. Pfeiffer u.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library Beschaftigungstherapie und Rehabilitation. 28. 86:2555. Tagung der Rheinisch-Westfalischen Kinderarzte-vereinigung in Diisseldorf. Kosenow W: Zur Frage einer exogenen Ver-ursachung von schweren http://www. 26. Dtsch Med Wochenschr 1961. 4:279-287. Rettig H. 23. 24. Deutsche Vereinigung fur die Rehabilitation Behinderter. Lenz W. pp 52-55. 48:115-135. 1963. International Society for the Welfare of Cripples (in German). zu dem Vortrag von R. Stuttgart. Lenz. 21.asp[21/03/2013 21:58:20] . 1977. Marquardt E: Information on standard prostheses for armless children. Marquardt E. West Germany. 47:425-434. Frechen. vol 2. Beschaftigungstherapie Rehabil 1978. Knapp K: Die Thalidomid-Embyropathie. 33. 1961. Marquardt E: The management of infants with malformation of the extremities. in To-maszewskiej J (ed): Protesowanie Typu Czynnego po Am-putcjach w Obrebie Konczyn Gornych. 15. 38:1170-1175. 22. pp 48-51. in Information on Measures for Habilitation of Children With Dysmelia. West Germany. 36. W. Keyl R: Erfahrungen mit der Krukenberg-operation und deren Nachbehandlung. Ferdinand Enke Verlag. 29. in Information on Measures for Habilitation of Children With Dysmelia. 87:1232-1242. 1965. Chir Plast 1979. Lenz W: Diskussionsbemerkung. 13. Neff G. 11:244-248. pp 56-57. New York University Medical Center. Marquardt E. Lindemann K. Heidelberg. Institute of Rehabilitation Medicine. Kuhn GG: Kunstarmbau in GieSharztechnik. Stuttgart. movement. von Volkmann R: Die Muskelfunktion im Krukenberg-Arm sowie einige operative Folgerungen. in Aktu-elle Orthopadie. Med Welt 1961. Inter-Clin Info Bull 1972. 47. Chapter 36A . Jager M: Die angehorenen Fehlbildungen der Hand. 48. 38. Stuttgart. Spitzy H. 43. Proc Inst Mech Eng [J] 1968. 63:1181-1186. 46:1540. 1972. Swanson AB: The Krukenberg procedure in the juvenile amputee. Stuttgart.und aplastische Fehlbildungen der Gliedmassen (DysmelieSyndrom). Verh Dtsch Orthop Ges 1955. Orthop Clin North Am 1981. Verh Dtsch Orthop Ges 1951. vol 5. Prosthetic. 37. Georg Thieme Verlag.36A: The Multiple-Limb-Deficient Child | O&P Virtual Library Extremitatenmissbildungen. Orthop Tech 1972. 40. Miinchner Med Wochenschr 1916. Swanson AB: Congenital limb defects.asp[21/03/2013 21:58:20] .org/alp/chap36-01. 41. Wiedemann HR: Hypo. West Germany. 43:193-200. 33:6-8. Schollner D: Die Klumphand bei Radiusaplasie. 26:351-354. Miichner Med Wochenschr 1962. Tubiana R: Krukenberg's operation. 45.oandplibrary. Witt AN. 46. Weil S: Die Heidelberger pneumatische Armprothese. 104:68-74. 183:11. West Germany. Georg Thieme Verlag. 42. Steinruck. and control of artificial limbs. Contact Us | Contribute http://www. 39. Cotta H. Feldschareck: Die Versorgung beiderseits Ar-mamputierter. Swanson AB: Silicone-rubber implants to control the overgrowth phenomenon in the juvenile amputee. 49.Atlas of Limb Prosthetics: Surgical. J Bone Joint Surg [Am] 1964. 38:293-297. The basic problems of prehension. 23:1863-1866. Simpson DC: An externally powered prosthesis for the complete arm. Katthagen A: Versorgung von Hand und Ar-mamputierten mit Werkprothesen. 12:819-826. 44. 1966. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 36A The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Ciba Clin Symp 1981. Simpson DC: Eine Prothese fur beidseitig armgeschad-igte Dysmeliekinder. classification and treatment. Chirurgie 1955. 24:363-364. 11:58. particularly for a person of relatively tall stature or a person inclined toward physical and athletic activity. this usually meant transfemoral (above-knee) amputation or a hip disarticulation and. replacing the excised knee segment with autograft or allograft bone. F. i. if not centuries.P. This use of the rotation-plasty in children with proximal femoral focal deficiency (PFFD) gained popularity in a number of centers. Thus in the last 15 years or so the surgical science of limb salvage surgery came into being.asp[21/03/2013 21:58:26] .e. This familiarity with the operation and availability of both surgical and prosthetic expertise allowed relatively smooth adoption of this procedure as a limb salvage technique in North America." The technique that appears to address at least some of the problems associated with the above-described procedures is a modified Van Nes rotation-plasty. It must be understood that this metallic-plastic implant has a finite life span due to material fatigue. with resultant leg length discrepancy..Atlas of Limb Prosthetics: Surgical.O. 1992. In the lower limb with the tumor usually situated around the knee. Reproduced with permission from Bowker HK. F. Dietrich Bochmann. new imaging techniques. and others a number of surgical techniques have been developed that are aimed at preserving limbs. Prosthetic. The newer technique of limb salvage using a tumor replacement endoprosthesis is currently quite popular.D.C. The standard treatment for malignant tumors of the limbs has for decades. Although this technique is still quite useful in many patients. it also has significant limitations. PRINCIPLES AND INDICATIONS http://www." The technique was first adapted to treat osteosarcoma of the distal third of the femur by Saltzer and Kotz in Vienna in late 1970s. The biggest challenge to the surgeons engaged in this practice has been the problem of the loss of the knee joint in a young patient.S. in young children. it has very significant drawbacks. From the pioneering work of Campanacci. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution. however. He used the technique in children and young adults affected by congenital limb deficiency.C. The technique was later made popular in the English literature by Van Nes in 1950. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies).B. IL. in more proximal lesions.oandplibrary.(C) J. is a significant problem in using an endoprosthesis in this age group. In addition. Prosthetic. The rotation-plasty itself was first described by Borggreve in Germany in 1930 for a patient whose knee was destroyed by tuberculosis. C. Click for more information about this text. The metal-bone interface also has the potential for long-term problems due to the shear stresses secondary to different Youngs moduli of elasticity of the two dissimilar.R. Prosthetic. The consequent absence of the lower portion of the leg and foot is then replaced by an external prosthesis. This technique replaces the excised knee with a biological joint. American Academy of Orthopedic Surgeons. reprinted 2002. With the advent of modern chemotherapy. and Rehabilitation Principles. been an amputation. the patient's own ipsilateral ankle. Rosemont.(C. Again.org/alp/chap36-02. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. the technique is impractical in young children due to the necessary resection of growth plates around the knee and the resultant leg length discrepancy. and consequent improved survival rates came a renewed interest in improved surgical techniques to avoid ablative surgery. A sufficient soft-tissue-muscle envelope must be preservable to stabilize and motorize the new endoprosthetic knee. This is in spite of efforts to produce a satisfactory version of a "growing endoprosthesis.C. such as bone and a metal or plastic. which is rotated 180 degrees and fixed at the level of the opposite knee. It is hoped that the patients function will approximate the function of a transtibial (below-knee) amputee with a fully functional "knee joint. The early efforts tried to avoid this problem by creating a knee arthrodesis. edition 2. M. a transpelvic amputation (hemipelvectomy).). yet intimately apposed materials. ©American Academy or Orthopedic Surgeons. the loss of the growth centers. and Rehabilitation Principles Van Nes Rotation-Plasty in Tumor Surgery Ivan Krajbich. Enneking.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 36B Chapter 36B . Even at the best of times it can lead to at least a delay in reemployment of the chemotherapy treatment. A poorly perfused. Adequate nerve and blood supply of the distal part of the limb must be preservable. Principles Specific to Rotation-plasty Rotation-plasty is a technique where the ankle and foot replace the knee joint. i. a radical or wide margin as defined by Enneking is the only admissible margin in stage IIA or IIB tumors. can quickly escalate into a disaster. 5.oandplibrary. This is one of the most important principles and yet the most difficult one to heed. It is sometimes very tempting to perform a technically demanding limb salvage surgery in the face of a borderline or inadequate soft-tissue coverage. The technique for all those modifications follow the same principles: 1. Muscle and skin coverage must be sufficient for at least a two-layer closure of the soft-tissue envelope. and adequate muscle can be found to power it. The ankle and foot must be disease free. Adequate surgical margins together with the realization of the importance of soft-tissue coverage plus objective evaluation of the functional results allow us at the present time to employ a rational approach to sarcoma surgery that is based on several basic principles: 1. 4. its primary advantage is the fact that it can be safely performed even in situations where other forms of limb salvage are not possible or are functionally inadequate. which was originally described for lesions of the distal end of the femur. has been modified for use in lesions of the proximal parts of the femur and the tibia. This is particularly important where foreign materials such as metal endoprostheses or allograft bone transplants are employed. insensitive. It must be possible to restore muscle power to the ankle joint. compounded by the presence of underlying foreign material. One only has to realize that every minor wound breakdown or superficial infection in the face of immunosuppression from ongoing chemotherapy.. it can potentially be used in any of the lesions of the lower limb provided that the ankle and foot are disease free. We have found that in borderline cases. Large amounts of tissue can be resected. and infection rates. 4. Adequate nerve supply to the foot and ankle must be preservable. Van Nes rotation-plasty can be performed in the following situations: http://www. Not surprisingly then. The surgical procedure performed should be carefully selected and discussed with the patient and his family to carefully match the patients physical. 1. thus potentially jeopardizing a patients survival. 3. Specifically. A single violation invalidates or jeopardizes the whole effort. their blood and nerve supply can be maintained. In rotation-plasty careful planning of the procedure is needed to ensure viability of the skin flaps and the distal part of the limb. 2. physiologic. functional. It was not until Enneking's pioneering work in classification of musculoskeletal neoplasms and their surgical resection margins that some sound principles were introduced into tumor surgery practice. Adequate blood supply to the foot and ankle must be either preservable or restorable after resection of a segment of a disease-involved vessel. Indications The modified Van Nes rotation-plasty is a versatile procedure that can be used for virtually every lesion involving the femur or proximal third of the tibia. and life-style makeup to the planned operation.e.Margins of the resection must be adequate to the tumor stage. psychological.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library General Principles The early efforts in limb salvage surgery were hampered by a relatively high complication rate. combined with sometimes-questionable functional results that tempered the early surgical enthusiasm. thus. it is better to utilize soft-tissue flap transfers to improve local coverage or to employ another procedure that is less demanding on the availability of healthy local tissue such as a rotation-plasty. wound breakdowns. In particular. this included the high local recurrence rate. the technique. The targeted margin must be achieved all through the surgical field and planes of resection. 2. paralyzed limb is a poor substitute for an appropriate amputation with a functional prosthesis. thus making this procedure possible even in cases where there are quite extensive and large lesions ( Fig 36B-1.). However.asp[21/03/2013 21:58:26] . 3.org/alp/chap36-02. distal to their origin on the back of the femoral condyles. gastrocnemius heads are divided 2.. Mosely's straight-line graph for leg length growth and a simple calculation allows for a determination of the appropriate length of the Van Nes thigh during the surgery. however. it is safer to resect them together with the tumor and reanastomose the transected ends. This gives the patient equal knee levels in both the standing and sitting positions. if the vessels are either involved by the tumor or are within the reactive zone of the tumor. Lesions where blood supply to the distal part of the limb is compromised by the tumor and can be safely re-established only by segmental resection of the major blood vessel and reanastomosed. and in the case of vessel resection.5 cm. The two circumferential incisions are connected by longitudinal incisions medially and laterally to facilitate the dissection of the neurovascular bundles. A decision has to be made preoperatively based on the staging studies (magnetic resonance imaging [MRI] or contrast-injected computed tomography [CT]) ( Fig 36B-3. In most cases the vessels can be preserved.oandplibrary. at skeletal maturity the distal aspect of the os calcis in the Van Nes rotation-plasty thigh will be at the level of the distal aspect of the femoral condyles of the normal limb. Lesions of the distal or proximal thirds of the femur and proximal end of the tibia in young children where the expected remaining growth in the opposite healthy leg is greater than 10 cm. The goal of the surgical procedure is to end up with a thigh segment that will be of the same length as the opposite thigh at the end of skeletal growth. Pes anserinus tendons are divided near their insertion on the proximal end of the tibia. and adductors are then transected at the level of the planned bone transection. Osteotomies of the tibia and femur are completed. Children and young adults where function and physical or athletic performance is of major importance and subjectively outweighs the importance of cosmesis and the necessity of a prosthesis.asp[21/03/2013 21:58:26] . 2. For the procedure the whole lower limb is prepared and draped free ( Fig 36B-5.org/alp/chap36-02. unacceptable sequelae of previous. Ideally. hamstrings. for example. these are now cross-clamped and divided. The femoral vessels are either dissected free along the entire length or isolated proximally and distally when the vessels are involved by tumor..). Cases where the size of the tumor necessitates removal of so much of the bone or soft-tissue stock as to make any other form of limb salvage impractical. The sciatic nerve needs to be isolated along the entire length of the surgical wound. and by the growth of the calcaneotalar unit) and the normal thigh (contributed to by the proximal femoral and distal femoral epiphyses).). Distal Femoral Lesions Rotation-plasty in tumor surgery was originally described for lesions of the distal part of the femur and is still most widely used in this situation ( Fig 36B-4.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library 1. provided that the nerve supply can be safely preserved. This is particularly so in the cases of skeletally immature children where the expected remaining growth has to be taken into consideration. Incisions are marked on the skin. tibial fragment. Distally. We usually employ a circular circumferential incision proximally and an oval circumferential incision dis-tally to compensate for the difference in the diameter of the leg distally and proximally. Cases of failed reconstruction due to infection in an allograft reconstruction or local recurrence in endoprosthesis replacement. SURGICAL TECHNIQUE Careful preoperative planning is an important aspect of the Van Nes rotation-plasty technique. Each patient should have full-length leg ortho-grams taken preoperatively together with a lateral radiograph of the foot and a determination of skeletal age ( Fig 36B-2. by the distal tibial epiphysis. Quadriceps. 5. 6.A and B) regarding the need for vascular resection.A and B). the length of the new "thigh" needs to correspond exactly to the opposite member and is made up of a femoral fragment. and the calcaneotalar unit. more conventional reconstructions. The resected http://www. 4. 3. Cases of late. late unmanageable leg length discrepancy or long-term failure of endoprosthetic components with corresponding loss of bone stock. In the preoperative planning for a young child we have to take into account the differential growth in the rotation-plasty thigh (contributed to by the proximal femoral epiphysis. In the case of skeletally mature individuals. The limb is then immobilized in a neutral position in a well-padded plaster cast. Osteosynthesis using an Arbeitsgemeinschaft fur Os-teosynthesefragen (AO.). ). and a segment of the femoral vessels can also be resected and later reanastomosed. ). which includes the middle and distal portion of the femur. and the proximal portion of the tibia. with the exact length being determined by the necessary extent of the proximal excision. the level of the rotated knee joint is at the same level as the opposite hip. the extent of the proximal dissection will vary depending on the extent of the tumor involvement ( Fig 36B-12. Bones are osteotomized and the specimen removed.A and B).asp[21/03/2013 21:58:26] . gracilis. It should be such that after the femur-to-pelvis osteosynthesis. as does the deep branch of the peroneal nerve. joint abduction and adduction and any rotation are lost ( Fig 36B-13. ). and the gracilis and sartorius to the peronei. is then removed and submitted to pathology for assessment of margins and degree of tumor necrosis ( Fig 36B-6. Vessels and nerves are then sacrificed as necessary or dissected free and preserved as planned preop-eratively. Skin flaps are then trimmed and closed ( Fig 36B-8. these are now reanastomosed to re-establish circulation to the distal part of the limb. together with their soft tissue and skin covers.). Osteosynthesis of the distal part of the femur is either to the side of the pelvis just cranial to the acetabulum in the case of a disarticulation or to the stump of the ilium in the case of a partial transpelvic amputation. thus converting knee flexion into a new "hip" flexion and knee extension into "hip" extension. Because the knee joint is essentially a one-plane hinge joint rather than a multiplane ball and socket. labeled. and hamstring muscles are divided approximately 5 cm proximal to their insertions and labeled. the semitendinosus to the extensor hallucis longus and extensor digitorum longus tendons. It can be as little as an internal hip disarticulation or as extensive as almost complete internal transpelvic amputation. and the vessels are reanastomosed where required. The muscles are then reattached by suturing the proximal quadriceps to the heads of gastrocnemius and the hamstrings and adductor to the fascia of the anterior and lateral compartments of the leg. adolescents. The tension on these tendons should balance the foot in a neutral position ( Fig 36B-11. and divided. Osteosynthesis is carried out ( Fig 36B-10. The structures to be sacrificed are then divided distally. Association for Osteosynthesis) (AO) plate or intramedullary fixation is carried out between the proximal ends of the femur and tibia. Distally the femur is transected above the knee. The tumor was in the distal portion of the femur in 18 http://www. children.).. The osteosynthesis is carried out with the distal fragment rotated 180 degrees. Proximal Tibial Lesions The technique for the procedure in cases of proximal tibial lesions uses similar skin incisions to the ones described above. The quadriceps tendon is attached to the Achilles tendon and the vastus lateralis to the tendon of the tibialis posterior. all with the diagnosis of osteogenic sarcoma. except that they are based over the distal ends of the femur and tibia. Skin edges are trimmed as needed and the wound closed. but the femoral nerve can be sacrificed if needed. The tendons that control the ankle and foot are identified. The medial and lateral heads of the gastrocnemius are detached from their origins on the distal part of the femur. knee joint. Results Our experience is based on 27 patients. respectively. with the distal fragment being turned 180 degrees ( Fig 36B-7.org/alp/chap36-02. respectively ( Fig 36B-9. The rest of the thigh musculature is removed together with the tumor. Following fixation the foot points directly posteriorly.oandplibrary. the thigh muscles are attached to the tendons of the ankle and foot: the biceps femoris and semimembranosus to the tibialis anterior tendon. This facilitates exposure of the neurovascular bundle in the proximal part of the popliteal fossa. . Proximal Femoral Lesions In lesions of the proximal end of the femur and around the hip joint. The sartorius. An attempt is made to preserve as much of the iliopsoas and gluteus maximus as possible and to later reattach them to the distal stump of the hamstrings and quadriceps.A and B). In the case of vessel resection. The sciatic nerve must be preserved. care being taken not to place the skin under undue tension. and young adults. Finally. The anterior tibial artery almost always has to be divided at its origin. respectively.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library specimen. The rotated ankle again functions as a knee. play soccer. With minimal weight in the cast the patient stands on the spacers. Plumb lines are marked on the wrap anteriorly to record the http://www. The ankle and foot are manipulated into full plantigrade position. no late derotation or psychological decompensation (two frequently mentioned objections to this procedure). and ride bicycles among many other activities. The range of motion of the ankle postoperatively varies with the site of intervention. During the casting procedure the patient should be standing with the limb in a relaxed vertical position and the foot in the utmost plantar flexion ( Fig 36B-15. and no delayed or nonunions. i. Plaster wrap is applied over a tailored cotton stockinette.A-D).. Ten patients required resection of the main vessels with anastomotic repair because of tumor involvement. in the proximal part of the tibia in 8. 5 have died.asp[21/03/2013 21:58:26] .e. Our patients run. The anterosuperior iliac spines must be level. When the plaster is set to moderately bear weight. and in the proximal part of the femur in 1. and the ankle joint should be at a height equal to the level of the center of the knee of the sound leg. These were most likely explained by the early reinstitution of chemotherapy. There was one significant wound breakdown requiring debridement and long-term management. spacers are placed on the floor and are built up to reach the distal end of the plaster wrap. Virtually all of our patients participate actively in sports and athletics. The rest of the patients are alive and well with no evidence of disease. There were no long-term complications related to the rotation-plasty. The prosthetist is required to reset the foot socket alignment only minimally to utilize the additional range of motion gained during the first few weeks of walking with the prosthesis. Several of our patients underwent energy consumption analysis during gait training and demonstrated significantly better functional results over a comparable group of patients with either transfemoral amputation or knee arthrodesis. The removal of a tumor from the femur only slightly affects the muscle motors that drive the ankle and foot. The wrap covers the foot and extends proximal to about 7. The removal of a tumor from the proximal portion of the tibia or fibula temporarily impairs the function of the muscle motors driving the ankle and foot. This patient appeared to have generalized poor tissue healing because he experienced similar breakdown of a thoracotomy wound for resection of metastatic deposits. participate in karate. The prosthetist should delay final completion of the prosthesis until a satisfactory range of ankle motion is realized. Frequent resetting of the foot socket into plantar flexion is necessary. More importantly. 4 of metastatic disease and 1 from a second malignancy (leukemia).36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library patients. below the ischial tuberosity. there have been no local recurrences. baseball. the shelf for the plantar ligament. The procedure was successfully completed in all cases. and the spacers are adjusted accordingly.oandplibrary. His function could not be fully evaluated since he died of metastatic disease 8 months after the original surgery and was in poor physical condition for virtually the whole postoperative interval as chemotherapy and repeat thoracotomies took their toll. Postoperatively we had one deep infection requiring debridement. Therapy and an exercise program to stretch the muscles that are now activating the ankle is of utmost importance. Six patients had minor delayed healing that responded well to local dressings and did not interfere with either chemotherapy or prosthetic fitting. no neurovascular compromises. Function in these patients is approaching the desired and planned-for transtibial amputee level ( Fig 36B-14. ski. the bottom of the heel. many of them competing against their normal-bodied peers.org/alp/chap36-02. and the sole of the foot are hand-molded to achieve an intimate interface. and the weight-bearing areas. ). with the exception of the one patient with wound breakdown and metastatic disease described above. Walking with the prosthesis contributes to improved mobility and strength. and there were no intraoperative complications. Of the 27 patients. All patients with at least 6 months' follow-up became excellent prosthetic users with range of motion in their ankle-knee of at least 70 degrees. Full ankle range of motion can be realized early after the operation.5 cm. . but this had no influence on the eventual outcome. In order to achieve a precise reading. Prosthetic Management To permit ultimate mechanical advantage in the construction of the prosthesis the foot should be rotated precisely 180 degrees. the knee center level of the prostheses is measured. skate. and badminton. The positive mold is removed. The child can approach the activity level of a http://www. When filling the cast with plaster later. layer of plaster. and our work in this area will continue. The foot socket is cemented to a wood base and mounted onto a gait alignment coupling. The lower units of the side hinges are cemented to the foot socket with acrylic resin and glass overlay. Because of the ankle's capability to move in multiple planes.asp[21/03/2013 21:58:26] . The instep strap spans the posterior opening of the foot socket. Both of these factors make standard limb salvage operations such as knee resection. arthrodesis. The areas below the heel and the plantar ligament are reduced and modified to form the weight-bearing shelf. and the foot socket is trimmed to ease entrance for the foot. ). The hinges are contoured to match the outline of the foot socket and the corset. CONCLUSION Limb salvage in skeletally immature individuals presents a number of challenges. ). Recent experiments with a soft and pliable socket limb interface to improve comfort show promise. Dynamic-response feet perform well and are popular with athletes. and the prosthetic foot is attached.oandplibrary. After the plaster is set. The upper side hinges are marked on the corset for future reference. The foot socket is laminated with conventional fabrication procedures. and thus the recorded angles are transferred to the positive. Additional glass reinforcement to strengthen the side hinge mounting area is recommended. Tension is adjustable via the Velcro closure. The axis is positioned horizontally at a level slightly distal to the anatomic medial malleolus and slightly proximal to the anatomic lateral malleolus. During the curing of the resin the hinges are held parallel and at equal level by the hinge alignment fixture module of the transfer jig. and the intimate fit of the side hinges and corset. it exerts the necessary force to the instep of the foot to stabilize the heel on the heel cup shelf ( Fig 36B-16. It must be approximately 1. generous build-ups are applied to the toes. the holding mandrel is set in parallel with the plumb lines. The selection of a suitable prosthetic foot depends on the level of activity of the individual. or internal knee arthroplasty less than optimal options because the child faces significant limitation in physical activities and leg length discrepancy. The leather corset is stretched around the mold and stapled in place. Next the level and external rotation of the prosthetic knee axis is located and marked on the wrap. posterior to the actual rotation of the ankle. ). The cast is removed from the patient and filled with plaster of paris.3 cm.org/alp/chap36-02.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library abduction/adduction angle and laterally to record the flexion/extension angle of the hip. The Van Nes rotation-plasty provides a partial answer to these problems. The prostheses may be completed in the endoskele-tal or exoskeletal configuration ( Fig 36B18. The side hinges and corset ensure lateral stability. The area over the Achilles tendon is padded with Plastazote. The cast-holding mandrel with the positive mold and the fabrication is suspended in a transfer jig and adjusted to permit accurate fixation of the knee hinges to be centered at the protrusions created by the tacks in the mold. an instep strap. The prosthesis is suspended by a heel strap. and the extension stop prevents excessive stretching of the ankle. In addition to providing suspension. the knee axis location marks are transferred by piercing the plaster wrap at these points with a scriber. The most important of these is the high functional demand of the lower limbs in physically active youngsters and the problem of loss of the major growth centers around the knee. The side hinges are assembled. During modifications of the positive mold. Its purpose is twofold. A thumb tack is pressed into place on the medial and lateral knee axis marking. Full-length cosmetic foam fairings are preferred by most female patients. The protruding head of the tack is easily detected after socket lamination and serves to identify the knee hinge location. It is of utmost importance to align the knee axis close to 5 degrees of external rotation in order to achieve a satisfactory swing phase during gait regardless of the physiologic alignment of the ankle. The heel strap attaches on the medial side of the foot socket anterior to the lower side hinge and arches above the heel to a tuck loop on the lateral side of the foot socket. The dynamic alignment procedure follows the conventional technique described for transtibial prostheses with side joints and a corset ( Fig 36B-17. The malleoli are moderately covered with an ?-in. it readily accepts the superimposed forces of the prosthetic knee hinges. and the corset is fastened according to the reference marking. The surgical staging of muscoloskeletal sarcoma. 59:223. Coster P: Total resection of distal femur or proximal tibia for bone tumors. 28:175. 62:1027-1030. Any minor discrepancy can be adjusted by the prosthetic component. Present DA: Functional evaluation of resection-arthrodesis for lesions about the knee. Colorado Springs. http://www. However. It is a dependable procedure with a dependable result. expert prosthetic fitting using a dynamic-response prosthetic foot allows a relatively high degree of athletic participation. May 8. Use of the external prosthesis is. such as in cases of large tumors. for patients who place function ahead of cosmesis and in cases in which the transfemoral amputation is the only other alternative. of course. J Bone Joint Surg [Br] 1979. Enneking WF.oandplibrary. Arch Orthop Un-fallchir 1930. in Proximal Femoral Focal Deficiency: A Congenital Anomaly. As far as the leg length discrepancy is concerned. 1969. p 389. Presented at the Pediatric Orthopaedic Society of North America Annual Meeting. so every new patient who was a candidate for Van Nes rotation-plasty had an opportunity to meet a patient from the network. Shirley PD: Besection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. 62:93-101. J Bone Joint Surg [Am] 1980. The disadvantages of an exoprosthesis and cosmesis are well known. Borggreve J: Knieglenksersaty durch das in der Beinlang-achse um 18 Grad gedrehte Fussgelenk. Autogenous bone grafts and arthrodesis in twenty-six cases. Orthop Prosthet 1980.asp[21/03/2013 21:58:26] . in Enneking WF (ed): Limb Salvage in Musculoskeletal Oncology. Pagani P. Another advantage of the Van Nes rotation-plasty is the low complication rate. New York. Langer F: Large allografts in reconstruction procedures in children.org/alp/chap36-02. Modern. inevitable in a procedure that converts a potential transfemoral amputee to a functional transtibial amputee. Spanier SS. et al: Multiple-drug chemotherapy for the primary treatment of osteosarcoma of the extremities. 65:529-630. Fixsen JA: Rotation-plasty (editorial). Springfield DS. 12:4. in cases with poorly placed biopsy incisions. Most patients were well aware of the appearance and function of the rotation-plasty before surgery. 61:455. cosmesis did not seem to cause a problem. Hall JE. DeBari A.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library transtibial amputee and participate in a number of sporting activities. in tumors involving skin. 1987. J Bone Joint Surg [Am] 1977. or in cases in which other reconstructions have failed. JI: Modified Van Nes rotationplasty for osteosarcoma of the proximal tibia in children. New York. Churchill Livingstone Inc. National Academy of Sciences. Enneking WF. Goodman MA: Current concepts review. Campanacci M. J Bone Joint Surg [Br] 1990. It can be used in cases in which other alternatives are not feasible. BIBLIOGRAPHY Bochmann D: Prosthetic devices for the management of proximal femoral focal deficiency. J Bone Joint Surg [Br] 1980. 72:1065. 1988. Bochmann D: The surgical and prosthetic management of proximal femoral focal deficiency. Bacci G. J Bone Joint Surg [Br] 1983. Enneking WF. Krajbich. Campanacci M. DeBari A. objective psychological evaluation may be a better indicator of this parameter. careful preoperative planning using predicted normal thigh length at skeletal maturity and predicted expected growth in the Van Nes thigh allows the surgical procedure to be performed so that the patient's thighs will be of equal lengths at skeletal maturity. In this study group. Krajbich JI. We now have an established network of patients who have had rotation-plasty. The Van Nes rotation-plasty is a worthwhile alternative for skeletally immature individuals. Cancer 1976. Feb 11. Orthopedics 1987. Watts HG: Introduction to resection of musculoskeletal sarcoma. Prosthetic. Clin Orthop 1990. Hall JE. Antonelli D.Atlas of Limb Prosthetics: Surgical. 1987. J Bone Joint Surg [Am] 1976. Las Vegas. J Bone Joint Surg [Am] 1982. Perry J. J Bone Joint Surg [Am] 1975. 1988. Kristen H. et al: Complications following limb-sparing surgery of the extremities.asp[21/03/2013 21:58:26] . et al: Van Nes rotational osteotomy for treatment of proximal femoral focal deficiency and congenital short femur. 50:613. 256:7-13. Feb 11. McClenaghan BA. Krajbich JI. Gillespie B. Clin Orthop 1991. Sim FH. Chao EYS: Prosthetic replacement of the knee and a large segment of the femur or tibia. Mankin HJ: Massive bone allografts for tumor and other reconstructions in children. the influence of level of amputation. 188:217. Pirone A. Winkelmann WW: Hip rotationplasty for malignant tumors of the proximal part of the femur. Springer Publishing Co Inc. Clin Orthop 1984. 1987. 37:1-11.36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library Jacobs PA: Limb salvage and rotationplasty for osteosarcoma in children. Presented at the Pediatric Orthopaedic Society of North America Annual Meeting. Murphy ML. Proceedings of the International Symposium on Limb Salvage in Musculoskeletal Oncology. Clin Orthop 1980. and prosthetic bone replacement in the treatment of osteogenic sarcoma. Salzer M: Botation-plasty for childhood osteosarcoma of the distal part of the femur. New York. Jaffe KA. et al: Prosthetic management and functional evaluation of patients with resection of the distal femur and rotationplasty. J Bone Joint Surg [Am] 1986. 57:1039. Carroll NC: Van Nes rotationplasty with segmental limb resection. Winkelmann W: Botationplasty for malignant tumors of the femur and tibia. 58:42-46. Biagini B. Bosen G. Las Vegas. Kostuik JP. et al: Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. Contact Us | Contribute http://www. Huvos AG. 10:1241. J Bone Joint Surg [Am] 1979. Mankin HJ. Krajbich JI: Modified Van Nes rotationplasty in the treatment of malignant neoplasms in the lower extremities of children. 68:1331-1337. May 19. Krajbich JI. et al: Chemotherapy. p 153. Chapter 36B . et al: Energy cost of walking of amputees. Toronto. 262:74-77. J Bone Joint Surg [Am] 1986. Kyoto. Sullivan TB. Presented at the Association of American Orthopaedic Surgeons 56th Annual Meeting. et al: Osteoarticular and intercalary allograft transplantation in the management of malignant tumors of bone. Simon MA.org/alp/chap36-02. J Bone Joint Surg [Am] 1989.oandplibrary. 61:887. Gebhardt MC. Bitschl P. 1989. en bloc resection. Kotz B. Waters BL. Japan. 153:31-38. Doppelt SH. Knahr K. Cancer 1980. McDonald JD. 68:362-369. 1989. 64:959. Krajbich JI: The method of predicting the level of the knee in the modified Van Nes rotationplasty. et al: Comparative assessment of gait after limbsalvage procedures. Capanna B. Aschliman MA. 71:1178. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 36B The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . Thomas N. Presented at the American Association of Orthopedic Surgeons 56th Annual Meeting. Recreation. And although these children may still perceive themselves as being physically limited. whether congenital or acquired.org/alp/chap36-03. Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists You can help expand the O&P Virtual Library with a tax-deductible contribution.).Atlas of Limb Prosthetics: Surgical. and far greater opportunities become available to them. and potential injury all contribute to parents' sheltering and/or protecting the child from exposure to seemingly risky or challenging activities. physical challenges are met with success. they learn to take pride in their physical abilities. Prosthetic. Through controlled and guided group activities. Michael JW (eds): Atlas of Limb Prosthetics: Surgical. rejection by peers. Recreation can be a significant factor in eliminating the web of obstacles restricting the person with a disability. 1992. Children are accepted for who they are regardless of disability or illness. Children in these programs return to their environments with renewed and positive energy. They find lifelong sporting activities to enjoy with family and friends ( Fig 36C-1. and their self-image is enhanced. Prosthetic. and concerns. This recognition has a significant impact on a child's development of self-perception and self-esteem. Messner. Not only is acceptance of this physical difference a barrier for the child. IL. but often it is a factor that is difficult for the parents to accept. and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies). Fear of their child's failure. rafting a river or running the Boston Marathon. PHILOSOPHY Children with limb deficiencies. no. common needs. Duane G. Reproduced with permission from Bowker HK.asp[21/03/2013 21:58:30] . and they develop a camaraderie not often found in their mainstreamed environment. 1) and supportive organizations are Medical facilities recognizing the needs of children with limb deficiencies by developing rehabilitative programs outside the confines of the facility. can now occur anywhere that life can be fully tasted-on a mountain. Click for more information about this text. and an improved level of physical fitness often results. (see Annotated Resource List. Prosthetic. edition 2. These programs have proved to have a significant positive impact on the lives and future of these children.oandplibrary.T. Recreational and sporting programs for children with limb deficiencies and other handicapping conditions are designed to promote challenge and achievement within the group.D. and Rehabilitation Principles. American Academy of Orthopedic Surgeons. Their social realm expands. Body integrity is threatened. once confined to institutions and hospital settings with a resulting emphasis on illness. These groups provide a unique opportunity to educate and encourage these children to develop strategies to deal with everyday problems and to take appropriate responsibility for their individual needs. and Fig 36C-2. Since programs for children with limb deficiencies often take place in a facility that nurtures and shows concern for these children. M. They perceive such programs as providing "safe" environments that permit them to let go and allow their children to develop in ways they thought were only available to "able-bodied" siblings and peers. As children share similar experiences. and Rehabilitation Principles Special Considerations: Juvenile Amputees: Sports and Recreation Program Development Carol J. Page. problems and concerns are shared. reprinted 2002.36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library Search GO O&P Library > Atlas of Limb Prosthetics > Chapter 36C Chapter 36C . are conscious of being physically different when they interact with their families and peers. they may hinder children with limb deficiencies from physically exploring their environment to learn and achieve. PROGRAM PLANNING http://www. ©American Academy or Orthopedic Surgeons. the parents may be more inclined to "trust" their child to such a program. P. Rosemont. Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical. they develop a sense of identification within this physically challenged group. Although parents are well meaning. Key elements of program planning include establishing program goals. recommended adaptive aids. including children with resulting amputations (see Annotated Resource List. Park systerns throughout the country are developing trails for the disabled.g. http://www. Participant Selection and Background Information Assessing whether or not a child fits within the program guidelines is important in helping to ensure that all participants achieve optimum benefit from program involvement. staff/volunteer requirements and training needs. 2 and 3). Programs are often developed by specific medical disciplines or organizations according to their patient population needs.asp[21/03/2013 21:58:30] . and training programs (see Annotated Resource List. 4 and 5). Community-based programs have flourished as the needs of disabled populations have gained recognition. identifying resources available to the program. This information helps to determine realistic expectations for the child's participation. positive impact on program success. nos. For example. water sports. no.). determining staffing needs and training requirements. and Fig 36C-4. including camping. level of social functioning.. and better documentation regarding each child's background and needs. and evaluation of the needs required for participation. They can give guidance to program leaders and. and identifying program needs. Individual assessment should include identification of physical ability. considering financial and liability issues. In contrast. can provide activities year-round. programs for children diagnosed and treated for cancer. especially if the program involves sports or recreation. and life-threatening disease progress. Such groups allow a mix of children to develop empathy. precautions and/or contraindications to be considered. National and local organizations (see Annotated Resource List. adaptive equipment. Detailed medical background information on each child is essential. e. winter activities are abundant in the mountainous regions and northern states-both downhill ( Fig 36C-3. Many city-owned botanical gardens have special gardening programs for children and adults with special needs. may be able to provide the actual source for the sports or recreational activity. Most city recreation programs now include a wide variety of activities for all individuals. southern states. and support for one another through group involvement. communication. Participant Population A variety of sporting and recreational programs have been developed for children with limb deficiencies.. Strong parental support also has a significant. determining the participant population.g. The latter can be of great value but requires more planning. the children share many common concerns and needs (see Annotated Resource List. in addition. Existing programs and organizations can be great resources for fledgling programs because they can provide information about established teaching techniques. nos.oandplibrary. Groups for children specifically with limb deficiencies help participants deal with their limb loss but do not focus on providing assistance with dealing with the cause of the deficiency. tennis. 6) have developed resource lists of programs and accessible recreation facilities for disabled persons. Awareness of the impact of the illness and/or the disability on the child and family is also of value.) and cross-country skiing are readily available in these areas. A diagnosis-specific group also allows interaction with qualified staff who can enhance this process. This latter group has identifiable needs in dealing with painful procedures. selecting appropriate participants. nos. there are many factors to consider during the program-planning stages.org/alp/chap36-03. by virtue of their milder climate. Resource Considerations Geographic location and existing community resources are key factors in developing recreation and sports programs.36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library When developing programs for disabled children. 4 and 5). These data provide valuable participant information (e. understanding. long hospitalizations. Successful groups can vary in participant mix. and behavior considerations). Groups that include children with a variety of physical limitations demonstrate that notwithstanding individual diagnoses. and golf ( Fig 36C-5. or may be diagnosis-specific groups. whereas the northern plains may be limited to crosscountry skiing. the need for medical intervention. Program leaders may choose to limit participation to the facility's immediate population or may include children from other facilities and/or the community. 36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library Staffing Needs and Requirements Dedicated staff members committed to providing "a little bit extra" are extremely important. volunteers are essential ( Fig 36C-6.). In most cases. nos. Additional costs may include awards and program souvenirs if not donated by a sponsor. Proof of insurance should be obtained. For the safety and success of the program.oandplibrary.asp[21/03/2013 21:58:30] . Thus. and health screening of the volunteers may be necessary. Although these fees may not cover program costs completely. 4 and 7).org/alp/chap36-03. a payment toward the participation fee has a significant positive impact on participants' and their families' interest and investment in the program. Financial Considerations Operational costs are significant for all sports and recreation programs for the handicapped. 4 and 5). nos. concerns. no. skin concerns. general health and physical fitness. And regardless of the amount of financial aid provided. and salary may not be included. should be considered.. resource contractual fees. Volunteer qualifications should be determined according to the expertise required. Volunteer health screening. If the program is sponsored by a medical facility. And although there are many similarities in teaching techniques and equipment modifications for each disability. Written liability releases from volunteers that acknowledge and waive the program's responsibility for potential risks http://www. and fund-raising events. and behavior management). guidance and supervision are essential for the child's safety and successful participation. Scholarships for program fees may need to be established for participants with documented financial need. and special equipment used for program activities all contribute to program expenditures. Transportation costs. This risk may be higher in the disabled population since this group may experience increased fatigue and diminished endurance. Disabled children competing with their able-bodied peers may fail to recognize their limitations. 7) for camps and recreational activities? (4) Does the outside recreational resource provide adequate liability coverage for the participants and volunteers as well as the facility the program represents? A thorough investigation of this issue must be completed and resolved before the program is initiated. staff must be familiar with and understand the particular needs of each child and identify contraindications. Legal advice regarding liability is an important element of program planning. lower-limb weight-bearing status. For liability protection. and a signed contract may be advisable. prosthetic needs.g. Local companies and philanthropic organizations may be sources for financial scholarships for program participation. they do help to defray expenses. staff must be trained to evaluate the participants for their own unique abilities and needs. programs must contract for services with these or other outside specialty resources. for the betterment of the participant as well as the volunteer. Adequate insurance coverage is necessary. additional liability insurance may need to be obtained to supplement the institutional umbrella. Staff training in a specific activity may be necessary (see Annotated Resource List. and medical needs (e. Liability Issues Some degree of risk is involved in all sports and recreation activities. Some well-established programs may own and operate their own facilities (see Annotated Resource List. and volunteers? (2) Do volunteers need to be accepted into a volunteer association of the sponsoring organization for proper coverage? (3) Are group policies available for purchase from specialty organizations (see Annotated Resource List. Several considerations may need to be investigated: (1) if sponsored by a medical facility. Guidelines and/or job descriptions must be identified in writing. Staff salaries as well as food and lodging may need to be provided. Often medical staff involvement is over and beyond the normal work hours. staff. medical management needs. staff/volunteer training requirements may be specified by the insurance carrier. In addition. and the type of coverage it provides should be reviewed on a regular basis and a copy kept with program files. does participation in a sanctioned activity provide adequate liability coverage for the participating children. Participant fees should also be a consideration. Insurance coverage may need to be purchased. Financial support for program operation may be obtained through grants. donations. (713) 524-1264. Additionally. Transportation Considerations Regulations regarding chauffeuring of clients by staff and volunteers are usually established by the insurance carrier of the sponsoring facility or organization. Since participation in higher-level activities puts increased stress on these devices. These changes include the use of lighter-weight materials and more sophisticated components and designs engineered for increased activity levels.. In all instances.asp[21/03/2013 21:58:30] . Special Love Inc: PO Box 3243. these regulations need to be examined carefully. Pediatrician 1990. adaptation and precaution to preserve the life of the prosthesis. It would be ideal for a child to have a wheelchair.36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library during program participation may be indicated. ).) (see Annotated Resource List. for giving permission to use general information from Page CJ. 80218.. Proof of a chauffeur's license and adequate personal vehicle insurance coverage may be required before a volunteer or staff member may chauffeur any participants. Since children require frequent replacement of these devices for growth. (703) 667-3774. 5. VA 22601.oandplibrary. To participate in recreational activities. and Fig 36C-9. wheelchair. Winchester. parents/guardians of participating children must sign appropriate forms to release the program sponsor and volunteer(s) in matters of emergency care. A nonprofit organization sponsoring special programs for children with cancer. CO. no. and basic program participation. photographic and media releases. SUMMARY Sports and recreation for the juvenile amputee should ideally be an integral part of the total rehabilitation program. or orthosis are imperative. Winter Park. prosthesis. Karger AG. Specialized sports equipment must be proved safe and must be maintained properly. Producer of films featuring sports and recreation for children with handicapping conditions. Printed documentation of the carrier's proof of insurance should be obtained annually. transportation. The Children's Hospital Handicapped Sports Program. Internationally known center for recreational and competitive winter and summer activities for the disabled. TX 77019.org/alp/chap36-03. National Sports Center (NSCD) for the Disabled: PO Box 36. http://www. 4. 1056 E. CO 80482. 17:297-307. 4. ANNOTATED RESOURCE LIST 1. Acknowledgments The authors would like to thank the S. Equipment Needs Specialized equipment enhances the performance and enjoyment of participation in sports and recreation activities for children with limb deficiencies ( Fig 36C-7. Utilizing sports as a means of rehabilitation has a definite positive impact on the child and results in a rewarding experience for both the child and the staff of volunteers who are participating in the rehabilitation process. Houston. they should be considered. the additional expense of specialized sports equipment is unaffordable for many families. Sunshine Kids Foundation: 2902 Ferndale Place. 2. Basel. Specific guidelines have been formulated to achieve this goal. Pearson J: Creating therapeutic camp and recreation programs for children with chronic illness and disabilities. 19th Ave. (303) 726-5514. many children must use their regular appliance(s) ( Fig 36C-10. When program-sponsored transportation is considered. Fig 36C-8. or orthosis to use solely for the purpose of engaging in a sports activity.. Costs often rise dramatically with these changes. publishers of Pediatrician. 3. A nonprofit organization providing unique experiences for children with cancer and their families. instructors. and 8). Although contractual services for transportation with a public carrier add considerable cost to the program. and volunteers must be adequately instructed in its use. Users. the amount of coverage provided should be within the guidelines established by the quality assurance program of the supporting facility. as well as in prosthetics and orthotics. Appropriate safety gear is essential. there continue to be dramatic changes in wheelchair design. Denver. In addition. A facility known for providing organized outward-bound programs for the disabled. Evergreen.org/alp/chap36-03. Colo. Joswick. (303) 453-6424. Cheff Center for the Handicapped: Augusta. Prosthetic. Breckenridge Outdoor Education Center (BOEC): PO Box 697. 17:297-307. 1988. 7. Chicago.oandplibrary.36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library 5. IL 60614. MI 49012. 20850. Cheff Center. (312) 880-4564. Pearson J: Creating therapeutic camp and recreation programs for children with chronic illness and disabilities. and Rehabilitation Principles O&P Library > Atlas of Limb Prosthetics > Chapter 36C The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community . 2300 Children's Plaza. Ronald McDonald Children's Charities: National Directory of Children's Cancer Camps.. National Handicapped Sports (NHS): 451 Hungerford Dr. Rockville. 8. 2. Pediatrician 1990. 3. Chapter 36C . Well-known North American training center for horseback riding for the handicapped. MD. Contact Us | Contribute http://www. Cordillera Press Inc. Breckenridge. O'Leary H: Bold Tracks: Skiing for the Disabled. Augusta.asp[21/03/2013 21:58:30] . et al: Aspects and Answers: A Manual for Therapeutic Horseback Riding Programs. National sports and recreational organization supporting the handicapped with many regional chapters throughout the United States. Winter Park Sports and Learning Center. (301) 217-0960. 1986. 6. Page C. Suite 100. References: 1. Mich.Atlas of Limb Prosthetics: Surgical. Memorial Hospital. CO 80404.