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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
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8B / 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
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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
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34A / Surgical Management 34B / Prosthetic and Orthotic Management 34C / Externally Powered Prostheses 34D / Developmental Approach to Pediatric Upper-Limb Prosthetic Training
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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
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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.
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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 Mnster 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
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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
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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.
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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.
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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.
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
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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. 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. Known as the Hydra-Cadence, this unit retained the swing phase and hydraulic ankle features, but because of the high cost, the stance-phase control feature was not included. Mauch, who along with Henschke had been developing a hydraulically actuated stance-phase control unit under the auspices of the U.S. Air Force since 1946, 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. The swing-phase phase. feature was later incorporated into the stance-phase system (model A) and called the Mauch S 'n' S System, which is the unit available today. Many hydraulic swing-phase units are now available as a result of the research program. To overcome the high costs involved in manufacturing hydraulic units and yet retain the advantages, a pneumatically controlled system designed at the University of California, Berkeley, is now available and known as the UC-BL Pneumatic Swing Control. To eliminate the bulk usually associated with knee disarticulation prostheses, Lyquist in 1973 designed the OHC (Orthopaedic Hospital, Copenhagen) knee unit, which uses a fourbar linkage within the shank to provide an effective knee axis that approximately matches the normal knee axis. The OHC unit, by virtue of the four-bar linkage, is quite stable during stance phase, and it is available with a hydraulically controlled swing-phase system. This principle has been adopted by several manufacturers, and knee units similar to the OHC are used in many transfemoral prostheses as well as knee disarticulation limbs. Other stance-phase controls have been developed by commercial organizations. These are essentially mechanical systems with an incremental resistance added upon weight bearing.
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. 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. An outstanding achievement of the early years was the "Navy ankle" developed by the Naval Prosthetic Research Laboratory in Oakland, California. This ankle contained a block of rubber with variable stiffness to control motions in all three planes. However, excessive maintenance prevented it from being a commercial success. The Greissinger foot, developed in Germany to offer the kind of function provided by the Navy unit, has commonly been used to provide "three-way action." Meanwhile the introduction of the SACH (solid ankle, 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. To retain most of the simplicity of the SACH foot while providing some of the function of three-way feet, John Campbell developed and introduced in the late 1970s the SAFE (stationary attachment-flexible en-doskeletal) foot, which proved to be well accepted in spite of a slight increase in weight over the SACH foot. The Prosthetic Research Study at the University of Washington, in an effort to provide the athletic lower-limb amputee with more function, pioneered the concept of energy-storing feet with the introduction of the "Seattle" foot in the early 1980s. 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, and several competitive designs are now available and used widely, especially the Carbon Copy II. 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.
Endoskeletal Prostheses
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During the first decade of the U.S. 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, poorly fitting sockets mounted on peg legs. However, 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, the idea of temporary prostheses was revived. Pylons, or endoskeletal prostheses, with adjustment features began to appear about 1960. Staros established the criteria for their use as temporary limbs. Their use was then accelerated by immediate postsurgical fitting studies, and various designs began to appear on both sides of the North Atlantic, the ultimate concept being an adjustable endoskeletal structure that could be carried over into the definitive prosthesis, the "pylon" being covered with a resilient foam shaped to match the contralateral leg. These designs, usually referred to as modular en-doskeletal limbs, have gradually had more and more success despite the difficulty in shaping and maintaining their foam covers. They have become the norm rather than an alternative.
External Power
Although some work was done in Germany earlier, it was Alderson who, with support from the United States government and International Business Machines, developed the first working model of an electrically powered artificial arm, which appeared about 1949. Demonstrations were impressive, but evaluations at New York University and UCLA in 1953 revealed that amputees could not operate any of the designs without conscious thought, primarily because the sensory feedback so necessary for automatic or semiautomatic operation was not adequate. For this reason, the development of devices was discontinued at that time, and some effort was put into a study of sensory feedback.
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In 1958 Russian workers announced that a "thought-controlled" artificial arm had been perfected, 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. Again, adequate feedback signals were lacking. Rights to manufacture these devices were purchased by groups in Canada and Great Britain, but these units were never widely accepted. However, Otto Bock Orthopaedic Industry, Inc., in Germany and Viennatone in Austria made versions of the Russian design available that they marketed with some success. An interesting design was proposed in Yugoslavia but was never carried to fruition. 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. New socket designs for transradial amputees that provide self-suspension were developed, thus eliminating the need for any wiring or harness above the elbow. created a great deal of interest in externally powered prostheses, The thalidomide tragedy Sweden, England, and Canada, beginning about 1960. Initial efforts especially in Germany, in Germany centered around pneumatically operated prostheses, and by arrangement with in the United States undertook the University of Heidelberg, Kessler and Kiessling complementary development work. Results on some severely disabled adults and children were impressive, but a lack of funds curtailed this effort in 1968. Simpson in Edinburgh used pneumatic prostheses of his own design quite successfully for severely disabled children, but the design did not get beyond the United Kingdom. During the 1980s the application of externally powered upper-limb prostheses gradually increased, and such prostheses are no longer novelties. Now available, in addition to the Utah arm for transhumeral amputees, are electric elbows for children and youths from Variety Village in Toronto, Canada; controls developed at the University of New Brunswick, Canada; the Liberty Mutual electric elbow; artificial hands from Otto Bock; and other devices that can be assembled in prostheses to meet the particular needs of individual patients.
Special Procedures
The idea of harnessing a muscle directly to power an arm prosthesis (Vanghetti in Italy, in Germany, and Bosch Arana in Argentina) appealed to a Sauerbruch and ten Horn number of investigators in the United States immediately after World War II. After extensive investigation of use of muscle tunnels through the wrist flexors and extensors in transradial amputees, biceps and triceps in transradial and transhumeral amputees, and pectoral muscles in transhumeral and shoulder disarticulation cases, the only practical system that could be Although many devised was one involving the biceps tunnel for the transradial amputee. kine-plasty procedures were performed, 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. 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. The Krukenberg procedure, 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, was originated in Germany and is used there today, especially for blind amputees because of the sensory feedback provided. Because of its somewhat grotesque appearance, the Krukenberg procedure is seldom used in the United States despite the success reported by Swanson.
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teamwork between the two disciplines would result in improved service, little was done until 1949 when the Veterans Administration PSAS organized 30 amputee clinic teams consisting of a surgeon, prosthetist, physical therapist, occupational therapist, and prosthetics representative. While this experimental teaching program on the suction socket was being carried out and the clinic teams were being formed, a body of knowledge in upper-limb prosthetics was being accumulated at UCLA. A rationale for socket and harness design was developed for every level of amputation in the upper limb, including shoulder disarticulation and the forequarter amputation. Components that could be selected and assembled to meet the individual needs of upper-limb amputees were designed and tested, and most were available through regular commercial channels. 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. With financial assistance from the Veterans Administration, UCLA initiated a series of formal 6-week courses in upper-limb prosthetics for the amputee clinic teams in 1952. Twelve of these courses were offered to clinicians in the United States on a regional basis during 1953 and 1954 with tremendous success. Private as well as Veterans Administration teams attended. Approximately 140 Veterans Administration and private teams were trained. Because the Veterans Administration teams, almost without exception, consisted of surgeons and prosthetists in private practice, the results of the training program reached the nonveteran population as well, and private clinics were established throughout the United States and Canada. 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, Berkeley, Biomechanics Laboratory. A pilot school based on this material and presented to leading prosthetists, surgeons, and therapists in Berkeley in 1955 led the way to establishing formal courses in 1956 at UCLA in transfemoral prosthetics for practicing clinic teams. Because UCLA could not meet the needs of the country with respect to the number of teams that desired training, the Veterans Administration sponsored the establishment of a Prosthetics Education Program at New York University in the Post-Graduate Medical School in 1956. To provide a similar facility in the Midwest the Office of Vocational Rehabilitation (now Rehabilitation Services Administration) of the Department of Health, Education, and Welfare sponsored the establishment of the Prosthetic Education Program at Northwestern University in 1959. Over the years, these three universities were joined by others to provide preparatory education programs in all aspects of prosthetics. The nationwide program reached a peak in the late 1980s when 12 universities offered preparatory education programs in prosthetics and orthotics. Five were at the baccalaureate level, and 7 offered One baccalaureate and 1 certificate program were discontinued certificates of completion. in 1991 owing to a lack of fiscal support from the federal government. 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).
SUMMARY
The development of artificial limbs and amputation surgery has had a long history, stimulated mostly by the aftermath of war. There seems to have been little progress made between the American Civil War and World II, although World War I did arouse a small flurry of interest that had little effect on clinical practice. However, considerable progress, led for some years by the United States, has been made throughout the world since World War II. The U.S. 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. References: 1. Aitken GT: Hazards to health, etiology of traumatic amputations in children. N Engl J Med 1961; 265:133-134. 2. Alderson SW: The electric arm, in Klopsteg PE, Wilson PD: Human Limbs and Their Substitutes. New York, McGraw-Hill International Book Co, 1954. Reprinted by Hafner Press, New York, 1960.
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3. American Academy of Orthotists and Prosthesists- American Orthotic and Prosthetic Association: Orthotics/ prosthetics education issue. J Prosthet Orthot 1990; 2. 4. Anderson MH, et al: Prosthetic Principles, Above-Knee Amputations. Springfield, Ill, Charles C Thomas Publishers, 1960. 5. Arbogast R, Arbogast CJ: The Carbon Copy II-from concept to application. J Prosthet Orthot 1988; 1:32-36. 6. Bechtol CO, Aitken GT: Cineplasty, in American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas, vol 2. Ann Arbor, Mich, Edwards Brothers, 1960. 7. Bell CA: Canadian hip disarticulation prosthesis. Orthop Prosthet Appliance J 1956; 10:35-39. 8. Berger N: The ISNY (Icelandic-Swedish-New York) flexible above-knee socket, in Donovan RG, et al (eds): International Workshop on Above-Knee Fitting and Alignment- May 1987. International Society for Prosthetics and Orthotics, Miami, 1987. 9. Berlemont M, Weber R, Willot JP: Ten years of experience with the immediate application of prosthetic devices to amputees of the lower extremities on the operating table, Prosthet Orthot Int 1969; 3:8-18. 10. Bier A: Uber amputationen und exarticulation. Chirurgie 1900; 78:1439-1474. 11. Borchardt M, et al (eds): Ersatzglieder und Arbeitshilfen. Berlin, Springer-Verlag, 1919. 12. Bosch Arana G: Kineplastic amputations: Arm bimotor and a prosthesis. Surg Gynecol Obstet 1926; 42:416-420. 13. Brav EA, et al: Cineplasty, an end-result study. J Bone Joint Surg [Am] 1957; 46:5976. 14. Burgess E, Traub JE, Wilson AB Jr: Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees, Washington, DC, Veterans Administration, 1967. 15. Carnelli WA, DeFries MG, Leonard J: Color realism in the cosmetic glove. Artif Limbs 1955; 2:57-65. 16. Ceci A: Amputations cineplastiques des membres su-perieurs (Cineplastic amputations of the upper extremity). Presse Med 1906; 14:745-747. 17. Childress D, Billock JN: Self-containment and self-suspension of externally powered prostheses for the forearm. Bull Prosthet Res 1970; 10:4-21. 18. Committee on Artificial Limbs, National Research Council: Terminal Research Reports on Artificial Limbs (Covering the Period From April 1, 1945, Through June 30, 1947). National Research Council, Washington, DC, 1947. 19. Committee on Prosthetic Research and Development: Immediate Postsurgical Fitting of Prostheses - Report of a Workshop. Washington, DC, National Academy of Sciences, 1986. 20. Dederich R: Amputationsstumpf Krankheiten und ihre chirurgische Behandlung. Mschr Unfallheilk 1960; 63:101. 21. DeFries MG: Sizing of Cosmetic Hands to Fit the Child and Adult Population. Washington, DC, U.S. Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, Technical Report No. 5441, 1954. 22. Donovan RG, Pritham C, Wilson AB Jr (eds): International Workshop on Above-Knee Fitting and Alignment- May 1987 and Workshop on Teaching Material for Above-Knee Socket Variants- October 1987. International Society for Prosthetics and Orthotics, Miami, 1987. 23. Durr-Fillauer Medical, Inc, Orthopedic Division, 2710 Amnicola Highway, Chattanooga, TN 37406. 24. Eberhart HD, Inman VT, Dec JB, et al: Fundamental Studies of Human Locomotion and Other InformationRelating to the Design of Artificial Limbs, a Report to the National Research Council. Berkeley, Calif, Committee on Artificial Limbs, University of California, 1947. 25. Eberhart HD, McKennon JC: Suction-socket suspension of the above-knee prosthesis, in Klopsteg PE, Wilson PD: Human Limbs and Their Substitutes. McGraw-Hill International Book Co, New York, 1954. Reprinted by Hafner Press, New York, 1960. 26. Ertl J: Uber amputationsstumpfe. Chirurgie 1949; 20:218-224. 27. Esslinger JO: A basic study in semiburied implants and osseous attachments for application in amputation prostheses. Bull Prosthet Res 1970; 10:219-225. 28. Fletcher MJ: Problems in designing of artificial hands. Orthop Prosthet Appliance J 1955; 9:59-68. 29. Frantz CH: An evolution in the care of the child amputee. Artif Limbs 1966; 10:1-4. 30. Garrison FH: An introduction to the History of Medicine. Philadelphia, WB Saunders Co, 1963. 31. Golbranson FL, Asbelle C, Strand D: Immediate postsurgical fitting and early ambulation. Clin Orthop 1968; 56:119-131.
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32. Goldner JL, Clippinger FW Jr, Titus BR: Use of Temporary Plaster or Plastic Pylons Preparatory to Fitting a Permanent Above Knee or Below Knee Prosthesis. Final Report of Project No. 1363 to (U.S.) Vocational Rehabilitation Administration by Duke University Medical Center, Durham, NC, 1967. 33. Haddan CC, Thomas A: Status of the above-knee suction socket in the United States. Artif Limbs 1954; 4:29-39. 34. Hall CB, Bechtol CO: Modern amputation technique in the upper extremity. J Bone Joint Surg [Am] 1963; 45:1717-1722. 35. Hall CW, Cox PH, Mallow WA: Skeletal extension development: Criteria for future designs. Bull Prosthet Res 1976; 10:69-96. 36. Inman VT, Ralston HJ: The mechanics of voluntary muscle, in Klopsteg PE, Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill International Book Co, 1954. Reprinted by Hafner Press, New York, 1960. 37. Kay HW, Newman JD: Relative incidences of new amputations. Orthot Prosthet 1975; 29:3-16. 38. Kessler HH, Kiessling EA: Pneumatic arm prosthesis. Am J Nurs 1965; 65:114-117. 39. Kobrinski AE, Bolhovitin SV, Voskoboinikova LM, et al: Problems of bioelectric control in automatic and remote control, in Proceedings of the First International Congress of the International Federation of Automatic Control, Moscow, 1960, vol 2. Butterworth, London, 1960. 40. Kristinsson O: Flexible sockets and more, in Donovan RG, et al (eds): International Workshop on Above-Knee Fitting and Alignment May 1987. International Society for Prosthetics and Orthotics, Miami, 1987. 41. Loon HE: Below-knee amputation surgery. Artif Limbs 1962; 6:86-99. 42. Lyquist E: The OHC knee-disarticulation prosthesis. Orthot Prosthet 1976; 30:27-28. 43. Marquardt E: Heidelberg pneumatic arm prosthesis. J Bone Joint Surg [Br] 1965; 47:425-434. 44. McLaurin CA: The evolution of the Canadian-type hip-disarticulation prosthesis. Artif Limbs 1957; 4:22-28. 45. Mercer W: Syme's amputation, J Bone Joint Surg [Br] 1956; 37:611-612. 46. Michael JW: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987; 11:154-172. 47. Michael JW: Upper limb powered components-current concepts. Clin Prosthet Orthot 1986; 10:66-74. 48. Mondry F, Der muskelkraftige ober- und underschenkel-stumpf. Chirurgie 1952; 23:517. 49. Mooney V: Personal communication, 1978. 50. Mooney V, Snelson R: Fabrication and application of transparent sockets. Orthot Prosthet 1972; 26:1-13. 51. Motis GM: Final Report on Artificial Arm and Leg Research and Development. Final Report to the National Research Council, Advisory Committee on Artificial Limbs, Hawthorne, Calif, Northrop Aircraft Inc, 1951. 52. Murdoch G (ed): Amputation Surgery and Lower Limb Prosthetics. Boston, Blackwell Scientific Publications Inc, 1988, pp 335-336. 53. Murphy EM: Lower-extremity components, in American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas, vol 2. Ann Arbor, Mich, Edwards Brothers, 1960. 54. Pare A: Oeuvres Completes, vol 1. Paris, Edition Mal-gaigne, 1840, pp 616-621. 55. Pederson HE: The problem of the geriatric amputee. Artif Limbs 1968; 12:1-3. 56. Pritham CH: Above-knee flexible sockets-the perspective from Durr-Fullauer, in Donovan RG, et al (eds): International Workshop on Above-Knee Fitting and Alignment- May 1987. International Society for Prosthetics and Orthotics, Miami, 1987. 57. Radcliffe CW, Foort J: Patellar-Tendon-Bearing Below-Knee Prosthesis, Berkeley, Calif, Bioengineering Laboratory, University of California Press, 1961. 58. Rakic M: Practical design of a hand prosthesis with sensory elements. Presented at the International Symposium of the Application of Automatic Control in Prosthetics Design, Belgrade, Yugoslavia, Aug 27-31, 1962. 59. Sauerbruch F, ten Horn C: Die willkurlich bewegbare kunstliche Hand (artificial hand capable of voluntary movement). Berlin, Springer-Verlag, 1923. 60. Saunders C, et al: The CANFIT system: Shape management technology for prosthetic and orthotic applications. J Prosthet Orthot 1989; 1:122-130. 61. Selincourt A (ed): Herodotus, the Histories. New York, Penguin Books, 1954. 62. Simpson DC: Powered upper arm prostheses for young children (digest). Presented at the Sixth International Conference on Medical Electronics and Biological Engineering, Tokyo, 1965.
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63. Staros A: The temporary prosthesis for the above-knee amputee, in The Geriatric Amputee, Publication 919. Washington, DC, National Academy of Sciences, 1961. 64. Staros A, Peizer E: Northwestern University intermittent mechanical friction system (disk-type). Artif Limbs 1965; 9:45-52. 65. Swanson AB: The Krukenberg procedure in the juvenile amputee. J Bone Joint Surg [Am] 1964; 46:1540-1548. 66. United States Army, Surgeon General's Office, Commission on Amputations and Prostheses: Report on European Observations. Washington, DC, 1946. 67. Vanghetti G: Plastica dei monconi a scopo di protesi cine-matica (plastic surgery of stumps for cinematic prostheses). Arch Ortop 1899; 41:305, 385. 68. Veterans Administration, Prosthetic and Sensory Aids Service: Clinical Application Study of the Dupaco "Hermes" hydraulic Control Unit. New York, TR-4, 1965. 69. Veterans Administration, Prosthetic and Sensory Aids Service: Clinical Application Study of the Henschke-Mauch "Hydraulik" Swing Control System, New York, TR-3, 1964. 70. Veterans Administration, Prosthetic and Sensory Aids Service: Clinical Application Study of the Hydra-Cadence Above-Knee Prosthesis. New York, TR-2, 1963. 71. Weiss M, Gielzynski A, Wirski J: Myoplasty Immediate Fitting Ambulation. New York, International Society for Rehabilitation of the Disabled (Reprint of paper presented at the sessions of the World Commission on Research in Rehabilitation, Tenth World Congress of the International Society for Rehabilitation of the Disabled, Wiesbaden, Germany, September 1966). 72. Wilson AB Jr: Limb Prosthetics, ed 6. New York, Demos Publications, 1989. 73. Wilson AB Jr: Lower-limb modular prostheses: A status report. Orthot Prosthet 1975; 29:23-32. 74. Wilson AB Jr: Prostheses for Syme's amputation. Artif Limbs 1961; 6:52-75. 75. Wilson AB Jr: Recent advances in above-knee prosthetics. Artif Limbs 1968; 12:1-27. 76. Wilson AB Jr, Stills M: Ultra-light prostheses for below-knee amputees, Orthot Prosthet 1976; 30:43-47. 77. Zanoli R: Krukenberg-Putti amputation-plasty. J Bone Joint Surg [Br] 1957; 39:230232.
Chapter 1 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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expectation of a good outcome based on technological advances is offset by the cost of many of the more advanced procedures. While this dichotomy cannot be ignored, the fact remains that prosthetic replacement following amputation falls far short in restoration of motor and sensory function. Until this situation changes, limb salvage rather than amputation should be the goal, provided that the salvaged limb is functionally better than its prosthetic counterpart.
Chapter 2A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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reality. As orthopedic traumatology developed into a subspecialty, surgeons began to view amputation of a mangled lower limb as an admission of defeat. Salvage of even the most complex injury became technically possible. Published reports of these heroic procedures, however, did not clearly define the nature and severity of the skeletal injury, and little was written about long-term results. Additionally, decision-making alogorithms for amputation vs. salvage were considered unnecessary.
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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.
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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
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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
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2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library
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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.
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.
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
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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.
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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.
Interventional Radiology
A further, small number of patients may be suitable for percutaneous angioplasty (PTA),
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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
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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.
Infection
In patients with PVD, "dry" gangrene is a result of reduced arterial inflow or stasis in the
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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.
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
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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.
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 m 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.
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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.
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.
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There are several major problems that can be identified when attempting to analyze data relating to amputation level selection. Principal among these is the enormous variation in approach on the part of physicians. Specifically, if the benefits of a certain test to predict healing in transtibial amputations are to be examined, then the optimum conditions under which that amputation is to be performed must be provided. This is certainly not the case in many of the published series, which renders much of the accumulated data of dubious value. One obvious example of this issue is the problem of who performed the amputation. In many cases, it is undoubtedly not the most experienced surgeon available. The second major area concerns clinician prejudices. Where there is a partiality for trans-femoral amputations in a unit, 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. This is a particularly important area because transfemoral/transtibial amputation ratios vary enormously from region to region and country to country. Again, if there is a predilection for primary amputation rather than attempted reconstructive surgery, a better amputation healing rate may be attained because many of these patients would not have strictly "end-stage" PVD. In other words, some would undoubtedly be technically reconstructable with one or more patent tibial vessels. In these instances, any attempt to perform noninvasive vascular tests is largely irrelevant because most amputations in such patients will heal. It is only when surgery is being performed at the edge of tissue viability that sophisticated evaluation techniques have a valuable role to play. Therefore, 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. 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, and results are difficult to reproduce. Therefore, while they may provide useful data for a particular specialist unit, the methods often prove quite difficult to duplicate effectively elsewhere. In particular, no one method has proved completely reliable for the purposes of partial-foot amputations, although skin perfusion pressure techniques appear to be most predictive. 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. For general purposes, the single most readily available (and cheapest) test is undoubtedly Doppler-de-rived systolic pressure measurement. Although relatively insensitive, 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. With this reference, many transfemoral amputations could probably be avoided, with few transtibial failures as a consequence. It is probably only in those limbs with marginal skin flap viability that other techniques of evaluation have a major role to play. Of these, skin blood flow measurements would seem to offer the most precise objective criteria. Although skin blood flow is a local measurement and therefore not necessarily representative of the blood flow in an entire region, multiple skin blood flow measurements appear to be more dependable and A mean skin blood flow of less than 2.5 mL/100 mg/min may correlate well with outcome. be regarded as likely to result in flap failure. It is probably worth corroborating these data with some other regional methodology to look for specific well-vascular-ized flaps. Fluorescein angiography or thermography offers the best methods for this approach, with fluorom-etry perhaps being much cheaper although more difficult to perform and interpret. It is clear that clinical assessment alone is inadequate for the majority of surgeons in decision making for amputation surgery, and therefore adjunctive preoperative laboratory testing has become a crucial part of any amputation service that is committed to preserving limb length.
CONCLUSIONS
The dilemma facing the present-day physician regarding critically ischemic limbs is increasing rather than disappearing. 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. Although this prejudice can be unreasonable at times, successful surgical revascularization of a critically ischemic limb is the optimum management in the vast majority of such patients. 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. These patients are, in general, obvious to the clinician and require only good nursing and analgesia to keep them comfortable. The main difficulty lies in the group of patients in whom it is not clear whether a primary amputation or revascularization should be attempted.
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There are several rules of thumb that may be used in this difficult group, however. Where tissue necrosis has impinged upon the midtarsal area or hindfoot, 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. Occasionally, 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, but these cases are very few. Indeed, it is likely that unless partial-foot amputation can be confined to the digital or transmetatarsal level after revascularization, primary transtibial amputation should be undertaken. Fortunately, the vast majority of limbs with CLI may be salvaged with no amputation or else "minor" partial-foot amputation. These patients have a very limited life span, and prolonged reconstruction, amputation, and rehabilitation should be avoided if they are not to spend most of the rest of their lives in hospital. Conversely, it is obvious that there are still many legs being lost to major amputation without sufficient thought being given to revascularization. In the absence of prior vascular reconstruction or pure diabetic microangiopathy, the lowest level that should ever be contemplated for primary amputation is the transtibial level. This is simply because if a more distal level is to heal, there must be at least one reasonable tibial or pedal vessel patent and therefore distal revascularization should be possible. Patient expectations and improvements in therapeutic options have changed our approach to the patient with end-stage lower-limb vascular disease today. 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. The approach to these patients must of necessity involve a multidisciplinary team, with each member realizing the limits of his own expertise. Inevitably, the patient can only benefit from such a team approach. References: 1. Beard J, Scott DJ, Evans JM, et al: Pulse generated run off: A new method of determining calf vessel patency. Br J Surg 1988; 75:361. 2. Bell PRF: Are distal vascular procedures worthwhile? Br J Surg 1985; 72:355. 3. Bounameaux H, Verhaeghe R, Verstraete M, et al: Thromboembolism and antithrombotic therapy in peripheral arterial disease. J Am Coll Cardiol 1986; 8:98. 4. Burgess EM, Matsen FA, Wyss CR, et al: Segmental transcutaneous measurements of po 2 in patients requiring below-the-knee amputation for peripheral vascular insufficiency. J Bone Joint Surg [Am] 1982; 64:378. 5. Burgess EM, Matsen FA: Determining amputation levels in peripheral vascular disease. J Bone Joint Surg [Am] 1981; 63:1493. 6. Cina C, Katsamouris A, Megerman J, et al: Utility of transcutaneous oxygen tension measurements in peripheral arterial occlusive disease. J Vase Surg 1984; 1:362. 7. Cooper JC, Welch CL: The role of transluminal angioplasty in the treatment of critical limb ischaemia. Eur J Vase Surg 1990; 4:449. 8. Corson JD, Karmody AM, Sham DM, et al: In situ vein bypasses to distal tibial and limited outflow tracts for limb salvage. Surgery 1984; 96:756. 9. Cronenwett JL, Zelenock GB, Whitehouse WM Jr, et al: Prostacycline treatment of ischaemic ulcers and rest pain in unreconstructable peripheral arterial occlusive disease. Surgery 1986; 100:369. 10. Department of Health and Social Security: Amputation Statistics for England, Wales and Northern Ireland (1986). London HMSO, 1990. 11. Dormandy J: Natural history of intermittent claudication. Hosp Update 1991; 314. 12. Dormandy J, Mamir M, Ascady G, et al: Fate of the patient with critical leg ischaemia. J Cardiovasc Surg 1989; 30:50. 13. Dormandy JA, Stock G: Definition and epidemiology of chronic critical limb ischaemia, in Dormandy JA, Stock G (eds): Critical Leg Ischaemia; Its Pathophysiology and Management. Berlin, Springer-Verlag, 1990. 14. Dotter CT, Judkins MP: Transluminal treatment of arteriosclerotic obstruction. Description of a new technique and a preliminary report of its application. Circulation 1964; 30:654. 15. Dowd GSE, Linge K, Bentley G, et al: Measurement of transcutaneous oxygen pressure in normal and ischaemic skin. J Bone Joint Surg [Br] 1983; 65:79. 16. Fletcher JP, Fermanis GG, Little JM, et al: The role of percutaneous transluminal angioplasty and femoro-popli-teal bypass in patients with threatened limb. J Vase Surg 1988; 8:226. 17. Gaines PA, Beard JD: Radiological management of acute limb ischaemia. Br J Hosp
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Med 1991; 45:343. 18. Griintzig A, Hopff H: Perkutane Rekanalisation chron-isher arterieller Verschliisse mit einem neuen Dilatation-skatheter. Modification der Dotter-Technik. Dtsch Med Wochenschr 1974; 99:2502. 19. Hammersgaard E, Baadsgaard K: Healing of below knee amputations in relation to perfusion pressure of skin. Acta Orthop Scand 1977; 48:335. 20. Harris P, Read F, Eardley A, et al: The fate of the elderly amputee. Br J Surg 1974; 61:665. 21. Harris P, Moody P: Amputations, in Dormandy JA, Stock G (eds): Critical Leg Ischaemia; Its Pathophysiology and Management. Berlin, Springer-Verlag, 1990. 22. Harward TRS, Volny J, Golbranson F, et al: Oxygen inhalation-induced transcutaneous po 2 changes as a predictor of amputation level. J Vasc Surg 1985; 2:220. 23. Hess H, Mietaschk A, Deischel G, et al: Drug induced inhibition of platelet function delays progression in peripheral occlusive arterial disease. A prospective double blind arteriographically controlled trial. Lancet 1985; 1:415. 24. Hess H, Mietaschk A, Brucki R, et al: Peripheral arterial occlusions: A 6-year experience with local low-dose thrombolytic therapy. Badiology 1987; 163:753. 25. Holloway GA, Burgess EM: Preliminary experience with laser Doppler velocimetry for the determination of amputation levels. Prosthet Orthot Int 1983; 7:63. 26. Holstein P: Distal blood pressure as guidance in choice of amputation level. Scand J Clin Lab Invest 1973; 31:245. 27. Holstein P, Lund P, Larsen B, et al: Skin perfusion pressure measured as the external pressure required to stop isotope washout. Scand J Clin Lab Invest 1977; 37:649. 28. Kannel WB, McGee DI: Update on some epidemiological features of intermittent claudication. J Am Geriatr Soc 1985; 33:13. 29. Ketty SS: Measurement of regional circulation by the local clearance of radioactive Sodium. Am Heart J 1949; 38:321. 30. Lepantalo M, Isoniemi H, Kyllonen L, et al: Can the failure of a below knee amputation be predicted? Ann Chir Gynaecol 1987; 76:119. 31. Lusby RJ, Wylie EJ:. Acute lower limb ischaemia: Pathogens and management. World J Surg 1983; 7:340. 32. McCollum PT, Walker WF, Spence VA, et al: Amputation for peripheral vascular disease: The case for level selection. Br J Surg 1988; 75:1193. 33. McCollum PT, Spence VA, Walker WF, et al: Antipyrine clearance from the skin of the foot and the lower leg in critical ischaemia: Clinical implications, in Spence VA, Sheldon CD (eds): Practical Aspects of Skin Blood Flow Measurement. London, Biologic Engineering Society, 1985. 34. McCollum PT, Spence VA, Walker WF, et al: A rationale for skew flaps in amputation surgery. Prosthet Orthot Int 1985; 9:100. 35. McCollum PT, Spence VA, Walker WF, et al: Circumferential skin blood flow measurements in the ischaemic lower limb. Br J Surg 1985; 72:310. 36. McCollum PT, Kent P, O'Driscoll K, et al: Intravenous oxpentifylline in the treatment of rest pain. Ann Vase Surg 1989; 3:220. 37. McCollum PT, Spence VA, Walker WF, et al: Oxygen induced changes in the skin as measured by transcutaneous oxymetry. Br J Surg 1986; 73:882. 38. McFarland DC, Lawrence PF: Skin fluorescence, a method to predict amputation site healing. J Surg Res 1982; 32:410. 39. Mehta K, Hobson RW, Jamil Z, et al: Fallibility of Doppler ankle pressure in predicting healing of transmetatar-sal amputation. J Surg Res 1980; 28:466. 40. Miller JH, Foreman RK, Ferguson L, et al: Interposition vein cuff technique for anastomosis of prosthesis to small artery. Aust N Z J Surg 1984; 54:283. 41. Moore WS, Henry RE, Malone JM, et al: Prospective use of xenon Xe-133 clearance for amputation level selection. Arch Surg 1981; 116:86. 42. Neilsen PE, Poulsen HL, Gyntelberg F, et al: Arterial blood pressure in the skin measured by a photoelectric probe and external counterpressure. Vasa 1973; 2:65. 43. Norgen L: Non-surgical treatment of critical limb ischaemia. Eur J Vase Surg 1990; 4:449. 44. Ratcliff DA, Clyne CAC, Chant ADB, et al: Prediction of amputation wound healing: The role of transcutaneous po 2 assessment. Br J Surg 1984; 71:219. 45. Ristkari SKK, Vorne M, Mokka REM, et al: Early assessment of amputation level in frostbite by 99m Tc pertechne-tate scan. Acta Chir Scand 1988; 154:403. 46. Robbs JV, Ray R: Clinical predictors of below knee stump healing following amputation for ischaemia. S Afr J Surg 1982; 20:305. 47. Romano RL, Burgess EM: Level selection in lower extremity amputations. Clin Orthop
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2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library
1971; 74:177. 48. Roon AJ, Moore WS, Goldstone J, et al: Below knee amputation: A modern approach. Am J Surg 1977; 134:153. 49. Rutherford RB, Patt A, Pearce WH, et al: Extra-anatomical bypass: A closer view. J Vase Surg 1987; 6:437. 50. Rutherford RB, Jones DN, Bergensz SE, et al: Factors affecting the patency of infrainguinal bypass. J Vase Surg 1988; 8:236. 51. Samson RH, Gupta SK, Scher LA, et al: Treatment of limb-threatening ischaemia despite a palpable popliteal pulse. J Surg Res 1982; 32:535. 52. Schwartz JA, Schuler JJ, O'Connor RJA, et al: Predictive value of distal perfusion pressure in the healing of amputation of the digits and the forefoot. Surg Gynecol Obstet 1982; 154:865. 53. Silverman DG, Roberts A, Reilly CA, et al: Fluorometric quantification of low-dose fluorescein delivery to predict amputation site healing. Surgery 1987; 101:335. 54. Spence VA, McCollum PT, McGregor IW, et al: The effect of the transcutaneous electrode on the variability of dermal oxygen skin tensions. Clin Phys Physiol Meas 1985; 6:139. 55. Szilagyi DE, Mageman JH, Smith RF, et al: Autogenous vein grafting in femoropopliteal atherosclerosis: The limits of its effectiveness. Surgery 1979; 86:836. 56. Taylor RS, McFarland RJ, Cox MI, et al: An investigation into the patency of PTFE grafts. Eur J Vasc Surg 1987; 1:335. 57. Thyregod HC, Holstein P, Steen Jensen J, et al: The healing of through-knee amputations in relation to skin perfusion pressure. Prosthet Orthot Int 1983; 7:61. 58. 58.Verstraete M, Vermylen J, Donati MB, et al: The effect of streptokinase infusion on chronic arterial occlusions and stenoses. Ann Intern Med, 1971; 74:377. 59. Welch GH, Leiberman DP, Pollock JG, et al: Failure of Doppler ankle pressure to predict healing of conservative forefoot amputations. Br] Surg 1988; 72:888. 60. Widmer LK, Greensher A, Kanwel WB, et al: Occlusion of peripheral arteries-a study of 6400 working subjects. Circulation 1964; 30:836. 61. Wilson SB, Spence VA: Dynamic thermographic imaging method for quantifying dermal perfusion: Potential and limitations. Med Biol Eng Comput 1989; 27:496. 62. Windsor T: Vascular aspects of thermography. J Cardio-vasc Surg 1971; 12:379. 63. White RA, Nolan L, Harley D, et al: Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension. Am J Surg 1982; 144:68. 64. Working party of the International Vascular Symposium: The definition of critical ischaemia of a limb. Br J Surg 1982; 69(suppl):2. 65. Young AE, Couch NP: Muscle perfusion and the healing of below knee amputations. Surg Obstet Gynecol 1978; 146:533.
Chapter 2C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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ulcers in any plantar location or a hindfoot shoe for forefoot lesions ( FIG 2D-2.). Due to a lack of compliance, the use of crutches or a walker is much less effective in insensate patients. In this discussion, however, we are primarily concerned with grade 3 lesions, i.e., ulcers penetrating bone and joint. The extent of penetration and involvement of bone beneath an ulcer is easily determined by probing the wound. If bone is exposed in the depths of the wound, osteomyelitis with or without septic arthritis is usually present. Plain radiographs are useful in determining the extent of bony involvement as opposed to bone scans, which are not necessary in the usual penetrating lesion. On occasion, however, neuroarthropathy (Charcot joint) and an ulcer may coexist and lead to an erroneous diagnosis of osteomyelitis. Magnetic resonance imaging (MRI) rather than bone scans is best able to make the distinction. The wound should be cultured and the patient initially given intravenous antibiotics that cover a wide range of organisms, including gram-positive, gram-negative, and anaerobic bacteria. Definitive antibiotics will be determined by culture sensitivities. Gentle probing will also give a good idea of the extent of any abscess that has developed in the forefoot. Prior to embarking on a definitive surgical solution, the patient's potential for healing a wound should be evaluated. This includes evaluation of blood flow to the foot, nutritional status, and immunocompetence. There are a number of methods available that will give an indication of blood flow to the distal part of the foot, but the simplest reliable bedside test remains the Doppler ultrasonic evaluation. 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.). If the ischemic index (foot systolic pressure divided by the brachial systolic pressure) is 0.5 or more, foot salvage is attempted. If the ischemic index is below 0.5 and the problem is one of low-grade infection or distal dry gangrene, the patient should be referred to a vascular surgeon regarding the possibility of vascular reconstruction prior to limited distal amputation (see Chapter 2C). When accurate Doppler data are unobtainable due to severe vessel calcification, transcutaneous oxygen measurements will give reliable information regarding local tissue perfusion, especially when tested during inhalation of 100% oxygen. Nutritional status is considered adequate with a serum albumin level of 3.5 g/dL or above, while a total lymphocyte count of at least 1,500/mm is considered evidence of immunocompetence.
Charcot changes in the foot are commonly mistaken for acute osteomyelitis. 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. In doubtful cases, MRI has been shown to be the most definitive test available to date.
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. Rather than delay the opening of an obvious abscess if operating room time is not immediately available, the abscess should be widely opened to reduce its internal pressure while the patient is still in the emergency room. This may be accomplished by using ankle block anesthesia or, in many cases, no anesthesia at all due to the patient's sensory neuropathy. During both temporizing emergency room and formal operating room procedures, the surgeon should use longitudinal incisions to preserve as many neural and vascular structures as possible. Normal weightbearing surfaces such as the heel pad, lateral portion of the sole, and metatarsal head areas should be respected. The surgeon should not unnecessarily compromise a later ablation, such as a Syme ankle disarticulation, by extending a midsole incision into the heel pad or a dorsal incision proximal to the ankle joint. It may be necessary to do multiple dorsal and plantar incisions to gain full open drainage of all abscess pockets. Tissues to be removed include grossly infected bone and soft tissue, as well as poorly vascularized tissues exposed in the area of infection such as tendon, joint capsule, and volar plates of the metatarsophalangeal joints. All wounds should be lightly packed with gauze to allow free wicking of the infective fluids to the surface. In many chronic, nonpurulent cases of chronic osteomyelitis, following removal of necrotic tissue the possibility of loosely closing the wound primarily should be considered ( FIG 2D-
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4A. ). The surgeon should individually assess the feasibility of closed vs. open management for each case of this type. The criteria for this method include a wound presenting with minimal or no pus, remaining tissues that are not inflamed or necrotic, and a situation in which debridement results in a grossly clean wound. A small polyethylene The methodology originally described by Kritter is quite simple. irrigation tube is placed in the depths of the wound and sutured to the skin. Skin sutures are placed only at wide intervals ( FIG 2D-4B. ). One liter of irrigation fluid is run through the wound each 24 hours for a period of 3 days. The fluid passes from the wound between the sutures and is absorbed by the dressing ( FIG 2D-5.). The outermost wrap is changed every 4 to 5 hours. If pus formation occurs after discontinuation of the irrigation, the wound can be simply reopened and packed at the bedside. The advantage is that primary healing of the wound will usually occur in a 3- to 5-week period. The alternative is the prolonged morbidity associated with several months of healing by secondary intention when the wound is packed and left open. Better cosmesis is also generally achieved by eliminating the need for skin grafting of residual defects. The Kritter irrigation system can be used to assist in the closure of minor foot-salvaging procedures such as toe and ray amputations. Amputations of a single toe, with the exception of the entire great toe, result in little loss of foot function. Amputation of only the distal phalanx of the great toe will also give a good result. Following disarticulation of the second toe alone, the first toe may go into a valgus position due to loss of the lateral support provided by that toe ( FIG 2D6.). Resection of the second ray (toe and metatarsal) will allow the foot to narrow and thus avoid secondary hallux valgus ( FIG 2D-7.). Any single-ray amputation can result in an excellent functional result except for loss of the first ray. In this case, as much metatarsal length as possible should be left to allow for effective orthotic restoration of the medial arch. The removal of two or more central rays is less desirable. In this situation, a transmetatarsal amputation may give a better functional and cosmetic result.
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. Success in this endeavor depends on timely presentation of the patient, control of infection and hyperglycemia by a combination of early and complete debridement and appropriate antibiotics and insulin. When gangrene or poor healing is related to vascular occlusion alone, a vascular surgeon should be consulted regarding the feasibility of vessel recanalization or reconstruction. Once healing is achieved, the patient should be actively engaged in a program devoted to prevention of further lesions by the use of proper footwear, tight control of diabetes, and education in foot care with emphasis on assumption of responsibility for selfcare.
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BIBLIOGRAPHY
Goodson WH III, Hunt TK: Wound healing and the diabetic patient. Surg Gynecol Obstet 1979; 149:600-608. Kwasnik EM: Limb salvage in diabetics: Challenges and solutions. Vasc Surg 1986; 66:305318. References: 1. Bagdade JD, Nielsen K, Root R, et al: Host defense in diabetes mellitus: The feckless phagocyte during poor control and ketoacidosis. Diabetes 1970; 19:364. 2. Boulton AJM, Kubrusly DB, Bowker JH, et al: Impaired vibratory perception and diabetic foot ulceration. Diabetic Med 1986; 3:335-337. 3. Dickhaut SC, DeLee JC, Page CR: Nutritional studies: Importance in predicting woundhealing after amputation. Bone Joint Surg [Am] 1984; 66:71-75. 4. Harward TRS, Volay R, Golbranson F, et al: Oxygen inhalation-induced transcutaneous Po2 changes as a predictor of amputation level. Vasc Surg 1985; 2:220-227. 5. Kritter AE: A technique for salvage of the infected diabetic gangrenous foot. Orthop Clin North Am 1973; 4:21-30. 6. Louie TJ, Bartlett JG, Tally FP, et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Ann Intern Med 1976; 85:461-463. 7. Wagner FW Jr: Orthopaedic rehabilitation of the dysvas-cular limb. Orthop Clin North Am 1978; 9:325-350. 8. Wang A, Weinstein D, Greenfield L, et al: MRI and diabetic foot infections. Magn Reson Imaging 1990; 8:805-809.
Chapter 2D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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http://www.oandplibrary.org/alp/chap02-05.asp[21/03/2013 21:53:09]
Treatment strategy following the staging of the tumor is dependent on the tumor characteristics: in the case of high-grade, chemotherapy-sensitive bone tumors such as osteosarcoma and Ewing's sarcoma, treatment is initiated with neoadjuvant preoperative chemotherapy ; no such therapy is given in low-grade bone tumors including chondrosarcoma. A similar strategy is followed in soft-tissue tumors: high-grade soft-tissue or radiotherapy, or both, sarcomas are treated preoperatively with either chemotherapy whereas low-grade soft-tissue sarcomas are not. Definitive surgical treatment is then performed and consists of resection with limb saving, if feasible, or amputation. 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. An additional advantage of preoperative chemotherapy is the possible reduction of tumor size. Sometimes there is sufficient reduction in tumor size to change an equivocal limb-saving situation into a definitely feasible one. Moreover, the chemotherapy-induced necrosis could conceivably reduce the potential escape of viable tumor cells during the operation. Postoperatively, chemotherapy, radiotherapy, or both are usually administered, depending on the type of tumor and the surgical procedure performed.
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. 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. Recently, there have been serious efforts to examine the true merits of limb-saving procedures over amputations. Interestingly, a few studies have actually shown no significant difference in the psychological and quality-oflife parameters between patients with limb-saving and amputation procedures. A study specifically targeting tumors about the knee showed no significant difference in psychological showed that patients whose limbs were and physical function, 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. Obviously, 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. 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. This chapter describes the limb-saving procedures only. Amputations are discussed in another chapter.
By and large, if one or more of these criteria are considered unattainable, amputation becomes the preferred option. Tumors that lend themselves to limb-saving procedures include malignant tumors (stage I and II) and some recurrent aggressive benign tumors (stage 3). Obviously, early diagnosis is important for successful limb saving inasmuch as a delay in diagnosis allows the tumor to increase in size, thus making limb saving less feasible.
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In general, limb salvage procedures are technically more complex than amputations. In bone tumors, it comprises two procedures: tumor resection and skeletal reconstruction. In softtissue tumors, soft-tissue reconstruction is rarely needed.
TUMOR RESECTION
In both bone and soft-tissue tumors, resection should be performed according to strict surgical oncologic principles. The recommended procedure for malignant tumors is either radical or, more frequently, wide resection of the tumor. In bone, radical resection indicates removing the entire bone from joint to joint, whereas wide resection indicates removing the tumor with a wide margin of normal bone around it. In soft tissue, radical resection indicates removing the entire muscle compartment from origin to insertion, whereas wide resection indicates removing the tumor with a wide surrounding cuff of normal soft tissues in all dimensions ( Fig 2E-1,A-C ). At the present time, most orthopaedic oncologists perform wide resection of the tumor combined with chemotherapy and radiotherapy. The adequacy of the resection cannot be overemphasized inasmuch as inadequate resection is the main cause of local recurrence, which in turn implies a worse prognosis. Optimal resection should not be compromised for the sake of subsequent reconstruction. The resectability of the tumor, based on its intraosseous and extraosseous extent, is preoperatively determined by radiologic staging studies, especially MRI and CT studies. Previous biopsy scars and tracts are excised in continuity with the tumor. The level of bone resection should include a margin of normal bone ranging from 3 to 5 cm beyond the tumor limit. For epiphyseal or metaphyseal tumors, an intra-articular resection including the articular surface is performed. If there is evidence of tumor extension into the joint, an extra-articular resection including the whole joint is indicated. An adequate surrounding cuff of soft tissues around the bone is also resected. Displacement or even involvement of adjacent neurovascular structures are not absolute contraindications to resection, i.e., indications for amputation. If a major indispensable vessel is displaced but not directly involved by the tumor, a careful subadventitial dissection is performed to preserve the vessel. Under proper circumstances, a vessel directly involved by tumor or circumferentially surrounded by tumor can be sacrificed and replaced by a vein graft or a synthetic graft. If necessary, resection of invaded major nerves may be performed. Resultant functional deficit is rectified by means of external orthoses or by reconstructive surgery. Adequacy of margins of excision is documented by frozen-section microscopic examination of sampled tissues intraoperatively.
SKELETAL RECONSTRUCTION
Postresection skeletal reconstruction constitutes the second stage of the operative procedure. The need and the type of reconstruction are determined preoperatively. In cases where dispensable or so called "nonessential" bones are resected, no reconstruction is needed to preserve function. The scapula (except the glenoid portion), clavicle, rib, proximal part of the radius, distal end of the ulna, metacarpal, phalanx, ischium, pubis, patella, fibula (except the distal end), and metatarsal bone can be resected with compensable disturbance of function. However, in nondispensable or "essential" bones, skeletal reconstruction is indicated to preserve the limb and its function. The choice of the reconstructive procedure is contingent on the location of the tumor, the size of the resected bone, the patient's lifestyle, and the surgeon's preference and expertise. There are three major methods of skeletal reconstruction: (1) intercalary (segmental) reconstruction, (2) arthrodesis, and (3) arthroplasty. By and large, the commonly used skeletal substitutes in these reconstructive methods include autografts, allografts, and metallic prostheses. Intercalary reconstruction is needed after diaphyseal resection, and it utilizes allografts, autografts, or rarely, metallic prostheses. Arthrodesis is used to reconstruct the limb after extra-articular resection of a joint such as the knee, shoulder, or wrist. It also utilizes allografts, autografts, or rarely, metallic prostheses. Arthroplasty is used to replace a resected hemijoint or whole joint with an articulating joint such as the knee, hip, shoulder, elbow, or wrist. It utilizes allografts, customized metallic prostheses, or allograft-prosthesis composites. Autografts are the best bone substitutes. However, these are not commonly used because they cannot replace large bone segments and articular joint surfaces cannot be provided.
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Nevertheless, two useful surgical techniques utilizing large autografts can be used in selected cases. 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, this technique produces a long-lasting and durable reconstruction. However, most patients prefer to have a movable rather than a fused knee. 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, the healing potential is greatly diaphyseal defect. improved, being similar to fracture healing. The graft is more readily incorporated and frequently hypertrophies with time. In contrast to autografts, both allografts and prostheses can replace large segments of bones and provide movable joints. Conceptually, allografts have certain advantages over prostheses. These are related to the biological nature of the allograft, which allows healing at the grafthost junction by a process of creeping substitution, and the presence of allograft stubs of tendons and ligaments, which serve as anchors to which host tendons and ligaments can be reattached, thus restoring motor function and joint stabilization. Conversely, metallic prostheses have the potential late complications of loosening or fatigue fracture of the prosthesis, especially in younger patients with high physical activity levels. Moreover, an osteoarticular allograft replaces only the involved half (or quarter) of the joint, thus sparing the uninvolved normal portions of the joint, whereas a joint prosthesis necessitates the sacrifice of the normal uninvolved half of the joint in order to accommodate the prosthesis. On the other hand, the advantages of prostheses include a simple operative procedure, quicker recovery, and easier rehabilitation, in contrast to the long rehabilitation following allografting procedures. Although we generally favor allografts, 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, in our experience, there has been an unacceptably high incidence of fragmentation and collapse of the allograft femoral and humeral head. Prostheses are also recommended in patients with metastatic tumors. in terms of To help solve some of the problems encountered with customized prostheses, fracture, loosening, need for customized implants, improper size, and high cost, 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. on a dual fixation concept, 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. The bone bridging around the prosthesis is accomplished by applying autogenous iliac grafts over the porous segment. Initial clinical results seem to be quite promising. Useful new "expandable" metallic prostheses have been successfully used in children with malignant tumors of long bones of the limbs. Previously, 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. These expandable prostheses allow periodic lengthening of the devices to gradually keep up with the growth of the contralateral limb ( Fig 2E-2,A-D ).
ALLOGRAFT PROCEDURES
We have used four types of allografting procedures to reconstruct large skeletal defects in bone tumors. These are massive osteoarticular allografts, allograft-prosthesis composites, intercalary allografts, and intercalary allograft-arthrodesis. The indication for each of these procedures is dictated by the skeletal location and extent of tumor resection. Osteoarticular allografts are glycerol-treated frozen allografts and are the most commonly used. They are usually utilized as hemijoints to reconstruct the knee, wrist, shoulder, and elbow joints. Wholejoint allografts have proved unsatisfactory because of articular cartilage degeneration and bone fragmentation reminiscent of Charcot (neuropathic) joints. Intercalary allografts are either frozen or freeze-dried and are used to reconstruct diaphyseal defects, to achieve arthrodesis following knee or shoulder joint resection, or as allograft-prosthesis composites to reconstruct the hip or shoulder joints.
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An allografting procedure is often complex and lengthy, being a two-in-one procedure combining resection and reconstruction. To achieve optimal results, particularly in the osteoarticular allograft, certain technical aspects have to be heeded. These include size matching of the graft to the resected segment; rigid fixation of the graft-host junction; congruent joint fit; reconstruction of ligaments, tendons, and joint capsule; and adequate skin and soft-tissue coverage by utilizing, if necessary, local muscle transfer, skin grafts, or free flaps. 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.
Humerus
The proximal or distal thirds of the humerus can be successfully replaced by an osteoarticular allograft. However, we have observed a relatively high incidence of late fracture or fragmentation of the humeral head ( Fig 2E-3,A-C ). This has not been a problem with distal humeral allografts. Accordingly, 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. When evaluation necessitates resection of the whole glenohumeral joint or resection of the deltoid muscle and rotator cuff, then we recommend an allograft-arthrodesis utilizing a proximal humerus allograft with fusion to the scapula ( Fig 2E-4,A-B ).
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,A and B ). We have observed a late complication of volar subluxation of the carpus on the allograft radius with progressive degenerative changes in the radiocarpal articulation. To prevent this complication we now recommend the use of the donor's contralateral radius with a 180-degree rotation on its longitudinal axis. Theoretically, by rotating the allograft, the normally long dorsal lip of the articular surface of the radius becomes volar, thus acting as a blocking strut against volar subluxation of the carpus.
Pelvis
In selected patients with tumors of the bony pelvis, a partial or complete internal hemipelvectomy can be as effective as a conventional transpelvic amputation. However, this procedure produces significant disability in terms of loss of hip function and stability. We favor the use of a massive pelvic osteoarticular allograft to replace the resected hemipelvis. When ( Fig 2Esuccessful, the pelvis allograft restores anatomy, stability, function, and leg length. 6,A and B ). In case the femoral head and neck have to be included in the resection, then a bipolar femoral prosthesis is used rather than a proximal femoral allograft.
Femur
In the proximal end of the femur, we favor the use of a proximal femoral allograft combined with a long-stem femoral prosthesis instead of an osteoarticular allograft ( Fig 2E-7,A and B ). This allograft-prosthesis composite provides a strong construct as well as a good osseous bed for reattaching tendons, particularly the hip abductors, either by directly suturing the tendons to the allograft trochanter or by fixing the patient's greater trochanter to the allograft. Diaphyseal defects are reconstructed by an intercalary allograft ( Fig 2E-8, A-C ). In the distal third of the femur, osteoarticular allografts have been successful in our hands. The whole distal part of the femur ( Fig 2E-9,A-C ) or one femoral condyle can be replaced. To restore joint stability and function, size matching of the allograft and joint fit as well as ligamentous repair are critical. The stubs of the allograft collateral and cruciate ligaments are sutured to the corresponding stubs of the patient. If such stubs are absent, we have reconstructed the ligaments by utilizing a hemi-Achilles tendon allograft.
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When the whole knee joint has to be resected, we have successfully used distal femur and proximal tibia allograft-prosthesis composites and incorporated a rotating hinged-knee prosthesis.
Tibia
Proximal tibial osteoarticular allografts have been used successfully ( Fig 2E-10,A and B ). Ligament reconstruction of the joint is similar to that used with the distal femoral allograft.
POSTOPERATIVE MANAGEMENT
Because of the increased potential risk of infection, antibiotic treatment is continued postoperatively for about 3 months. In proximal femur allograft-prosthesis composites, the patient walks by utilizing an abduction hip brace and crutches for 2 to 3 months, folowed by a crutch or a cane. In allografts in the knee region, we immobilize the limb in a long-leg plaster cast for 8 weeks to allow soft-tissue and ligament healing. This is followed by protection of the limb in a kneeankle-foot orthosis and gradual mobilization of the knee joint. The orthosis is kept until there is radiologic evidence of union at the al-lograft-host junction. Of course, the patient uses crutches to avoid weight bearing on the affected leg until union occurs. In proximal humerus allografts, a shoulder abduction splint is used for about 6 weeks, followed by protection in a sling and gradual mobilization of the shoulder joint. In distal radius allografts, the forearm is immobilized in a short-arm plaster cast, followed by protection in a volar splint and gradual mobilization of the wrist joint.
CLINICAL RESULTS
These limb-saving resection-reconstructive procedures utilizing massive allografts are often complex and long procedures with relatively high rates of complications. At the University of Miami, our 2- to 11-year follow-up retrospective evaluation of the massive osteoarticular allografts, which technically are the most complex and challenging, has shown the following results. According to Mankin's grading system, our results are 61% good or excellent, 13% fair, and 26% failure. The allograft-related complications consisted of 10% infection, 7% nonunion of the graft-host junction, 20% fracture of the allograft, and 5% resorption of a portion of the allograft (such as the humeral head). However, over half of these complications were salvaged by subsequent surgery such as autografting a fractured or nonunited allograft, replacing a fractured allograft with a new allograft, or replacing a resorbed humeral head with a Neer shoulder endoprosthesis. 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. In view of the biological advantages, availability, and versatility of allografts and despite the potential complications, 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. References: 1. Bradish CF, Kemp HBS, Scales JT, et al: Distal femoral replacement by custom-made prostheses. J Bone Joint Surg [Br] 1987; 69:276-284. 2. Campanacci M, Cervellati C, Guerra A, et al: Knee resection-arthrodesis, in Enneking WF (ed): Limb Salvage in Musculoskeletal Oncology. New York, Churchill Livingstone Inc, 1987, pp 364-378. 3. Chao EYS: A composite fixation principle for modular segmental defect replacement (SDR) prostheses. Orthop Clin North Am 1989; 20:439-453. 4. Dick HM, Malinin T, Mnaymneh W: Massive allograft implantation following radical resection of high grade tumors requiring adjuvant chemotherapy treatment. Clin Orthop 1985; 197:88-95. 5. Eckardt JJ, Eilber FR, Dorey FJ, et al: The UCLA experience in limb salvage surgery for malignant tumors. Orthopedics 1985; 8:612-621. 6. Eilber FR, Mirra JJ, Grant TT, et al: Is amputation necessary for sarcoma? A seven year experience with limb salvage. Am Surg 1980; 192:431.
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7. Eilber FR, Morton DL, Eckardt J, et al: Limb salvage for skeletal and soft tissue sarcomas: Multi disciplinary preoperative therapy. Cancer 1984; 53:2579. 8. Enneking WF: A system of staging musculoskeletal neoplasms. Clin Orthop 1986; 204:9-24. 9. Enneking WF: Surgical procedures, in Musculoskeletal Tumor Surgery, vol 1. New York, Churchill Livingstone Inc, 1983, pp 89-95. 10. Enneking WF, Shirley PO: Resection arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. J Bone Joint Surg [Am] 1977; 59:223-236. 11. Enneking WF, Spanier SS, Goodman MA: The surgical staging of musculoskeletal sarcoma. J Bone Joint Surg [Am] 1980; 62:1027-1030. 12. Gherlinzoni F, Bacci G, Picci P, et al: A randomized trial for the treatment of high grade soft tissue sarcoma of extremities: Preliminary observations. J Clin Oncol 1986; 4:552. 13. Goodnight JE, Bargar W, Voegeli T, et al: Limb sparing surgery for extremity sarcomas after preoperative intraarterial doxorubicin and radiation therapy. Am J Surg 1985; 150:109-113. 14. Harris IE, Leff AR, Gitelis S, et al: Function after amputation, arthrodesis, or arthroplasty for tumors about the knee. J Bone Joint Surg [Am] 1990; 72:1477-1485. 15. Jaffe N: Chemotherapy for malignant bone tumors. Or-thop Clin North Am 1989; 20:487-503. 16. Jaffe N, Knapp J, Chuang VP, et al: Osteosarcoma: Intra arterial treatment of the primary tumor with cis-dia-mine-dichloroplatinum II (CPD): Angiographic, pathologic and pharmacologic studies. Cancer 1983; 51:4021. 17. Lewis M: The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer 1986; 57:499. 18. Lindberg RD, Martin RG, Romsdahl MM, et al: Conservative surgery and postoperative radiotherapy in 300 adults with soft tissue sarcomas. Cancer 1981; 47:2391. 19. Link MP, Goorin AM, Angela WM: The effect of adjuvant chemotherapy on relapsefree survival in patients with osteosarcoma of the extremity. N Engl J Med 1986; 314:1600-1605. 20. Malawer M: Surgical technique and results of limb sparing surgery for high grade bone sarcomas of the knee and shoulder. Orthopedics 1985; 8:597-607. 21. Mankin HJ, Doppelt S, Tomford WW: Clinical experience with allograft implantation: The first 10 years. Clin Orthop 1983; 174:69. 22. Mankin HJ, Lange TA, Spanier SS: The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. J Bone Joint Surg [Am] 1982; 64:1121-1127. 23. Marcove RC, Rosen G: En bloc resection for osteogenic sarcoma. Cancer 1980; 45:3040. 24. Mnaymneh W: Unpublished data. 25. Mnaymneh W: Malinin T: Massive allografts in surgery of bone tumors. Orthop Clin North Am 1989; 20:455-467. 26. Mnaymneh W, Malinin T, Ghandur-Mnaymneh L, et al: Pelvic allograft. Clin Orthop 1990; 225:128-132. 27. Mnaymneh W, Malinin T, Ghandur-Mnaymneh L, et al: Scapular allografts-A report of two cases. Clin Orthop 1991;262:124-128. 28. Mnaymneh W, Malinin T, Head W, et al: Massive osseous and osteoarticular allografts in non-tumorous disorders. Contemp Orthop 1986; 13:13. 29. Mnaymneh W, Malinin T, Makely JT, et al: Massive os-teoarticular allografts in the reconstruction of extremities following resection of tumors not requiring chemotherapy and radiation. Clin Orthop 1985; 197:76. 30. Otis J, Lane JM, Kroll MA: Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above the knee amputation. J Bone Joint Surg [Am] 1985; 67:606. 31. Rao BN, Champion JE, Pratt CB, et al: Limb salvage procedure for children with osteosarcoma: An alternative to amputation. J Pediatr Surg 1983; 18:901-908. 32. Rosen G: Preoperative (neoadjuvant) chemotherapy for osteogenic sarcoma: A ten year experience. Orthopedics 1985; 8:659-664. 33. Rosen G, Caparros B, Huvos AG: Preoperative chemotherapy for osteogenic sarcoma: Selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. Cancer 1982;49:1221-1230. 34. Rosen G, Marcove RJ, Huvos AG, et al: Primary osteogenic sarcoma. Eight years experience of adjuvant chemotherapy. J Cancer Res Clin Oncol 1983; 106:55-67. 35. Rosenberg SA, Taffer J, Glatstein E, et al: The treatment of soft tissue sarcomas of the extremities. Ann Surg 1982; 196:305. 36. Rosenberg SA, Tepper J, Glatstein E, et al: Control of locally advanced extremity soft
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tissue sarcoma by function-saving resection. Cancer 1984; 53:1385. 37. Shiu MH, Turnbull AD, Nori D, et al: Control of locally advanced extremity soft tissue sarcoma by function-saving resection and brachytherapy. Cancer 1984; 53:1385. 38. Sim FM, Beauchamp CP, Chao EY: Reconstruction of musculoskeletal defects about the knee for tumor. Clin Orthop 1987; 221:188-201. 39. Sim FM, Bowman WE Jr, Wilkins RM, et al: Limb salvage in primary malignant bone tumors. Orthopedics 1985; 8:574-581. 40. Simon MA, Aschliman MA, Thomas N, et al: Limb salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg [Am] 1986; 68:1331-1337. 41. Sugarbaker PH, Barofsky I, Rosenberg SA, et al: Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery 1982; 91:17-23. 42. Suit HD, Poppe KH, Mankin HJ, et al: Preoperative radiation therapy for sarcoma of soft tissue. Cancer 1981; 47:2269. 43. Weddington WW Jr, Segraves KB, Simon MA: Psychological outcome of extremity sarcoma survivors undergoing amputation or limb salvage. J Clin Oncol 1985; 3:1393. 44. Weiland AJ: Vascularized free bone transplants: Current concepts review. J Bone Joint Surg [Am] 1981; 63:166-169. 45. Weiner MA, Harris MG, Lewis MM, et al: Neoadjuvant high dose methotrexate, cisplatin and doxorubicin for the management of patients with non metastatic osteosarcoma. Cancer Treat Rep 1986; 70:1431-1432.
Chapter 2E - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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PREOPERATIVE CONSIDERATIONS
Amputation vs. Limb Salvage Trauma
Modern advances in trauma management such as fracture stabilization and free-tissue
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transfers have allowed salvage in limbs that previously would have been amputated. Despite these advances, the amputation rate in grade IIIC tibial fractures is still greater than 50% in In addition, several series have shown that there is significant morbidity, recent series. increased economic cost, and psychological effects involved in limb salvage in severely traumatized limbs. Lange et al. 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. Other groups have developed more comprehensive rating systems to evaluate severe limb injuries to allow objective criteria for limb salvage vs. amputation decisions. (See Chapter 2B for a detailed discussion.)
Tumors
The field of musculoskeletal oncology is rapidly evolving. In the 1960s and early 1970s, 5year survival rates for patients with osteogenic sarcoma were in general less than 20%. 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. 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. 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. bloc resection because the patients selected for this treatment are likely to have more limited At the present time, en bloc resection with limb salvage in osteosarcoma should disease. 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. (See Chapter 2E for a detailed discussion.)
Site of Amputation
Before World War II, the majority of lower-limb amputations were transfemoral because such procedures yielded healing rates approaching 100% in ischemic limbs. In the 1960s and early 1970s, several factors combined to reverse the ratio of transfemoral to trans-tibial amputations. The use of a long posterior myofasciocutaneous flap in dysvascular patients, with its increased blood supply, improved the success rate in transtibial amputations. In addition, the development of preoperative objective criteria for amputation site viability allowed more distal amputations to be done. Lower-limb amputations in the dysvascular patient should be performed at the most distal site
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compatible with wound healing to achieve the optimal potential for ambulation. Several welldocumented studies have shown that energy expenditure with prosthetic ambulation is found that markedly increased in more proximal amputations. Waters and coworkers energy expenditure during ambulation, as measured by oxygen consumption per kilogram of body weight per meter traveled, was significantly increased in transfemoral amputees vs. in a review of previous energy studies in amputees, transtibial amputees. Fisher et al., 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. Huang and showed that oxygen consumption during ambulation was increased 9% in associates transtibial amputees, 49% in transfemoral amputees, and 280% in bilateral transfemoral amputees when compared with nonamputees. Preservation of the knee joint has even more significance when the rate of contralateral limb amputation is considered. Mazet and coworkers, in their series of dysvascular amputees, had a 33% contralateral limb amputation rate within 5 years. Other authors reported contralateral amputation rates of 15% to 28%. Ambulation ability in bilateral amputees is, of course, less than in unilateral amputees. For geriatric patients with bilateral transfemoral amputations, ambulation is probably not feasible in most cases, and wheelchair locomotion is indicated. In contrast to some older reports, 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. However, in elderly debilitated patients with limited or no ambulatory potential, knee disarticulation or transfemoral amputation is preferable to transtibial amputation to prevent knee flexion contractures and subsequent breakdown of the stump. 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. pulse, skin temperature, and bleeding at surgery have been used with varying success to The use of Doppler ultrasonography to measure arterial predict healing of amputation sites. blood pressure at the proposed amputation site has been advocated as a predictor of found that transtibial amputations healed in all amputation success. Barnes and coworkers patients with popliteal systolic pressures of more than 70 mm Hg. Wagner has suggested comparing the pressure at the proposed amputation site to that of the brachial artery; a ratio of >0.35 is adequate for healing in the nondiabetic, while a ratio of 0.45 is adequate for the diabetic. However, there are inconsistencies with Doppler determinations of the amputation site. A calcified, non-compressible artery will give falsely elevated values. In addition, the pressure in a deep artery may not correlate with skin healing. Other authors also suggest that the segmental arterial pressure in diabetics is not always helpful in preoperative determination of amputation levels. Two methods use clearance of 133 Xe to measure dermal vascularity. In one method, cutaneous diastolic pressure is estimated by determining the applied pressure necessary to stop clearance of intradermally injected 133 Xe. Holstein et al., in a study of 60 transtibial amputees, found that when the skin perfusion pressure was <20 mm Hg, only 25% of these amputations healed; when the skin perfusion pressure was >30 mm Hg, 90% healed. From 20 mm Hg to 30 mm Hg of pressure, 67% of amputations healed. In a second method, cutaneous blood flow is measured by determining the rate of clearance of 133 Xe injected intradermally or epicutaneously. 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. With intradermally injected 133 Xe, Moore found that amputation sites with a value of ࣙ 2.7 mL/ min/100 g healed successfully 97% of the time. Kostuik et al. injected
133 Xe epicutaneously and determined that wound healing was predictable with skin blood
flow above 0.90 mL/min/100 g of tissue. Other authors have not found the skin flow measurements with 133 Xe to be so reliable. The method is exacting to carry out, and the trauma of injecting 133 Xe may in and of itself elevate the skin blood flow. Measurement of transcutaneous Po2 is another method of determining the amputation level. It is not invasive and does not require radioactive isotopes. This method involves warming the skin to 44C with a heated electrode, which then measures the oxygen emanating from the skin. 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
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potential. In a study of 37 dysvascular patients, Burgess and Matsen found that with transcutaneous Po2 values >40 mm Hg, transtibial amputations in 15 patients healed with no delay. 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, transtibial amputations healed. 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. Other preoperative methods of determining amputation level such as fluorescein angiography, skin temperature measurements, and pulse volume recordings have been used. Recently, laser Doppler velocimetry has been used to assess the viability of amputation levels. Burgess and Matsen have pointed out that preoperative measurements to determine amputation level are more beneficial in predicting failure than in predicting success. Factors such as alteration in collateral circulation, decreased distal vascular runoff as a result of surgery, surgical technique, the nutritional status of the patient, infection, concomitant medical illnesses, and postoperative care cannot be assessed in the preoperative period. However, preoperative laboratory assessment of the amputation level does give an indication whether adequate circulation exists for a favorable outcome.
Nutrition
The significant incidence of malnutrition in hospitalized patients has been well documented. reported a 42% incidence of laboratory-proven malnutrition in Jensen and associates orthopedic patients undergoing surgical procedures, including elective total-hip replacements. Patients undergoing lower-limb amputations are often elderly and debilitated. In addition, diabetics with dysvascular limbs often have open wounds and systemic sepsis causing increased metabolic demands. Protein malnutrition has an adverse affect on morbidity and mortality in hospitalized patients. The cell-mediated and humoral immune systems are impaired with resultant decreased host resistance. Dickhaut and coworkers, using serum albumin levels and total lymphocyte counts, 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. Trauma or infection increases energy requirements 30% to 55% from basal values. Patients undergoing a semielective lower-limb amputation should undergo at least a baseline nutritional assessment, including a serum albumin determination and total lymphocyte count. If the initial values are abnormal (serum albumin <3.4 g/dL or a total lymphocyte count of < 1,500 cells per cubic millimeter), then a more formal assessment should be done. There have been no prospective series to demonstrate decreased mortality or morbidity in malnourished patients treated with nutritional supplementation before amputation. However, if time permits, enteral or intravenous hyperalimentation should be considered in a malnourished patient being evaluated for amputation.
Antibiotics
The use of antibiotics as prophylaxis in orthopedic surgery, especially surgery involving implants, is well established. The use of antibiotics as prophylaxis in patients undergoing lower-limb amputation is less well defined. In cases of open, draining wounds or gas-forming infection, the use of antibiotics in the perioperative period is mandatory. Most lower-limb amputations for dysvascular disease in the United States are in diabetic patients. In neurotrophic ulcers in diabetes mellitus, the infection is usually polymicrobial, including both anaerobic and aerobic species. Therefore, broad-spectrum antibiotics should be used initially until specific organisms are recovered in culture. In dysvascular patients undergoing elective amputation, the effectiveness of prophylactic antibiotics in the perioperative period has not been established. However, 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. At Rancho Los Amigos Medical Center, patients with infected dysvascular limbs who are being considered for amputation are initially debrided surgically,
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and specimens for aerobic and anaerobic culture and sensitivity are obtained at this procedure. Broad-spectrum antibiotics are begun parenterally until specific organisms and antibiotic sensitivities are available. Parenteral antibiotic treatment is continued until clinical evidence of infection (e.g., leukocytosis, erythema) is diminished. Then a definitive amputation can be carried out. In most cases, the wound can be loosely closed over drains. In cases of systemic sepsis or severely infected limbs, a preliminary guillotine amputation is done. Parenteral antibiotic therapy is continued until the sepsis is quiescent, at which time the definitive amputation is done. In cases of noninfected dysvascular amputations, prophylactic antibiotic therapy (usually a first-generation cephalosporin) is begun at the time of surgery and continued for 48 hours following the amputation.
Diabetes
Five out of six major lower-limb amputations are done in diabetics. Although previously it was believed that diabetics were doomed to an amputation in a dysvascular limb, several series have shown equivalent results with vascular reconstructive procedures in diabetics and nondiabetics. However, there are problems unique to diabetics that require consideration. Neuropathy develops in the majority of diabetic patients, and therefore, minor traumatic events in the insensate limb can result in limb-threatening ulcers. 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. Vigorous control of blood glucose in diabetics undergoing lower-limb amputation, especially in the perioperative period, can enhance collagen synthesis and the inflammatory response to In some series, healing of amputations of lower limbs in patients with diabetes infection. mellitus has been similar to healing in nondiabetics. In addition, amputations in diabetics with dysvascular and neurotrophic ulcers can be avoided with conservative nonoperative care and education.
OPERATIVE CONSIDERATIONS
In order to enhance the potential for prosthetic ambulation following lower-limb amputation, the amputation surgeon must apply appropriate surgical technique to allow wound healing at the most distal amputation site possible. This involves, especially in dysvascular patients, handling soft tissue in a nontraumatic manner. Therefore, tissue forceps should be avoided in handling the skin in these patients. As already described, it is important to salvage the most distal amputation site feasible (transtibial vs. transfemoral amputations) in potential prosthetic ambulators. In addition, Gonzales et al. have shown that there is decreased energy expenditure in transtibial amputees with a long stump. They defined the stump as being long if it is 50% of the length of the remaining contralateral leg, medium if 20% to 50% the length the contralateral leg, and short if less than or equal to 25% of the length of the contralateral limb. 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. Modern management of soft-tissue injuries such as free-muscle transfers and tissue expanders has allowed salvage of longer amputation stumps in trauma. Large skin defects can be covered by utilization of viable skin from amputated parts. Inadequate short transtibial amputation stumps have even been lengthened by the Ilizarov technique. Grossly contaminated traumatic wounds and some infected dysvascular limbs with gangrene should not be closed primarily following amputation. In general, skin traction should not be used, especially in dysvascular amputees. Delayed primary closure, split-thickness skin grafting, or free-muscle transfer can be done when local sepsis is diminished. When clinical judgment is not clear on timing of closure of contaminated wounds, then a centimeter of tissue can be obtained for quantitative bacterial counts. If the quantitative bacterial count is less than 10 , then closure can be done. If the quantitative bacterial count is greater than 10 , then further debridement is necessary before attempting closure. In addition to the goal of obtaining the most distal amputation site possible, the stump should have sufficient soft-tissue coverage to resist the shear forces involved in prosthetic ambulation. Weight bearing occurs at the distal part of the stump in transfemoral amputations and knee disarticulations. Painful neuromas should be avoided at the site of weight bearing by sharply dividing nerves and allowing their retraction into sufficient soft-tissue cover.
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POSTOPERATIVE CONSIDERATIONS
In the immediate postoperative period, amputation stumps should be splinted with wellpadded rigid dressings to prevent joint contractures. The use of an immediate postoperative prosthesis (IPOP) has been advocated to allow early prosthetic ambulation, decrease stump However, others have found significant edema, and diminish postamputation depression. wound problems with IPOP. In general, IPOP should probably be reserved for young, traumatic amputees. The most basic decision following wound healing in amputees is determination of appropriate candidacy for prosthetic ambulation. Moore et al. evaluated the variables associated with successful prosthetic ambulation in lower-limb amputees. The presence of coronary artery disease in transfemoral amputees precluded prosthetic ambulation, presumably because of insufficient cardiac reserve for the increased energy demands of prosthetic ambulation. In this study, 32% of lower-limb amputees fit with a prosthesis did not utilize it. An overall assessment of the lower-limb amputee should be done prior to prosthetic fitting. The patient's social situation should be evaluated. Such factors as impaired vision from diabetic retinopathy, poor balance from concomitant cerebral vascular accidents, significant or additional musculoskeletal problems such as rheumatoid psychological problems, arthritis should be considered prior to prosthetic fitting. In an elderly, dysvascular lower-limb amputee with significant coronary artery disease, optimum planning in amputation surgery may involve wheelchair locomotion, which has been shown to be equivalent in energy expenditure to normal bipedal gait. References: 1. Aver A, Hurley J, Binnington H, et al: Distal tibial vein grafts for limb salvage. Arch Surg 1983; 118:597. 2. Barner H, Kaiser G, Willman V: Blood flow in the diabetic leg. Circulation 1971; 43:391. 3. Barnes R, Shank G, Slovmaker E: An index of healing in below knee amputations: Leg blood pressure by Doppler ultrasound. Surgery 1976; 79:13. 4. Barnes R, Thornhill B, Nix C: Prediction of amputation wound healing. Arch Surg 1981; 116:80. 5. Bistrian B, Blackburn G, Hallowell E, et al: Protein status of general surgical patients. JAMA 1979; 230:858. 6. Bistrian B, Blackburn G, Vitola J, et al: Prevalence of malnutrition in general medical patients. JAMA 1976; 235:1567. 7. Bodily K, Burgess E: Contralateral limb and patient survival after leg amputations. Am J Surg 1983; 246:280. 8. Bondurant F, Colter H, Buckle R, et al: The medical and economic impact of severely injured lower extremities. J Trauma 1988; 28:1270. 9. Bowker J: Surgical techniques for conserving tissue and function in lower limb amputation for trauma, infection and vascular disease. Instr Course Led 1989; 39:355. 10. Burgess E: Immediate postsurgical prosthetic fitting. J Bone Joint Surg [Am] 1966; 48:1022. 11. Burgess E, Marsden F: Major lower extremity amputations following arterial reconstruction. Arch Surg 1974; 108:655. 12. Burgess E, Matsen F: Determining amputation levels in peripheral vascular disease. J Bone Joint Surg [Am] 1981; 63:1493. 13. Burgess E, Matsen F, Wyss D, et al: Segmental transcutaneous measurements of Po2 in patients requiring below the knee amputation for peripheral vascular insufficiency. J Bone Joint Surg [Am] 1982; 64:378. 14. Burgess E, Romano R, Zettl J, et al: Amputation of the lower extremity for peripheral vascular insufficiency. J Bone Joint Surg [Am] 1971; 53:74. 15. Burgess E, Traub J, Wilson A: Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees, Technical Report 10-5. Washington, DC, U.S. Government Printing Office. 1967. 16. Carter S: The dilemma of adjuvant chemotherapy for osteogenic sarcoma. Cancer Clin Trials 1980; 3:29. 17. Caudle R, Stern P: Severe open fractures of the tibia. J Bone Joint Surg [Am] 1987; 69:801. 18. Cederberg P, Pritchard D, Joyce J: Doppler-determined segmental pressures and wound healing in amputations for vascular disease. J Bone Joint Surg [Am] 1983;
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65:363. 19. Cohen S, Coldman L, Salzman E, et al: The deleterious effect of immediate postoperative prosthesis in below knee amputation for ischemic disease. Surgery 1974; 76:992. 20. Conrad M: Large and small artery occlusion in diabetics and non diabetics with severe vascular disease. Circulation 1967; 36:83. 21. Couch N, David J, Tilney N, et al: Natural history of the leg amputee. Am J Surg 1977; 133:459. 22. Dahlin D, Coventry M: Osteogenic sarcoma: A study of 600 cases. J Bone Joint Surg [Am] 1967; 49:101. 23. Dickhaut S, DeLee J, Page C: Nutritional status: Importance in predicting wound healing after amputation. J Bone Joint Surg [Am] 1984; 66:71. 24. Dovcette M, Fylling C, Knighton D: Amputation prevention in a high risk population through comprehensive wound-healing protocol. Arch Phys Med Behabil 1989; 70:78. 25. Eilber F, Eckhardt J, Morton D: Advances in the treatment of sarcomas of the extremity: Current status of limb salvage. Cancer 1984; 54:2695. 26. Eilber F, Muria J, Grant T, et al: Is amputation necessary for sarcomas? A seven year experience with limb salvage. Ann Surg 1980; 192:431. 27. Eldridge J, Armstrong P, Krajbich I: Amputation stump lengthening with the Ilizarov technique: A case report. Clin Orthop 1990; 256:80. 28. Enneking W, Durham W: Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg [Am] 1978; 60:731. 29. Fisher D, Clagett G, Fry R, et al: One stage versus two stage amputation for wet gangrene of the lower extremity: A randomized study. J Vasc Surg 1988; 8:428. 30. Fisher S, Gullickson G: Energy cost of ambulation in health and disability: Literature review. Arch Phys Med Behahil 1978; 59:124. 31. Ger R: Prevention of major amputations in the diabetic patient. Arch Surg 1985; 120:1317. 32. Gibbons G, Wheelock F, Siembiedig C: Non-invasive prediction of amputation level in diabetic patients. Arch Surg 1979; 114:1253. 33. Goldenberg S, Alex M, Joshi R, et al: Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. Diabetes 1959; 8:261. 34. Gonzalez E, Corcoran P, Reyes R: Energy expenditure in below knee amputations: Correlation with stump length. Arch Phys Med Behahil 1974; 55:111. 35. Goodson W, Hunt T: Wound healing and the diabetic patient. Surg Gynecol Ohstet 1979; 149:600. 36. Goorin A, Abelson H, Frei E: Osteosarcoma-Fifteen years later. N Engl J Med 1985; 313:1637. 37. Gregg K: Bypass or amputation. Am J Surg 1985; 149:397. 38. Harward T, Volny J, Golbranson F, et al: Oxygen inhalation-induced transcutaneous Po2 changes as predictor of amputation level. J Vase Surg 1988; 2:220. 39. Helfet D, Howery T, Sanders R, et al: Limb salvage versus amputation: Preliminary results of the mangled extremity severity score. Clin Orthop 1990; 256:80. 40. Holloway G: Cutaneous blood flow responses to injection trauma measured by laser Doppler velocimetry. J Invest Dermatol 1980; 74:1. 41. Holloway G, Burgess E: Cutaneous blood flow and its relation to healing of below knee amputation. Surg Gynecol Ohstet 1978; 146:750. 42. Holstein P, Sager P, Lassen N: Wound healing in below knee amputations in relation to skin perfusion pressure. Acta Orthop Scand 1979; 50:49. 43. Howe H, Poole G, Hansen F, et al: Salvage of lower extremities following combined orthopedic and vascular trauma: A predictive salvage index. Am J Surg 1987; 53:205. 44. Hunter G, Holeding P: Major amputations following vascular reconstructions (including sympathectomy). Can Med Assoc J 1978; 21:456 45. Huang C, Jackson R, Moore N, et al: Amputation: Energy cost of ambulation. Arch Phys Med Behahil 1979; 60:18. 46. Jensen J, Jensen T, Smith T, et al: Nutrition in orthopaedic surgery. J Bone Joint Surg [Am] 1982; 64:1263. 47. Johansen K, Burgess E, Zorn R, et al: Improvement of amputation level by lower extremity revascularization. Surg Gynecol Ohstet 1981; 153:707. 48. Johansen K, Darnes M, Howey T, et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30:568. 49. Johnson J: Reconstruction of the pelvic ring following tumor resection. J Bone Joint Surg [Am] 1978; 60:747. 50. Jorue T, Bartlett J Jr, Tally F, et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Ann Intern Med 1976; 85:461.
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51. Khouri R, Shaw W: Reconstruction of the lower extremity with microvascular free flaps: A 10 year experience with 304 consecutive cases. J Trauma 1989; 29:1086. 52. Kihn R, Warren R, Becke G: The geriatric amputee. Ann Surg 1972; 176:305. 53. Kostuik J, Wood D, Hornby R, et al: The measurement of skin blood flow in peripheral vascular disease by epicu-taneous application of 133 xenon. J Bone Joint Surg [Am] 1976; 58:833. 54. Kraeger R: Amputation with immediate fitting prosthesis. Am J Surg 1970; 120:634. 55. Kram H, Appel P, Shoemaker W: Prediction of below knee amputation wound healing using noninvasive laser Doppler velocimetry. Am J Surg 1989; 158:29. 56. Kwasnik E: Limb salvage in diabetics: Challenges and solutions. Surg Clin North Am 1986; 66:305. 57. Lane J, Harsh B, Boland P, et al: Osteogenic sarcoma. Clin Orthop 1986; 204:93. 58. Lange R: Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop 1989; 243:92. 59. Lange R, Bach A, Hansen S, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985; 25:203. 60. Larsen F, Christiansen J, Ebskov B: Prevention and treatment of ulcerations of the foot in unilaterally amputated diabetic patients. Acta Orthop Scand 1982; 53:481. 61. Law D, Dudrick A, Abdow N: The effects of protein calorie malnutrition on immune competence of the surgical patient. Surg Gynecol Ohstet 1974; 139:257. 62. Lee B, Trainor F, Kavner D, et al: Non-invasive hemodynamic evaluation in selection of amputation level. Surg Gynecol Ohstet 1979; 149:2241. 63. LoGerfo R, Coffman J: Vascular and microvascular disease of the foot in diabetes. N Engl J Med 1984; 311:1615. 64. Malone J, Snyder M, Anderson G, et al: Prevention of amputation by diabetic education. Am J Surg 1989; 158:520. 65. Mankin H, Doppelt S, Tourfort W: Clinical experience with allograph implantation: The first ten years. Clin Orthop 1982; 162:175. 66. Marcove R, Mike V, Hajek L Jr, et al: Osteogenic sarcoma under the age of 21. A review of 145 preoperative cases. J Bone Joint Surg [Am] 1970; 52:411. 67. Marcove R, Rosen G: En bloc resection for osteogenic sarcoma. Cancer 1980; 45:3040. 68. Matsen F, Wyss C, Robertson C, et al: The relationship of transcutaneous Po2 and laser Doppler measurements in a human model of local arterial insufficiency. Surg Gynecol Ohstet 1987; 159:418. 69. Mazet R: The geriatric amputee. Artif Limbs 1967; 11:33. 70. Mazet R, Schiller F, Dunn O, et al: The Influence of Prosthesis Wearing on the Health of the Geriatric Amputee, Project 431. Sacramento, California Office of Vocational Rehabilitation, March 1963. 71. McMurray J: Wound healing with diabetes mellitus: Better glucose control for better wound healing in diabetes. Surg Clin North Am 1984; 64:769. 72. Mooney V, Harvey J, McBride E, et al: Comparison of post-operative stump management: Plaster vs soft dressing. J one Joint Surg [Am] 1971; 53:241. 73. Mooney V, Wagner F, Waddell J, et al: The below knee amputation for vascular disease. J Bone Joint Surg [Am] 1976; 58:365. 74. Moore T, Barron J, Hutchinson F, et al: Prosthetic usage following major lower extremity amputation. Clin Orthop 1989; 238:219. 75. Moore T, Green S, Garland D: Severe trauma to the lower extremity: Long term sequelae. South Med J 1987; 82:843. 76. Moore T, Mauney C, Barron J: The use of quantitative bacterial counts in open fractures. Clin Orthop 1989; 248:227. 77. Moore W: Determination of amputation level: Measurement of skin blood flow with 133 xenon. Arch Surg 1973; 107:798. 78. Moore W, Hale A, Wylie E: Below knee amputation for vascular insufficiency. Arch Surg 1968; 97:886. 79. Oishi C, Fronek A, Golbranson F: The role of noninvasive vascular studies in determining levels of amputation. J Bone Joint Surg [Am] 1988; 70:1520. 80. Otteman M, Stahlgrew L: Evaluation of factors which influence mortality and morbidity following major lower extremity amputation for atherosclerosis. Surg Gynecol Obstet 1965; 120:1217. 81. Perdue G, Smith R, Veazez C, et al: Revascularization for severe limb ischemia. Arch Surg 1980; 115:168. 82. Pinzur M, Grahm G, Osterman H: Psychologic testing in amputation rehabilitation. Clin Orthop 1988; 229:236. 83. Rollins D, Towne J, Bernhard V, et al: Isolated profunda-plasty for limb salvage. J
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Vasc Surg 1985; 2:585. 84. Schlenker J, Wolkoff J: Major amputations after femo-ropopliteal bypass procedures. Am J Surg 1975; 129:495. 85. Sonne-Holm S, Boeckstyns M, Mauch H, et al: Prophylactic antibiotics in amputation of the lower extremity for ischemia. J Bone Joint Surg [Am] 1985; 67:800. 86. Stablgren L, Otteman M: Review of criteria for the selection of the level for lower extremity amputation for arteriosclerosis. Ann Surg 1965; 162:886. 87. Stoney R: Ultimate salvage for the patient with limb-threatening ischemia. Am J Surg 1978; 136:228. 88. Strandress D, Priest R, Gibbons G: Combined clinical and pathologic study of diabetes and non diabetic peripheral arterial disease. Diabetes 1964; 13:366. 89. Tanzer T, Horne J: The assessment of skin viability using fluorescein angiography prior to amputation. J Bone Joint Surg [Am] 1982; 64:880. 90. Thomas J, Steers J, Keushkerian S, et al: A comparison of diabetics and nondiabetics with threatened limb loss. Am J Surg 1988; 156:481. 91. Towne J, Rollins D: Profundaplasty: Its role in limb salvage. Surg Clin North Am 1986; 66:403. 92. Vergu M, D'Amore T: Microvascular free tissue transfer after arterial revascularization in the elderly: An alternative to amputation. Ann Plast Surg 1988; 21:348. 93. Volpicelli L, Chambers R, Wagner F: Ambulation levels of bilateral lower extremity amputees. J Bone Joint Surg [Am] 1983; 65:599. 94. Wagner F: Transcutaneous Doppler ultrasound in the prediction of healing and the selection of surgical level for dysvascular disease of the toes and forefoot. Clin Orthop 1979; 142:110. 95. Wagner W, Keagy B, Kolb J, et al: Noninvasive determination of major lower extremity amputation healing: The continued role of clinical judgment. J ase Surg 1988; 8:703. 96. Waters R, Perry J, Antonelli D, et al: Energy cost of walking of amputees: The influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42.
Chapter 3 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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sources, including a formal clinic, an amputee support group, or individuals such as the prosthetist, nurse, or social worker. Whenever possible, both the prosthetist and a support group should be contacted immediately following amputation because each can provide the patient with valuable information. Amputee support groups are not new in the United States, but they are now better organized and more widely available. 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. 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. An early visit by the prosthetist can also be helpful. 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. The prosthetist can also answer many of the basic questions, 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, elastic bandaging, or prosthetic shrinkers is employed to speed the maturation of the residual limb. When the amputee is ready for prosthetic fitting, additional orientation information should be offered. An explanation of the different stages of the rehabilitation process is in order, including how long the preparatory prosthesis will be used and when the evaluation for a definitive prosthesis will occur. Many amputees are seen in a prosthetic clinic setting 1 or more months following their amputation. Unfortunately, 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. Whenever a new patient is seen, 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. The amputee tends to develop confidence in the person willing to spend the time to provide a clear explanation of the rehabilitation process, and this can enhance the overall outcome.
TYPES OF PROSTHESES
There are five generic types of prostheses: postoperative, initial, preparatory, definitive, and special-purpose prostheses. Although progression through all five levels may be desirable, only selected amputees will receive the postoperative or initial prostheses, which are directly molded on the residual limb. Most amputees will have preparatory and definitive prostheses, but a much smaller number will receive special-purpose prostheses for showering or for swimming and other sports.
Postoperative Prostheses
Postoperative prostheses are, by definition, provided within 24 hours of amputation. These are often referred to by various acronyms including immediate postsurgical fitting (IPSF) and immediate postoperative prosthesis (IPOP). Although technically feasible for virtually any amputation, postoperative fittings are currently most commonly prescribed for the younger, healthier individual undergoing amputation due to tumor, trauma, or infection. Its use in the elderly or dysvascu-lar individual is controversial but can be successful when meticulous technique and close supervision are available.
Initial Prosthesis
The initial prosthesis is sometimes used in lieu of a postsurgical fitting and is provided as soon as the sutures are removed. This is sometimes referred to as an early postsurgical fitting (EPSF). Due to the usual rapid atrophy of the residual limb, the EPSF is generally directly molded on the residual limb by using plaster of paris or fiberglass bandages. An alternative is to use a weight-bearing rigid dressing such as the technique reported by Wu. Such devices are used during the acute phase of healing, generally from 1 to 4 weeks after amputation, until the suture line is stable and the skin can tolerate the stresses of more intimate fitting. Postoperative and initial prostheses are most commonly used in rehabilitation units or in hospitals with very active amputee programs.
Preparatory Prosthesis
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Preparatory prostheses are used during the first few months of the patient's rehabilitation to ease the transition into a definitive device. They are also used in marginal cases to assess ambulatory or rehabilitation potential and help clarify details of the prosthetic prescription. The preparatory prosthesis accelerates rehabilitation by allowing ambulation before the residual limb has completely matured. Preparatory prostheses may be applied within a few days following suture or staple removal, and limited gait training is started at that point. Originally, the preparatory prosthesis was a very rudimentary design containing only primitive components. The modern preparatory limb, however, usually incorporates definitive-quality endoskeletal componentry but lacks the protective and cosmetic outer finishing to reduce the cost, ( Fig 4-1 ). It allows the therapist and prosthetist to work together to optimize alignment as the amputee's gait pattern matures. Different types of knee mechanisms or other components can be tested to see whether individual patient function is improved. Preparatory prostheses are generally used for a period of 3 to 6 months following the date of amputation, but that time can vary depending on the speed of maturation of the residual limb and on other factors such as weight gain, weight loss, or health problems. The new amputee may begin by wearing one thin prosthetic sock in the preparatory prosthesis; after 3 months, he may be wearing ten plies of prosthetic socks to compensate for atrophy. When the number of plies of prosthetic socks the patient must wear remains stable over several weeks, it is usually an indication that the definitive prosthesis can be prescribed.
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. The definitive prescription is based primarily upon the experience the patient had when using the preparatory prosthesis. The information learned during those months will demonstrate to the clinic team the patient's need for a lightweight design, special types of feet or suspension, or any special weight-bearing problems that may arise. Unless a suction socket is used, 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, take up shear forces, and absorb perspiration. An additional advantage is the ability to accommodate minor volume fluctuations by wearing more or fewer layers (plies) of prosthetic socks. Once the amputee is wearing ten plies of prosthetic socks, the fit has degraded sufficiently that socket replacement should be considered. A definitive prosthesis is not a permanent prosthesis since any mechanical device will wear out, particularly one that is used during every waking hour. The average life span for a definitive prosthesis is from 3 to 5 years. Most are replaced due to changes in the amputee's residual limb from atrophy, weight gain, or weight loss. Substantial changes in the amputee's life-style or activities may also dictate a change in the prosthetic prescription. Overall physical condition is also a factor since the more debilitated individual generally requires a very lightweight and stable prosthesis.
Special-Use Prostheses
A certain number of patients will require special-use prostheses designed specifically for such activities as showering, swimming, or skiing. 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. Most require specialized alignment. For example, swimming prostheses are made waterproof and aligned so that the patient can walk without a shoe. In some cases the foot can be plantar-flexed and have a swim fin attached. Snow skiing prostheses require an increase in dorsiflex-ion at the ankle and may incorporate additional knee support or auxiliary suspension. 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. There are sports-related amputee organizations in every major city in the country, with the greatest participation in golf and snow skiing. The value of amputee sports and recreation has been recognized by the Veterans Administration, which decided several years ago to reimburse patients for the cost of special-use prostheses.
There are many factors to be considered when a new prosthesis is prescribed, including weight bearing, suspension, activity level, general prosthesis structure, components, expense, and certain unique considerations. These will be discussed in order. 1. Weight bearing.-For lower-limb prostheses, the weight-bearing characteristics of the socket are the first concern. If the patient has scarring, neuromas, or sensitive areas, specific provisions must be made in the design of the socket. Special impactabsorbing materials may be used, or modifications may be necessary to spread the load over a greater area. For example, in a trans tibial (below-knee) prosthesis, a thigh corset might be considered if weight bearing causes severe problems with the residual limb. 2. Suspension. -There are many methods of suspension, ranging from very basic leather belts to sophisticated suction sockets. Each alternative must be evaluated individually; anticipated volume change in the residual limb is a key factor. It is important to review any previous experience with other suspensions to determine the optimum recommendation. 3. Activity level. -A person using the prosthesis only indoors obviously presents different considerations from someone who anticipates being active in his job and in competitive sports. Activity level influences weight bearing, suspension, and structural strength of the prosthesis. 4. Structure of the prosthesis.-There are two basic structural types: endoskeletal and exoskeletal. En-doskeletal prostheses consist of internal tubes and components covered with a soft foam outer cover. They are becoming increasingly popular because of the inter-changeability of componentry for trial or repair, their relatively light weight, and the good appearance they offer. Exoskeletal prostheses, on the other hand, consist of wood or polyurethane covered with a rigid plastic lamination. For very active patients, the exoskeletal prostheses are more durable since the foam coverings of the endoskeletal designs tear easily and need replacement at intervals. 5. Prosthetic components. -Components need to be matched with the amputee's activity level, body weight, and functional goals. Obviously, the person with good strength and balance does not require a stance-control knee, while someone who intends to compete in the Boston marathon would require an artificial foot designed for a high activity level. Due to the large and expanding number of options now available in prosthetic componentry, close consultation with the prosthetist is imperative. 6. Expense. -The expense of a prosthesis may vary greatly, primarily depending on the need for lightweight or sophisticated componentry. Lightweight prostheses are often made from titanium or carbon fiber, aerospace materials that are both expensive to obtain and difficult to manufacture, which may increase the cost of componentry 50% and more. Sophisticated componentry such as hydraulic knees will increase the cost of the prosthesis as well. 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. 7. Unique considerations. -Many patients present unique factors that need to be considered in the design of the prosthesis. For example, someone who lives near the ocean may need a prosthesis designed with maximum protection from salt corrosion and water damage; the finish carpenter needs more comfort from the prosthesis in the kneeling position than the average wearer does. Cultural background is also significant; Asian amputees require a foot that allows the shoes to be removed easily when entering a home since that is customary. Such personal factors must be added to the more generic factors discussed previously to ensure the proper match between prosthetic configuration and amputee goals.
PATIENT EVALUATION
It is important for the prosthetist to thoroughly evaluate the amputee before starting to design the prosthesis. The prosthetist's physical examination should be very detailed and record such factors as adherent scar tissue and neuromas, range of motion, edema, and muscular development. A careful personal history helps identify the likelihood of weight fluctuations as well as medical factors that may have a bearing on prosthetic fitting, such as previous fractures, any visual impairments, and the presence of concomitant disease including arthritis or diabetes. Measurements are then taken of both the residual limb and sound limb. The length of the residual limb is measured, and circumferences are taken at intervals ( Fig 4-2 ). Those who
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are being evaluated for powered upper-limb prostheses will have myoelectric control sites identified by electromyographic (EMG) testing. Once the measurements are completed, a negative impression of the residual limb is obtained.
IMPRESSION PROCEDURE
The hollow plaster or fiberglass cast of the residual limb creates the negative impression. It is sealed and filled with liquid plaster, which hardens to form an accurate positive model of the patients limb. The impression is generally taken in a specified position and is usually handmolded by the prosthetist to more clearly define key anatomic landmarks. A number of fixtures have been specifically developed for taking this impression, especially for the transfemoral (above-knee) amputee. 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. Proper angulation for initial static alignment of the prosthesis is recorded by using plumb lines drawn onto the negative impression. Some specialized impressions are taken by using alginate, which is a gelatinous material commonly used for dental molds. In prosthetics, partial-hand and -foot amputations are often molded in alginate rather than plaster. In summary, the impression procedure provides much more than simply a model of the patients limb; it also simulates the socket design and provides alignment information. When combined with an accurate physical examination and personal history, the impression forms the foundation for prosthetic design.
Computer Input
Presently, 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, which holds it in a centered position. A probe, or digitizing arm, is then used to locate and identify different landmarks in the negative impression. 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 ). Other
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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.
Computer-Aided Design
Once the digitized impression of the residual limb is in the computer, the prosthetist can look at an exact replica of the patients residual limb on the computer screen. The replica is generally shown as a wire frame drawing that gives a good three-dimensional perspective, but it can also be viewed as if it were a solid model. 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 ).
Computer-Aided Manufacturing
Once the prosthetist is satisfied with the socket design, a numerically controlled milling machine can be used to carve the rectified plaster model from a blank ( Fig 4-6 ). The socket is then fabricated in the conventional manner or with a semiautomated machine ( Fig 4-7 ). 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. Although this first generation of CAD/CAM in prosthetics is very basic, it is a logical development that parallels related advances in other professions. 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. Recently, several central fabrication companies have purchased the extremely expensive carving and socket manufacturing equipment so that a prosthetist need only purchase the digitizer, computer, and software. 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. Although prosthetists presently freely trade disks of information regarding the modification techniques that they have developed on the computer, it is likely that such information will be commercialized in the future. 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.
TEST SOCKETS
Regardless of the method chosen for rectification and manufacturing of the socket, test socket fitting is recommended to ensure that the socket fits the patient optimally before it is attached to an artificial limb. Test sockets are made over the modified positive model from a number of materials; a transparent plastic is the most common choice ( Fig 4-8 ). A separate appointment is usually necessary for test socket fitting. The patient is instructed in the use of prosthetic socks (when applicable), and these are put on the patient's limb before the socket is applied. When weight-bearing test sockets are fitted, 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, or the test socket may be attached to the components of the prosthesis. Several methods may be used to evaluate the socket fit, but in most cases holes are drilled in the socket at strategic areas such as over bony prominences or areas critical to suspension. The tissue is then probed with a small, blunt rod to determine local skin pressures. 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. During the test socket fitting, the prosthe-tist will frequently split the socket to make volume adjustments or will heat-modify and trim away portions of the socket. Reference marks are made in those areas that cannot be fully relieved during the test socket fitting. When the test socket is filled with plaster to create a new positive model, the prosthetist can modify the mold in this area to ensure proper fit. The following four factors are evaluated during the test socket fitting: 1. Comfort 2. Even distribution of weight-bearing pressure and biomechanical forces 3. Suspension
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DYNAMIC ALIGNMENT
Since each patient has a unique gait pattern and activity level, dynamic alignment of the prosthesis must be done on an individual basis. The purpose of dynamic alignment is to provide maximum comfort, efficient function, and cosmesis by adjusting the relative position of the components while the patient is using the limb in a number of controlled situations. During the alignment stage, the prosthesis must be durable and functional but must also be adjustable in all planes. For example, in an upper-limb fitting, the suspension and control harnesses, cable attachments, and forearm length are all adjustable, and the efficiency of various configurations is measured by the use of prehension gauges and force scales. 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. Complicated cases, of course, also require additional time. Lower-limb alignment generally takes place within parallel bars in a private walking room in the prosthetist's office. The following procedures summarize the basics of the alignment process: 1. The function of the prosthesis is explained, and the amputee is instructed in how to don the prosthesis properly, including the use of prosthetic socks, if required. 2. Contours are checked to ensure that the socket fits properly and comfortably. 3. The length and angulation of the prosthesis is checked. 4. The suspension is tested. 5. The patient is instructed to stand in a relaxed attitude while wearing the prosthesis. 6. Static alignment of the components is refined ( Fig 4-9 ). 7. The patient begins to use the prosthesis in a controlled manner by walking inside parallel bars or operating the terminal device. Dynamic function of components is checked during use and adjusted to provide maximum efficiency, comfort, and cosmesis ( Fig 4-10 ). 8. The prosthesis is checked with the patient sitting, and adjustments are made to increase comfort or function in this position as well. Socket design and alignment complement each other and are the fundamental determinants of prosthetic function. No matter how sophisticated the components are, how well the prosthesis is finished, or how carefully it is fabricated, if it is malaligned or uncomfortable, the overall function will be drastically reduced. 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. More experienced individuals are usually able to provide accurate feedback concerning how the prosthesis fits and feels during walking. The prosthetist can then make adjustments in a rapid and accurate fashion, and the fitting proceeds smoothly ( Fig 4-11 ). New amputees, however, cannot always provide accurate feedback; therefore, 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, and further adjustments can be made as endurance and ability to use the prosthesis improve. Generally, 1 week in physical therapy with the prosthesis will afford adequate time for the prosthetist to make decisions concerning the final alignment. The therapist also helps the amputee master more advanced activities such as negotiating inclines, stairs, and irregular terrain. 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).
FOLLOW-UP
Proper patient follow-up is of critical importance in prosthetics. New amputees in particular require follow-up at frequent intervals; they should be developing not only tolerance to pressures of the prosthesis against the skin but also general physical endurance. Patients will have many questions after wearing the prosthesis for a week or two, such as how to use the prosthesis while driving a car and during sports activities and dancing, choosing the proper shoes, and wearing the prosthesis to the beach. In addition, a number of minor problems can occur during the first few weeks of prosthetic wear from pressure areas in the socket, discomfort while sitting, or problems when wearing different shoes. These concerns can be
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easily corrected during a follow-up visit. Patients should be seen, at the very minimum, every 4 to 6 months. The prosthesis contains many moving mechanical components that require cleaning, maintenance, or replacement at intervals. Some components, particularly joint mechanisms, must be cleaned and adjusted on a regular basis because they directly affect the function of the prosthesis. Changes in the volume or shape of the patient's residual limb will frequently require socket adjustments, particularly during the first month of wearing a new prosthesis. In some cases, varying the thickness or ply of the prosthetic socks will improve the fit of the prosthesis, but in many cases more extensive modifications are required. Socket adjustments are made only after a careful analysis of the cause of discomfort is completed by the prosthetist. 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, thereby redistributing the forces. In some cases, minor alignment changes can be made to further reduce discomfort or pressures. It is important for the prosthetist to keep a good record of all follow-up adjustments. Such information will help guide future decisions regarding socket or component modification and prosthetic design.
MATERIALS
A wide variety of natural and man-made materials are used in prosthetics today. Whether natural or man-made, however, they must still conform to the special requirements of the profession: biocompatibility, strength, durability, light weight, and ease of fabrication. The most common materials used in prosthetics today are various plastics, but the more traditional materials such as wood, leather, metal, and cloth still have a role to play.
Wood
Wood is often used in lower-limb prostheses to provide shape and interior structural strength. The inherent properties of wood make it a very difficult material to replace: it is lightweight, strong, inexpensive, easy to work, and consistent in texture. Basswood (linden), willow, and poplar wood are most commonly used for prosthetic knees and shins because they are lightweight, strong, and free from knots and can be shaped easily by using standard woodworking tools. When a prosthesis is finished, it is hollowed out until the wood is only 6 mm (1/4 in.) thick to reduce weight. Hardwoods are also used in lower-limb prosthetics. Solid-ankle, cushion-heel (SACH) feet have an interior hardwood keel that provides structural strength to the foot. This keel is bolted to the rest of the prosthesis and provides a strong anterior lever arm when the amputee stands and walks. Maple and hickory are commonly used for keels in prosthetic feet and to reinforce high stress areas of prosthetic knee units. 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.
Leather
Leather is another material still commonly used in prosthetics for suspension straps, waist belts, and socket linings. Leather is easy to work with, has a soft natural feel, and is biocompatible. Many years ago hides were available from horses, elk, deer, as well as cattle, but today cowhide is modified by the tannery to provide the same feel and working properties as the hides of other animals. Therefore, "horsehide" is actually cowhide that has been treated to provide the thin, soft flexible properties of the original horsehide. The properties of "horsehide" make it a very attractive material to use when the leather is to contact the skin; therefore, it is used to line waist belts, suspension straps, and inserts for patellar tendonbearing (PTB) sockets. Since "horsehide" will stretch easily with wear, it must be reinforced with another material such as cowhide or synthetic fabric. Other variations such as elk, calf, kip, and rawhide, 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. Plastics such as Naugahyde and thermoplastic foam have replaced leather in some applications but will probably never completely replace this readily available biological material.
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Cloth
Cloth is used for prosthetic socks, waist belts, straps, and harnesses for upper-limb prostheses. Probably the greatest use of cloth is for prosthetic socks, which can be considered analogous to athletic socks since they keep the skin dry, cushion the limb, absorb shear forces, and take up volume to improve the fit. Prosthetic socks are commonly made of wool, cotton, or blends of these natural fibers often combined with nylon, Orion, acrylics, or other man-made materials. Wool is the most common material used for prosthetic socks because of its characteristic elasticity, cushioning, and ability to absorb moisture without feeling damp. Wool also has good resistance to acids from perspiration. The blend of domestic and foreign wool fleece used in prosthetic socks provides greater resistance to shrinkage. Pure wool, however, must be washed carefully in a mild soap that will dissolve in lukewarm water. The sock should be rinsed in lukewarm water as well since a change in temperature will affect it adversely. Wool prosthetic socks should be dried carefully by first removing the excess water, wrapping them in a towel, and then drying them away from sunlight or any other direct heat. The recent development of machine-washable wool should reduce the need for hand washing in the future. 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. Cotton is also blended with wool in prosthetic socks, and some 100% cotton prosthetic socks are available. Cotton is a natural vegetable fiber that is soft, pliable, and absorbent, but falls short of wool in all of its properties. Cotton, however, is easier to care for and less expensive than wool, which makes it more practical for many uses.
Plastics
Nylon is used for prosthetic sheaths, plastic laminations, bushings, suction valves, and nylon stockings to cover prostheses. The major advantages of this man-made fiber are its strength, elasticity, and low coefficient of friction. Nylon prosthetic sheaths are in common use for transtibial amputees. 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. A nylon stockinette provides inherent strength to nearly all prosthetic laminations ( Fig 4-12 ). 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. Nylon is a thermoplastic material, which means that it can be heated and remolded without adversely affecting its physical properties. Acrylics are thermoplastics that have greater durability and strength than polyester resins do. Acrylic fibers are frequently used in the newer synthetic blends for prosthetic socks since this material is soft, durable, and machine washable. Acrylic resin is increasingly popular for laminations in prosthetics because its high strength permits a thinner, lighter-weight lamination and its thermoplastic properties allow easier adjustments of the prosthesis by reheating the plastic and remolding it locally. Acrylic resins tend to have a softer feel than polyester resins but are more difficult to use during fabrication. Clear acrylics have been used for years in the sign and building industry for skylights and enclosures for shopping centers; they do not yellow and have good weather resistance. Polyester resin is a thermosetting plastic that is most commonly used for laminations in prosthetics. Thermosetting plastics cannot be heated and reformed after molding without destroying their physical properties. Polyester resins come in a liquid form that can be pigmented to match the patient's natural skin tone. A benzoyl peroxide catalyst is then added to this resin to initiate the setting process, and a promoting chemical is added to speed up the setting time. Polypropylene is used for hip joints, pelvic bands, knee joints, and lightweight prostheses. Polypropylene is used in great quantities in industry for everything from fan shrouds in passenger cars to carpets and shipping containers. Polypropylene is an opaque white material that is relatively inexpensive, strong, durable, and easy to mold. This material can be welded by using hot air or nitrogen. Polypropylene sheets 1 to 9 mm (1/16 to 3/8 in.) thick are heated and vacuum-formed over the mold of a socket or complete limb. Polyethylene is an opaque white thermoplastic that looks like polypropylene but feels waxier.
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The properties of polyethylene vary depending on the density of the material. Low-density polyethylene (LDPE) is very flexible and easy to heat and mold; it is used for triceps cuffs in transradial (below-elbow) prostheses and for tongues in plastic thigh corsets and hip disarticulation sockets. High-density polyethylene (HDPE) is more difficult to modify and is used to make bushings in joint mechanisms. Ultrahigh-molecular weight (UHMW) polyethylene is sometimes used in partial-hand or partial-foot prostheses due to its tear resistance. Polyurethane foams are widely used in prosthetics for both soft cosmetic foam covers ( Fig 413 ) and rigid structural sections. Polyurethanes, also called ure-thanes, are available in three broad groups: flexible foam, rigid foam, and elastomers. Flexible urethane foams are generally purchased in prefabricated pieces from suppliers as covers for en-doskeletal prostheses. The foam is shaped by the pros-thetist from measurements and tracings of the patients limb. Flexible polyurethane foams are also widely used in the manufacture of prosthetic feet. Rigid polyurethane foams compete with wood in providing structural stability to knee units and ankle blocks. Prosthetists routinely use this foam to provide both strength and shape to exoskeletal prostheses. A plastic lamination covers the foam to provide additional strength and cosmesis. Silicones are used in prosthetics for distal end pads in sockets, to provide a flexible rubberlike end in air-cushion sockets, and for silicone gel insets. Silicones can be classified as fluids, elastomers, or resins, and all three are used in prosthetics. Silicone is synthesized from sand (a combination of silicon and oxygen) and undergoes a number of chemical reactions before liquid or solid silicone results. The room-temperature-vulcanizing (RTV) silicones are used most widely in prosthetics. Silicones have relatively uniform properties over a wide temperature range, repel water, are chemically inert, resist weathering, and have a high degree of slip or lubricity. Silicone fluid is used for lubrication of moving parts, as the liquid inside hydraulic knee mechanisms, and as a parting agent. A two-component silicone elastomer is used for foaming end pads in sockets while the patient is weight-bearing to ensure total contact. Silicone gel-impregnated gauze is an excellent cushioning and force distribution material for weight-bearing prosthetic sockets. Although the gel adds weight and bulk to a prosthesis, it has been proved to work well for many problem cases, particularly those with burns or severe scarring.
FIBER REINFORCEMENTS
Two basic types of high-strength fiber reinforcements are used in prosthetics today: glass and carbon. Fiberglass is commonly used to reinforce polyester resin laminations where mechanical attachments such as bolts and screws will fasten. It is also used to stiffen thin areas and to prevent breakage in vulnerable areas. Fiberglass is difficult to finish smoothly, so care must be taken to avoid exposed areas of this material. 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. A unidirectional arrangement of fibers found in continuous-strand roving allows the best reinforcement if placed directly in line with the stresses. 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 fibers are more expensive than fiberglass but have superior strength and stiffness. They are also being used by component manufacturers to replace metal. Carbon fibers are generally set in epoxy and can provide a material with a stiffness twice that of steel at a fifth the weight. In addition to this high strength-to-weight ratio, carbon fiber composites have a fatigue resistance twice that of steel, aluminum, or fiberglass. Prefabricated carbon fiber prosthetic components such as pylon tubes, knee joints, and connectors can significantly reduce the weight of the prosthesis while increasing its strength.
SUMMARY
Modern prosthetic care is far more complex and far more effective than was the case just a few decades ago. 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 ). Widespread availability of transparent test sockets allows more precise and more comfortable fittings, while sophisticated knee/ankle/foot mechanisms and myoelectrically controlled
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prehensors have increased the versatility of prosthetic devices. Rehabilitation begins prior to amputation and continues as the amputee progresses from the postoperative or initial device to the preparatory and definitive designs. Special-use prostheses for sports and recreational uses are now available. Although aerospace materials are increasingly common in prosthetic design, the traditional materials such as wood, cloth, and leather still have a role to play. References: 1. Wu Y, Keagy RD, Krick HJ, et al: An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg Am 1979; 61:724-729. 2. Wu Y, Krick HJ: Removable rigid dressing for below-knee amputees. Clin Prosthetics Orthotics 1978; 2:33-44.
Chapter 4 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library
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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.
SHOULDER COMPLEX
Motion in the Frontal or Coronal Plane
When the arm and forearm are held in the anatomic position, the antecubital surface facing anteriorly, the upper limb sweeps a circular surface in the frontal plane. The very distal point of the extremity traces an envelope of action E1 ( Fig 5-3 ). In position 1 the shoulder is in neutral rotation, and the extremity can be elevated in the outer half of the circle to positions 2 and 3. The elbow does not contribute to functional exploration in this segment of the arc of motion. If the wrist is initially held in neutral rotation, the hand sweeps the space E3 , and the digits explore the interior of this space through E4 . Beyond position 3 the shoulder externally rotates, and complete elevation is achieved at position 4. In this second arc of motion the elbow explores the segment of the space through its action envelope E2 . The sweeping of the inner half of the coronal circle is now possible from position 4 to 5 through internal rotation of the shoulder. The elbow action dissipates. From position 5 to 6 the shoulder externally rotates, and elbow functional capability in this plane reappears, whereas with further external rotation from position 6 to 1, the elbow action dissipates again. When the upper limb is maintained in neutral rotation at the shoulder, the motion is quite restricted ( Fig 5-4 ), and no elbow action is possible in this plane. Maintaining the extremity in complete external rotation permits exploration of the outer half of the frontal circle with ease, whereas any functional development in the inner half is very restricted. The elbow envelope of action is clearly visible now in all positions ( Fig 5-2 ). Placement of the limb in complete internal rotation significantly restricts the field of motion ( Fig 5-5 ). Elbow action is possible from position 1 to 2. The coronal plane is also explored posteriorly in the inner half space ( Fig 5-6 ). With a position of internal rotation at the shoulder, the limb traces a small arc of displacement just enough for the elbow, wrist, and hand to sweep the surface corresponding to the gluteal area and up to the opposite scapular region. From position 3 the elbow envelope of action scans the posterior aspect of the head, neck, and shoulder.
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5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library
During elevation of the upper extremity in the frontal plane, motion is determined by the scapulohumeral joint and scapulothoracic upward rotation. The acromioclavicular and sternoclavicular joints also participate in a synchronized manner ( Fig 5-7 ). External rotation accompanies the elevation for the performance of a smooth motion. Beyond 90 degrees of elevation this external rotation is necessary to free the greater tuberosity from the acromial process, and more humeral articular surface is offered to the opposing glenoid ( Fig 5-8 ). From 0 to 30 degrees of elevation ( Fig 5-7 ) the motion occurs at the scapulohumeral joint, and the scapular motion is variable. This is the "setting phase" of the scapular motion. In the remaining arc of motion of 150 degrees, 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. The total contribution of the scapulohumeral joint is 130 degrees. The clavicle does not remain still. In the initial 90 degrees of motion the clavicle is elevated at the sternoclavicular joint for about 40 degrees, and in the second half of the arc of motion the clavicle rotates on its long axis for another 40 to 50 degrees. A combined acromioclavicular motion of 20 degrees occurs during the initial and terminal phases of elevation. 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, infraspinatus, teres minor, and subscapularis muscles ( Fig 5-9 ). The deltoid acts as the upper vector component of a force couple, whereas the rotator cuff stabilizes the humeral head and acts as the lower vector force of the couple. indicates that the deltoid action Electromyographic study of these muscles ( Fig 5-10 ) potential increases steadily with elevation, reaches a maximum at 110 degrees, and maintains a plateau level of activity with a final peak at full elevation. The supraspinatus also reaches a peak at 110 degrees, and beyond this point its activity diminishes and traces a sine wave. The subscapularis reaches peak activity at 100 degrees, maintains a plateau level up to 130 degrees, and diminishes rapidly in action. The teres minor reaches the maximum at 120 degrees and from there maintains the high level of activity, whereas the infraspinatus increases steadily in activity from the initial position to that of full elevation. The action of these two last muscles is necessary to continue the external rotation of the humerus during the last stage of the elevation. The posterior segment of the deltoid also participates as an external rotator ( Fig 5-11 ). 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. They act on the scapula as a force couple ( Fig 5-12 ). When the upper limb moves in the lower and inner quadrant of the envelope of action E1 , it is adducted and internally rotated. The internal rotation is brought about by the subscapularis, pectoralis major, and anterior segments of the deltoid ( Fig 5-11 ). Adduction is determined by the latter two muscles, supplemented by the action of the coracobrachialis ( Fig 5-13 ). During the anterior adduction-internal rotation, the scapula is abducted. This motion is controlled by the serratus anterior and the pectoralis minor ( Fig 5-14 ). When the upper limb moves in a similar lower and inner quadrant but posterior to the body, the limb is once more adducted and internally rotated. The posterior adduction is brought about by the latissimus dorsi, teres major, long head of the triceps, and posterior segment of the deltoid ( Fig 5-13 ). The latissimus dorsi and teres major also determine the associated internal rotation ( Fig 5-11 ). During this same motion, the scapula is adducted by the middle segment of the trapezius and the combined action of the rhomboidei and latissimus dorsi( Fig 5-15 ). When the upper limb is in a maximum position of elevation and is brought down in the frontal plane in the outer half circle, the scapula makes a downward rotation. This is determined by the combined action of the latissimus dorsi, lower segment of the pectoralis major (the pectoralis minor acting as the lower component for a force couple), and the levator scapulae, with the rhomboidei acting as the upper component of the rotational couple ( Fig 5-16 ). Downward stabilization of the limb in the frontal plane is also of important functional significance, such as in crutch walking or parallel bar exercising. This function is determined by the depressors of the shoulder complex: la-tissimus dorsi, lower segment of the trapezius, lower segment of the pectoralis major, pectoralis minor, and subclavius ( Fig 5-17 ). The upward stabilization in the frontal plane is also necessary for functional purposes, as in carrying heavy loads on the shoulders. This is controlled by the elevators of the scapula: levator scapulae, upper segment of the trapezius, and rhomboidei ( Fig 5-18 ).
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5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library
ELBOW
The elbow joint determines an arc of motion, E2 , of 150 degrees. The orientation of the plane of action is closely influenced by the rotational position of the shoulder joint. When the arm is elevated in the frontal plane, for example, the envelope of action E2 of the elbow is located in this plane if the shoulder is in external or internal rotation. The main flexors of the elbow are the brachialis and the biceps. The brachioradialis and pronator teres are the accessory flexors ( Fig 5-26 ). There is an intricate interplay and a wide range of participation in the elbow flexors. The brachialis is the baseline flexor and is active at any rotational position of the forearm and any speed, 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; it then acts as an an-tigravity muscle, The biceps is a flexor of the supine forearm, and its activity is evident as soon as slight resistance is applied. Deactivation occurs when the forearm is pronated unless significant resistance is applied to the pronated flexing forearm. The biceps is minimally active as an antigravity muscle or in maintaining a static flexed position. The brachioradialis is active when the forearm is flexing rapidly at any rotational position. It is also a reserve flexor during flexion against resistance, especially in neutral rotation of the forearm. The pronator teres does not participate as a flexor unless resistance is encountered during flexion. The extensor of the elbow is the triceps assisted by the anconeus ( Fig 5-28 ). The baseline worker during extension is the medial head of the triceps. Without load being applied, the long head is not active, whereas the lateral head is minimally active. These last two reserve extensors come into play when resistance is applied to the motion of extension ( Fig 5-29 ).
FOREARM ROTATION
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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. The corresponding rotation measured at the wrist is 156 degrees. The difference of 17 degrees indicates participation of the radiocarpal and midcarpal joints. 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, the hand is in a position of minimal supination of 11 degrees. The average range of pronation is 62 degrees and ranges from 49 degrees to 84 degrees. The average range of supination is 104 degrees and ranges from 86 degrees to 122 degrees. The axis of pronation-supination is variable in location. 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." In the average habitual motion, the axis passes through the distal end of the radius in line with the third metacarpal or the long finger. 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 ). Starting from the position of supination, the head of the ulna is extended and laterally displaced in the neutral position. In pronation the ulnar head is flexed and further displaced laterally. When the hand rests on its ulnar border on a surface and rotation is initiated, the motion occurs around the axis passing through the head of the ulna and the little finger. The head of the ulna remains still. The hand then makes a circumferential transposition. The styloid process of the radius traces a large arc of motion ( Fig 5-30 ). When rotational motion occurs along an axis passing through the middle finger and near the radial styloid process, the head of the ulna traces a much larger arc of motion than the radius. One can easily appreciate the shift of the rotational axis by supinating and pronating the forearm, the elbow being held at 90 degrees flexion, with the tip of an extended finger applied against the wall or the border of a table. In other words, the peripheral point of fixation through the finger or through a tool held in the hand determines the location of the axis of pronationsupination. When the rotation occurs along the oblique axis passing through the head of the ulna, the radial styloid traces an arc corresponding to the base of a cone. In full pronation the styloid process then appears to be less distal relative to the head of the ulna. The interosseous membrane uniting the radius and ulna relaxes or tenses during pronationsupination. The interosseous distance measured in the distal, middle, and proximal thirds of the forearm is the largest in neutral position and the smallest in full pronation ( Fig 5-31 ). The tension in the membrane is thus minimal in full pronation. During a fall on the outstretched pronated hand, the interosseous membrane is not the main element of pressure transmission to the elbow through the ulna. When load is applied to the forearm from a distoproximal direction, the radius transmits 57% of the load directly to the humerus and 43% to the ulna . The forearm is pronated by the pronator quadratus and pronator teres ( Fig 5-32 ). The main pronator is the pronator quadratus, the action of the muscle being independent of the position of the elbow. The pronator teres is a reserve pronator reinforcing the power when speed is required or resistance is applied to the motion ( Fig 5-33 ). The participation of the accessory pronators, flex or carpi radialis and palmaris longus, is controversial. The forearm is supinated by the supinator ( Fig 5-34 ). The biceps is the reserve supinator and reinforces the action when fast supination is required or resistance is encountered ( Fig 5-35 ). The extensor carpi radialis longus and brevis are accessory supinators.
WRIST
The wrist acts as a universal joint. It develops a spheroid type of motion envelope E3 ( Fig 536 ) that permits the hand to move without digital motion. The wrist flexes, extends, deviates laterally, and participates minimally in pronation-supination. The wrist traces an arc of 121 degrees of flexion-extension with a minimum of 84 degrees and a maximum of 169 degrees. The average arc of extension is 55 degrees and ranges from 31 degrees to 79 degrees; the average arc of flexion is 66 degrees and ranges from 38 degrees to 102 degrees, as measured on 55 normal adult wrists. The radiocarpal and midcarpal joints participate in this motion, and both flexion and extension are initiated in the midcarpal joint ( Fig 5-37 ). Starting from the neutral position, when the wrist flexes, the average range of flexion is 40 degrees at the midcarpal joint and 26 degrees at the radiocarpal joint. The midcarpal joint contributes 60% of the arc of flexion, and the radiocarpal joint contributes 40%. During extension the average range of extension is 19 degrees at the midcarpal joint and 37 degrees at the radiocarpal joint. The midcarpal joint contributes 33.5% of the arc of extension, and the radiocarpal joint contributes 66.5% ( Fig 5-38 ). The scaphoid belongs anatomically to both rows, and yet functionally it is part of the distal row in extension and part of the proximal row
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in flexion. 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 rigidity of the carpal mass in extension favors fracture of the scaphoid or the distal end of the radius on impact. The combination of wrist extension and pronation-supination permits the hand to explore the outer half of a circle ( Fig 5-39 ). The flexed wrist, when rotated, permits the hand to explore the inner half of a circle ( Fig 5-40 ). This latter motion is concerned more with functional activities related to the body. Functionally the hand is used more frequently with the wrist extended and radially deviated or with flexion combined with ulnar deviation. The wrist is flexed by the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus. The long digital flexors are the accessory flexors of the wrist. The wrist extenders are the extensor carpi radialis longus and brevis and the extensor carpi ulnaris. The digital extensors are the accessory extensors of the wrist. The motion of lateral deviation of the wrist averages 40 degrees, with 30 degrees in the ulnar direction and 15 degrees on the radial side. The proximal and distal rows of the carpus participate and move in the opposite direction. During ulnar deviation the distal row rotates with the metacarpals ulnaward, and the proximal row, including the scaphoid, turns radialward. The reverse motion occurs during radial deviation. The range of ulnar deviation is greater when the hand is supinated. During radial deviation the scaphoid rotates posteroanteriorly, the proximal pole turning dorsally and the distal pole with its tuberosity anteriorly. The lunate follows the scaphoid and flexes. In ulnar deviation, the scaphoid derotates and exposes its full profile ( Fig 5-41 ). Pronation occurs when the hand extends in a radial direction starting from a neutral rotation position. Supination accompanies the motion of flexion with ulnar deviation. This combination of motion becomes quite evident during manipulative functions of the hand and wrist when involved in power-type performance (hammering, casting a fishing line, swinging a club, etc.). The center of rotation during radioulnar deviation is located in the head of the capitate. The radial deviators of the wrist are the abductor pollicis, extensor pollicis brevis, extensor carpi radialis longus and brevis, long extensors of the index, and the flexor carpi radialis. The ulnar de viators are the extensor carpi ulnaris, flexor carpi ulnaris, and long extensors of the middle, ring, and little fingers. The wrist is a key joint with regard to the functional activities of the hand. Grip power is maximal when the wrist is extended to 35 degrees and minimal with the wrist maximally flexed. The degree of participation of the digital motors determines, on the other hand, recruitment of the wrist motors. When the wrist is in extension and the fingers make a soft fist, the following wrist motors are active in a descending order: extensor carpi radialis brevis, extensor carpi ulnaris, and extensor carpi radialis longus. With a tight fist, all three extensors are maximally active ( Fig 5-42 ). When the fingers are gently extended and the wrist is held in extension, the extensor carpi ulnaris and flexor carpi ulnaris are active. The forceful opening of the fingers brings into action, in a descending order, the following additional wrist motors: extensor carpi radialis brevis, palmaris longus, extensor carpi radialis longus, and flexor carpi radialis ( Fig 5-43 ).
HAND
Fingers
Located at the end of a multisegmented system, the hand functions within the action envelope E3 of the wrist. The flexing finger traces an action envelope, E4 , that is an equiangular spiral ( Fig 5-36 ). When the wrist is extended, the field of motion of the fingers is within the wrist envelope E3 . With wrist flexion the action envelope E4 of the fingers extends beyond the field of motion of the wrist ( Fig 5-36 ). If the fingers are to be used for the purpose of prehension, 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. Separately the distal joint is flexed by the flexor profundus, the middle joint by the flexor superficialis and the metacarpophalangeal joint by the intrinsic muscles. 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.
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Furthermore, a fine mechanism of coordination is present locally in the fingers at the level of the interphalangeal joints as presented by Landsmeer. As soon as flexion is initiated at the level of the distal joint ( Fig 5-44 ) by the flexor profundus, the terminal extensor tendon is displaced distally, and the extensor trifurca-tion is carried distally through the lateral tendons, thus relaxing the middle slip. Simultaneously, the oblique retinacular ligament attached to the terminal tendon also increases in tension and, passing volar to the axis of motion at the proximal interphalangeal joint, automatically flexes the middle phalanx. This is a passive mechanism of interphalangeal joint coordination. When the finger reaches a position of flexion close to 70 degrees at the proximal interphalangeal joint, the previously relaxed middle slip goes under tension, and the extensor trifurcation is displaced further distally. This displacement relaxes the lateral slips, lateral tendons, and terminal tendon. This unloading of the extensor tendon at the distal joint allows completion of the flexion at this joint without encountering undue resistance. Any break in this system of activation and coordination interferes immediately with the function of prehension. 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. The three joints flex successively from a distoproximal direction rather than simultaneously, and this pattern of flexion prevents the palmar skin from making the necessary surface contact with the object. The opening of the fingers is an essential prerequisite for the act of prehension. Extension of the metacarpophalangeal joint is controlled by the long extensor. The mechanism is dual. 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. A direct action is present through a tendinous attachment of the long extensor to the dorsum of the proximal phalanx. This band is present in only 38.5% of dissected hands. The proximal interphalangeal joint is extended by the long extensor middle slip and spiral fibers arising from the intrinsic tendons. The distal joint is extended by the terminal tendon, which is essentially formed by the long extensor lateral slip but also receives a contribution from the corresponding intrinsic tendons. The oblique retinacular ligaments participate in the constitution of this tendon ( Fig 5-45 ). When the middle joint extends actively, the oblique retinacular goes under tension and This is another mechanism of coordination on the automatically extends the distal joint. extensor side of the finger. 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, 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. In maximum flexion, the lateral slips are at the level of the axis of motion of the joint. The side motion and rotation of the fingers are determined by the intrinsic muscles. The dorsal interossei abduct or spread the fingers, whereas the volar interossei adduct the fingers relative to a functional axis passing through the third metacarpal. There is more abduction to the finger in extension and less in flexion. A final passive mechanism of flexion-extension of the finger is present through a tenodesis effect: wrist extension flexes the fingers, and wrist flexion extends them.
Thumb
The thumb sweeps a conoid surface through circumduction. This curved surface is flattened on the palmar aspect ( Fig 5-46 ). All functional activities of the thumb occur within this envelope. 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 ). Through extension-abduction the ray returns to its initial position. A fundamental function of the thumb is opposition with the fingers. This occurs as the pad of the thumb is set against the pulp of a corresponding finger. To bring about this opposition, the thumb is abducted in a plane perpendicular to the palm and flexed and rotated pronated) on its long axis ( Fig 5-48 ). The thumb and the pulp of the finger make contact along the equiangular spiral curve of the finger. There are two phases to the opposition. In stage I the thumb is positioned against the pulp of a corresponding finger. This is determined by the abductor pollicis bre-vis, opponens, and superficial head of the short flexor. Stage I is a function of the median nerve. Stage II of the opposition is the clamping of the thumb pad against the opposed finger. This phase provides
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the power for the opposition. It is controlled by the adductor and deep head of the short flexor and is a function of the ulnar nerve ( Fig 5-48 ).
Functional Activities
The functional activities of the hand are extensive but can be grouped into nonprehensile and prehensile activities. The former includes touching, feeling, pressing down with the fingers, tapping, vibrating the cord of a musical instrument, lifting or pushing with the hand, stirring, etc. Prehensile activities are grouped into precision and power grips. Precision grip involves participation of the radial side of the hand with the thumb, index, and middle finger to form a three-jaw chuck. When the pulp of these digits comes into contact, the grip is of the palmar type, whereas for very precise work contact with the tip of the same digits, creates a tip type of grip. A lateral, or key, grip involves contact of the pulp of the thumb with the lateral aspect of the corresponding finger in its distal segment. Power grip predominantly involves the ulnar aspect of the hand with involvement of the little and ring fingers. 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. A typical power grip is the cylindrical grip. All fingers are flexed maximally, for example, around the handle of a tool, and the counterpressure to the flexing fingers is provided by the thenar eminence. More power is provided to this grip when the thumb wraps around the flexed fingers. If an element of precision is necessary, the thumb will adopt a longitudinal position of adduction that allows for small adjustments of posture. In general, the pattern of the grip during prehension is A scalpel is determined by the intention and not necessarily by the shape of the object. held in a precision grip for exact work or in a power grip for bold cuts. The hook power grip involves flexion of both inter-phalangeal joints and minimal participation of the metacarpophalangeal joint. This pattern is used in carrying a suitcase. The spherical grip is an interesting grip. If the object held by the digits is large, the grip is of the power type with minimal flexion of the fingers, which are abducted and rotated, and the thumb participates at the opposite pole by stabilizing the object and providing the necessary counterpressure. With a smaller spherical object the fingers are adducted, and the thumb is in opposition; this pattern of prehension is of the precision type. Despite the multitude of functional activities of the hand, any prehensile act when arrested instantaneously might fit in one of these patterns in a pure or combined form. 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. The flexor superficialis is a reserve flexor and participates when more power is necessary. The index finger is an The thumb brings its exception; here the flexor superficialis pattern predominates. contribution with the thenar muscles and the long motors, except for the abductor pollicis longus. In the hook type of prehension, the radial intrinsics are silent. The long flexors, fourth dorsal interosseous, lumbricales, and the abductor digiti quinti, are active. During soft opposition of the thumb with the index finger-palmar prehension-the opponens, abductor pollicis brevis, and short flexor are active in a decreasing order ( Fig 5-49 ). When pressure is exerted, the short flexor becomes the more active, followed by the opponens and abductor pollicis brevis. In the lateral grip the flexor pollicis brevis and the opponens are very active. The activity of the abductor pollicis brevis is negligible. References: 1. American Academy of Orthopaedic Surgeons: Joint Motion - Method of Measuring and Recording. Chicago, 1969. 2. Capener N: The hand in surgery. J Bone Joint Surg [Br] 1956;38:128-151. 3. Christensen JB, Adams JP, Cho KO, et al: A study of the interosseous distance between the radius and ulna during rotation of the forearm. Anat Rec 1968; 160:261271. 4. Darcus HD, Salter N: The amplitude of pronation and supination with the elbow flexed to a right angle. J Anat 1953;87:169-184. 5. Forrest WJ, Basmajian JV: Functions of human thenar and hypothenar muscles: An electromyographic study of 25 hands. J Bone Joint Surg [Am] 1965; 47:1585-1594. 6. Gemmill JF: On the movement of the lower end of the radius in pronation and
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supination and on the interosseous membrane. J Anat Physiol 1901; 35:101-109. 7. Halls AA, Travill A: Transmission of pressures across the elbow joint. Anat Rec 1964; 150:243-247. 8. Inman VT, Saunders M, Abbott LC: Observations on the function of the shoulder joint. J Bone Joint Surg 1944; 26:1-30. 9. Kaplan EB: Functional and Surgical Anatomy of the Hand, ed 2. Philadelphia, JB Lippincott, 1965. 10. Landsmeer JMF: The anatomy of the dorsal aponeurosis of the human finger and its functional significance, Anat Rec 1949; 104:31-44. 11. Littler JW: Hand structure and function. Symp Reconstr Hand Surg 1974; 9:3-12. 12. Littler JW: On the adaptability of man's hand. Hand 1973;9:187-191. 13. Long C, Conrad PW, Hall EA, et al: Intrinsic-extrinsic muscle control of the hand in power grip and precision handling: An electromyographic study. J Bone Joint Surg [Am] 1970; 52:852-867. 14. MacConaill MA, Basmajian JV: Muscles and Movements - a Basis for Human Kinesiology. Baltimore, Williams & Wilkins, 1969. 15. Napier JR: The prehensile movements of the human hand. J Bone Joint Surg [Br] 1956; 38:902-913. 16. Radonjic D., Long C: Kinesiology of the wrist. Am J Phys Med 1971; 50:57-71. 17. Sarrafian SK, Melamed JL: Unpublished data, 1975. 18. Sarrafian SK, Melamed JL, Goshgarian GM: Study of wrist motion in flexion and extension. Clin Orthop 1977; 126:153-159. 19. Travill AA: Electromyographic study of the extensor apparatus of the forearm. Anat Rec 1962; 144:373-376.
Chapter 5 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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OVERVIEW
Body-powered components have been used in upper-limb prostheses for centuries and are still commonly prescribed today. The term body powered acknowledges that the force to operate such components comes from mechanical transmission of muscular effort generated elsewhere in the body, remote from the amputation site. When body power is insufficient or undesirable, externally powered components may be utilized. "External power" comes from a source outside the body; contemporary versions are battery-powered electronic devices, although pneumatic, hydraulic, and other power sources have been utilized in the past. As a group, body-powered devices enjoy the triple advantages of low cost, light weight, and high reliability due to mechanical simplicity. Their widespread application today throughout the world verifies the practical advantages offered by such components. They also share significant disadvantages, however. The harness required to transmit muscle forces inevitably restricts the amputee's work envelope and often encumbers the noninvolved side. The amputee must exert effort to generate sufficient force and excursion to operate the component. Some find this objectionable; 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). Finally, the robotlike appearance of some body-powered components can be disconcerting to the general public as well as to the 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
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. Since passive devices have no moving parts and require no cables or batteries for operation, they are typically extremely lightweight and reliable.
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Prehensors
Prehensors offer active grasp and may be classified according to their mode of operation. "Voluntary-opening" devices are normally held closed by a spring or rubber band mechanism but open when the control cable is pulled. "Voluntary-closing" devices operate in a converse manner. Prehensors may also be subdivided into handlike and utilitarian shapes. The traditional utilitarian shape is the split hook.
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European manufacturers, most notably Otto Bock and Hugh Steeper, have recently made a number of terminal devices available to the American market. Many are really "tools" that interchange for specific tasks rather than multipurpose devices. Thus far, they have not developed widespread popularity in the United States ( Fig 6A-9.,A). 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.,B).
Voluntary-Closing Hooks
The APRL hook was developed by the Army Prosthetics Research Laboratory after World War II. It differs from all hooks previously discussed in several major respects: 1. The APRL hook is a voluntary-closing device. 2. The fingers automatically lock in any position once grasp is accomplished. 3. A selector switch permits the amputee to choose either a. A large finger opening (7.5 cm, 3 in.). b. A small finger opening (3.4 cm, l 3/8 in.). c. "Freewheeling"-a small opening with the locking function eliminated. 4. The operating lever or thumb is located on the ulnar side of the device ( Fig 6A-10. ). This device was originally developed to use biceps cineplasty as a source for body power. The voluntary-closing mode provides graded prehension: the pinch force is as gentle or strong as the force generated by the amputee. Particularly with a cineplasty, this can improve proprioception. Unfortunately, the mechanical complexity of this device makes it both expensive and prone to breakdown. The hollow aluminum lyre-shaped fingers it shares with the "two-load" hook make it somewhat fragile. Combined with the waning popularity of cineplasties, these factors limit its prescription primarily to previous wearers. The graded prehension may also be of value to selected bilateral upper-limb amputees. Bob Radocy, a recreational therapist and transradial amputee, has introduced a series of voluntary-closing utilitarian devices. They are available in both aluminum and steel versions as well as plastic-coated styles for children. Patient acceptance has been good, particularly for children and sports-minded adults (see Chapter 12C). None have a locking mechanism, which means that the amputee must maintain continuous force to grasp an object. Although this is physiologically normal, some find it objectionable. Acceptance has been greatest for unilateral transradial amputees, particularly those with long residual limbs ( Fig 6A-11. ).
Voluntary-Closing Hands
Although voluntary-closing hands theoretically offer the same advantage of graded prehension as do hook devices, the frictional losses in the mechanism are much greater. The rubber cosmetic glove that covers the hand further impedes motion, and the contours often block visual inspection of the fingertips. For all these reasons, voluntary-closing hands have never enjoyed widespread popularity. The APRL hand, available in an adult male size only, has similar features to the APRL hook: 1. Automatic locking when grasp is accomplished 2. Small opening (with the thumb in the standard position) 3. Large opening (with the thumb in the second position) ( Fig 6A-12. ) Otto Bock of Germany exports a lightweight and inexpensive voluntary-closing hand in several sizes. It uses many of the same internal components as their electronic hand and has an identical external appearance and cosmetic glove. It is also available in a voluntary-opening configuration ( Fig 6A-13. ).
Voluntary-Opening Hands
Although a number of voluntary-opening hands are available, few if any are used as active terminal devices. In addition to the problems of frictional loss, glove restriction of motion, and contours that block visual inspection, all voluntary-opening devices offer only limited pinch
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force. Many new amputees desire an interchangeable hand for social occasions in addition to a hook device for manual work. This is the most common indication for body-powered hands. As a result of their extremely limited functional capabilities, they are rarely appropriate for bilateral upper-limb applications. 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. Becker Plylite Hand. -The Becker Plylite hand is a simple, lightweight, voluntary-opening hand that is available in sizes 6 to 10 in 1.3-cm (-in.) increments (e.g., 6, 6, 7, 7, 8) ( Fig 6A-14. ). The only moving component is the thumb. The larger models permit sufficient thumb movement to grasp objects of up to 7.5 cm (3 in.) in thickness. An optional locking mechanism that locks the thumb in the closed position is available. Becker Lock-Grip and Imperial Hands. -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. ,A and B). The Lock-Grip model contains a mechanism that locks the fingers in the closed position. Finger opening from the fully closed position can be effected only by control cable tension. Lock-Grip hands are available in 1.3-cm (-in.) increments from size 6 to size 10. The Imperial model, available in size 8 only, permits easy adjustment of finger prehension force with the use of a screwdriver. Robin-Aids Mechanical Hand. -The Robin-Aids mechanical hand is a voluntary-opening hand with control cable tension that causes digits 2, 3, 4, and 5 to move away from a stationary thumb ( Fig 6A-16. ). The thumb can be manually prepositioned for normal or large opening prehension. The force of prehension is generated by springs and may easily be increased or decreased by the prosthetist. 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. Robin-Aids Soft Mechanical Hand. -The Robin-Aids soft mechanical hand is a voluntaryopening hand ( Fig 6A-17. ). Tension on the central cable causes the thumb and first two fingers to open. The endoskeletal frame is encased in plastisol and covered with a urethane foam of low density that provides "softness." Both of the Robin-Aids hands are available in sizes 7, 7, 8, 8, and 9. Sierra Voluntary-Opening Hand. -The Sierra voluntary-opening hand, like the APRL hand, has a two-position stationary thumb ( Fig 6A-18. ). From the fully closed position, control cable tension causes the first two fingers to move away from the thumb. As tension on the control cable is relaxed, springs cause the fingers to move close toward the thumb. A "Bac Loc" feature operates in all finger positions and permits the amputee to hold heavy objects securely. Finger opening and release of the Bac Loc mechanism are operated simultaneously through a single control cable. The Sierra voluntary opening hand is available in size 8 only. Hosmer-Dorrance Functional Hands. -Hosmer-Dorrance functional voluntary-opening hands permit the prosthetist to adjust finger prehension by the installation of different tension springs ( Fig 6A-19. ). The hands are available in four sizes: 8, 7, 6, and 5.
COSMETIC GLOVES
A cosmetic glove is the rubberized covering that determines the external appearance of the prosthesis. 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. Three levels of cosmetic restoration are possible. A stock glove is the most common covering and is ordered by the prosthetist on the basis of hand size and skin tone. Most come in generic male and female, adolescent and child's contours in a few shades of Caucasion and Negroid plastic. Many amputees find the manni-kin-like appearance quite acceptable. The appearance can be improved by subtle painting of the veins and other structural details; fingernail polish can be applied and removed by the amputee. A custom production glove is manufactured from a donor mold of a hand similar in shape to the amputee's. The prosthetist sends a precise mold of the remaining hand to the factory so that the best match can be selected. A wider selection of skin tones are available than in the stock glove; artistic painting and fingernail polish can add realism.
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The custom-sculpted glove offers the greatest cosme-sis: it is hand-made from a sculptured reverse copy of the remaining hand. 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). Some prosthetists refer the amputee, with the completed prosthesis, to a cosmetic restorationist who creates the custom-sculpted glove to match the amputee and to fit over the prosthetic mechanism ( Fig 6A-20. ). Even a myoelectric hand can be covered with a sculpted glove.
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. The need for the first function is obvious. To the uninitiated, the importance of the second function of wrist units may be less clear. The above-elbow (transhumeral) amputee has lost all ability to supinate and pronate the prosthetic forearm. 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. Even at the very long transradial levels of amputation, the motions of supination and pronation are severely restricted. Consequently, the upper-limb amputee must be provided with a device that permits some form of substitution for active forearm rotation.
Quick-change wrist units are designed to facilitate rapid interchange of different terminal devices, usually a hook and a hand ( Fig 6A-26. ). All commercially available quick-change units permit the amputee to do the following: 1. 2. 3. 4. 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, which is screwed tightly on the studs of the two (or more) terminal devices to be interchanged. In these units light downward pressure on the activating lever by the amputee unlocks the terminal device but does not cause its ejection. With the terminal device unlocked, the amputee manually rotates the hook or hand to the desired attitude of pronation or supination. Next, the application of a proximally directed axial force with the sound hand causes the terminal device to be locked in the new position. Heavy downward pressure on the activating lever causes ejection of the adapter and attached terminal device. Quick-change units are available from the Hosmer-Dorrance Corporation in the adult size and round configuration only ( Fig 6A-27. ).
Wrist Flexion
Wrist flexion is particularly useful for activities at the midline: toileting, eating, shaving, dressing, et cetera. Such activities are performed more easily with the remaining hand than with a prosthesis. For this reason, prosthetic wrist flexion is seldom necessary for the unilateral amputee unless there is a restricted range of motion in the more proximal joints. However, it is of crucial importance for the bilateral upper-limb amputee who must perform all daily functions with prostheses. Because the mechanism adds weight near the termination of the prosthesis, it is sometimes prescribed only for the dominant side. Two types of mechanism can provide wrist flexion. The "Flexion Wrist" replaces the common constant-friction wrist and allows manual prepositioning of the hook in neutral, 30 degrees of volar flexion, or 50 degrees of volar flexion ( Fig 6A-28. ). The hook can also rotate about its mounting stud in any of the positions. The "Sierra Wrist Flexion Unit" is used in addition to the friction wrist ( Fig 6A-29. ). This dome-shaped device also has three locking positions at zero, 30, and 50 degrees of volar flexion. Because the entire unit can rotate where it mounts to the wrist, the terminal device covers a much wider arc than with the first alternative. This can be advantageous for the bilateral amputee struggling to perform midline activities. On the other hand, this unit is significantly heavier than the Flexion Wrist.
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. Friction and constant-friction wrist units tend to permit unwanted rotation when subjected to very high torsional loading. Rotational wrist units are cable-controlled, positive-locking mechanisms ( Fig 6A-30. ). In the unlocked mode, these units permit manual prepositioning of the terminal device in almost any attitude of supination or pronation through a 360-degree range. Once locked in position, these units provide much greater resistance to rotation than do friction units. The bilateral amputee may find that rotational wrist units facilitate prepositioning of the terminal devices. With the wrist unit unlocked and the terminal devices fully supinated or pronated, tension on the terminal device control cable causes the terminal device to rotate back to the "neutral" position.
Ball-and-Socket Wrist
A ball-and-socket wrist unit is also available ( Fig 6A-31. ). The unit permits universal prepositioning of the terminal device with constant friction. The magnitude of the friction
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ELBOW UNITS
Elbow Units for the Transradial Amputee
With amputation through the distal third of the forearm, the amputee retains a limited amount of active supination and pronation. Flexible hinges facilitate the transmissions of this residual forearm rotation to the terminal device, thereby minimizing the requirement for manual prepositioning by the amputee.
Flexible Hinges
Flexible hinges of metal or leather are commercially available. Dacron webbing may also be used. Attached proximally to the triceps pad and distally to the prosthetic forearm, these hinges permit the transmission of approximately 50% of the residual forearm rotation to the terminal device ( Fig 6A-32. ).
Rigid Hinges
For all practical purposes, 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. Single-Axis Hinges.-Single-axis hinges are designed to provide axial (rotational) stability between the prosthetic socket and residual forearm during active prosthetic use ( Fig 6A-32. ). Correctly aligned single-axis hinges should not restrict the normal flexion-extension range of motion of the anatomic elbow joint. Single-axis hinges are available in both adult and child sizes. Polycentric Hinges.-Short transradial levels of amputation require that the anteroproximal trim line of the prosthetic socket be close to the elbow joint. With a high anterior socket wall, complete elbow flexion tends to be restricted by the bunching of soft tissues in the antecubital region. Polycentric hinges help to increase elbow flexion by reducing the tendency for bunching of the soft tissues ( Fig 6A-34. ). Polycentric hinges are available in adult, medium, and child sizes. Step-Up Hinges.-Amputations immediately distal to the elbow joint require a prosthetic socket with extremely high trim lines. Consequently, flexion of the anatomic elbow joint is often restricted to 90 degrees or less. In those situations in which a full range of elbow flexion is essential, step-up hinges may be employed. The use of step-up hinges requires that the prosthetic forearm and socket be separated ( Fig 6A-35. ). Consequently, protheses employing step-up hinges are frequently referred to as split-socket prostheses. Step-up hinges amplify the excursion of anatomic elbow joint motion by a ratio of approximately 2:1. 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. The increased range of motion requires that the amputee exert twice as much force to flex the step-up hinge. Step-up hinges are available in adult, medium, and child sizes. Stump-Activated Locking Hinge.-Amputees with very high transradial levels of amputation are often unable to operate a conventional transradial prosthesis for the following reasons: 1. Inadequate strength of the elbow flexors 2. Inadequate range of elbow flexion 3. 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, the transradial prosthesis is controlled in much the same manner as a transhumeral prosthesis ( Fig 6A-36. ). As in the case of step-up hinges, a splitsocket prosthesis is used. Shoulder flexion on the amputated side flexes the mechanical elbow joint. The residual limb is used only for locking and unlocking the mechanical joint. Stump-activated locking hinges are available in two sizes, adult and small.
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Outside-Locking Hinges
Elbow disarticulation and transcondylar levels of amputation usually require the use of a specially designed elbow unit. The length of the residual humerus preeludes, for both aesthetic and functional reasons, the use of standard prosthetic elbow units. Outside-locking hinges are available in standard and heavy-duty models ( Fig 6A-37. ). The standard units provide seven different locking positions throughout the range of flexion and come in adult, medium, and child sizes. The heavy-duty model provides five locking positions and comes in the adult size only.
Friction Units
Friction elbows require passive positioning of the forearm but are very lightweight and simple to operate. For this reason, they are often appropriate for cosmetic restorations, pediatric applications, congenital anomalies, and instances when brachial plexus injury or other factors preclude active elbow function.
SHOULDER UNITS
Shoulder mechanisms vary according to the degree of motion allowed. The simplest design is termed a bulkhead when the humeral segment is directly connected to the socket and no motion can occur. Many unilateral amputees find this acceptable and appreciate the weight savings from omitting the joint. Passively movable friction-loaded shoulder joints are available and provide some assistance with dressing and desktop activities. Single-axis units permit only abduction, double-axis units ( Fig 6A-39. ,A) allow abduction and flexion, and triple-axis ( Fig 6A-39. ,B) and ball-andsocket configurations permit universal passive motion. Most are available in small, medium, and large sizes.
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As noted in Chapter 10B, prosthetists sometimes must custom-build shoulder joints if locking functions are desired. Fig 6A-40. illustrates one such design commercially available on a limited basis.
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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/chap06-02.asp[21/03/2013 21:53:36]
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 indicated by its name, the axilla loop encircles the shoulder girdle on the nonamputated side ( Fig 6B-6.). The second component of the transradial harness is the anterior support strap or, as it is sometimes called, "the inverted Y suspensor." The anterior support strap originates at the axilla loop, passes over the shoulder on the amputated side, and is attached to the anteroproxi-mal margins of the triceps pad of the prosthesis. 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.). The control attachment strap originates at the axilla loop and terminates at the proximal end of the prosthetic control cable ( Fig 6B-8.). Anchored by the axilla loop, the control attachment strap acts, in effect, as an extension of the control cable. Located between the spine and inferior angle of the scapula, the control attachment strap permits the use of scapular abduction and shoulder flexion on the amputated side for operation of the terminal device. 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.) or connected by a stainless steel ring ( Fig 6B-10. ). In the latter case, the harness is referred to as a "transradial, ring-type harness." (Because they are less restrictive, ring-type harnesses enjoy a high degree of acceptability by most transradial amputees.) Whether the harness straps are sewn together or attached to the axilla loop by a steel ring, mechanical efficiency will be enhanced if the cross point is located below the spinous process of C7 and slightly toward the nonamputated side. The primary body control motion for operating the terminal device of a transradial prosthesis is flexion of the glenohumeral joint ( Fig 6B-11. ). Glenohumeral flexion is excellent for the generation of force and provides more than enough cable travel for full terminal device operation. When terminal device operation close to the midline of the body is required, as when buttoning a shirt, the standard transradial harness permits the amputee to use biscapular abduction for terminal device operation ( Fig 6B-12. ).
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anterior support strap for the left prosthesis. As in the case of the standard unilateral harness, 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, glenohumeral flexion and/or biscapular abduction, for terminal device operation as does the unilateral transradial amputee.
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Although the initial placement of the elbow flexion attachment 3.1 cm (1.25 in.) distal to the elbow axis is usually satisfactory, in most instances, its precise location should be determined on an individual basis ( Fig 6B-20. ).
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The lateral support strap is the primary suspensory element of the harness. Originating posteriorly from the upper portion of the axilla loop, the strap is directed horizontally and stitched to the anterior support strap at their intersection ( Fig 6B-24. ,A and B). 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. ,C). In addition to its suspensory function, 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. The control attachment strap originates at the posterior intersection of the axilla loop. Running obliquely downward across the amputee's back, the control attachment strap terminates with its direct attachment to the elbow flexion/terminal device control cable ( Fig 6B-25. ). With the control attachment strap firmly fixed at its proximal end by the axilla loop, 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. 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. If the control attachment strap lies too high on the amputee's back, shoulder flexion will not produce sufficient cable excursion for full operation of the mechanical elbow and terminal device. Too low a strap position requires the amputee to use unnecessarily forceful shoulder flexion for full operation. With the control attachment strap located at approximately the midscapular level, midway between the spine and inferior angle, the amputee will usually be able to achieve full operation of the components through the application of a moderate amount of force. A cross-back strap is sometimes used as an adjunct to the standard transhumeral harness ( Fig 6B-26. ). Originating at the axilla loop close to the posterior axillary fold, the cross-back strap passes horizontally across the amputee's back and terminates at the distal end of the control attachment strap. Indications for the use of this strap relate primarily to amputee comfort and ease of prosthetic operation. At midhumeral and higher levels of transhumeral amputation it becomes increasingly important that the harness be fitted as intimately as possible. Since a snug harness fit requires a relatively small axilla loop, the loop may tend to cause axillary discomfort on the non-amputated side. This discomfort is due, primarily, to vertical compression of the pectoral, teres major, and latissimus dorsi tendons by the axilla loop during strenuous prosthetic usage. 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. 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. With the posterior intersection of the harness on or superior to the spinous process of C7, the amputee is uncomfortable, and the work efficiency of the entire harness and control system is diminished. The cross-back strap helps to maintain the posterior intersection of the harness below the spine of C7. As noted earlier in this chapter, the standard transhumeral prosthetic control system requires approximately 11.3 cm (4 in.) of cable excursion for full elbow and terminal device operation. 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. Ideally, the path of the control attachment strap should run between the spine and inferior angle of the scapula. Cable excursion, normally produced by glenohumeral flexion on the amputated side, diminishes as the path of the control attachment strap moves closer to the shoulder joint. The addition of a cross-back strap helps to keep the path of the control attachment strap positioned lower on the back. Cross-back straps may be made of either elastic or Dacron webbing. The nonelastic strap provides the amputee with more positive control of the prosthetic components and overall tautness of the harness. An elastic strap provides less positive control but greater degrees of comfort and mobility of the shoulder girdle. The elbow lock control strap originates at the upper, nonelastic portion of the anterior support strap and is attached at its distal end to the elbow lock control cable ( Fig 6B-27. ). To either lock or unlock the prosthetic elbow the amputee must first apply tension and then, in rapid sequence, relax tension on the elbow lock control cable. Although the cable excursion requirement for prosthetic elbow operation is small, approximately 1.3 cm ( in.), the body motion is somewhat complex. The amputee applies tension to the elbow lock
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control strap and cable by slight extension and abduction of the gle-nohumeral joint combined with equally slight shoulder depression on the amputated side. This motion, in addition to exerting tension on the elbow lock control strap and cable, also stretches the elastic portion of the anterior support strap. With the rapid return of the prosthesis to the starting position, the elastic tension of the anterior support strap serves to complete the lock/unlock cycle. The ring-type harness does not enjoy the same degree of acceptability in transhumeral harnessing as it does at the transradial level. At midhumeral and higher levels of amputation it becomes increasingly important that the harness fit be as snug as possible. Ring-type harnesses do not permit the same degree of tautness in the straps of the system as do stitched harnesses. Consequently, 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, unless the straps are sewn in place after adjustment. The standard figure-of-8 harness is suitable for and acceptable to the great majority of unilateral transhumeral amputees. However, the unilateral transhumeral amputee who, on a regular basis, engages in unusually strenuous physical activity may find the standard harness uncomfortable. During periods of heavy work, the relatively narrow straps of a standard transhumeral harness tend to subject the soft tissues over which they pass to inordinately high unit pressures. Particularly vulnerable are the skin, tendons, and neurovascular structures of the axilla on the nonamputated side. The problem is further compounded at the transhumeral level because maximal control of the components of the prosthesis requires the use of a small, snug axilla loop. 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. The transhumeral shoulder harness distributes tension loading on the prosthesis to the shoulder on the amputated side. Since the control attachment and elbow lock control straps run along the same paths as they do in the standard harness, the body control motions for prosthetic operation remain essentially unchanged ( Fig 6B-28. ). The harness for the bilateral transhumeral amputee consists essentially of two figure-of-8 harnesses without axilla loops ( Fig 6B-29. ). 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. Likewise, the left control attachment strap becomes the right anterior support strap. At their intersection in the midline of the amputee's back the two straps are sewn together. As in the unilateral harness system, the elbow lock control straps of the bilateral harness originate on the nonelastic portion of the anterior support strap. 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. Posteriorly, the lateral support straps are stitched to the anterior support straps. Whereas a cross-back strap is considered optional in the standard unilateral transhumeral harness, it is an essential component in the bilateral harness. As seen in Figure 6B-29, the cross-back strap runs horizontally between the two control attachment straps. Two over-the-shoulder straps complete the bilateral figure-of-8 harness for the bilateral transhumeral amputee. At their posterior origins the over-the-shoulder straps are sewn to the control attachment straps. Prior to passing over the amputee's shoulder, the straps are also stitched to the lateral support straps. The over-the-shoulder straps terminate anteriorly by attachment to the nonelastic portions of the anterior support straps ( Fig 6B-30. ). The bilateral transhumeral harness permits the amputee to use glenohumeral flexion and/or scapular abduction for elbow flexion and terminal device operation. Elbow lock control is effected by slight glenohumeral extension and abduction combined with shoulder depression. Two major problems confront the bilateral amputee with the harness just described. First, there is some difficulty in operating both prostheses simultaneously. Tension applied to both elbow flexion/terminal device cables permits opening (or closing) of both terminal devices, but both terminal devices cannot be operated to effect simultaneous opening and closing on opposite sides without relaxing tension on one of the cables. Consequently, the possibility of active bimanual manipulation of objects is minimal. 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.
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control source requires the use of other body motions for prosthetic operation. Biscapular abduction is, at least for most adult male amputees, a satisfactory body motion for generating sufficient cable tension to flex the elbow and operate the terminal device of the prosthesis. The force generated by active biscapular abduction is best harnessed through use of a chest strap ( Fig 6B-31. , A). Composed of 3.8-cm (l-in.)-wide nonelastic webbing, the chest strap originates by a buckle on the anterior surface of the shoulder cap of the socket. Running horizontally across the amputee's thorax, the strap passes immediately inferior to the axilla on the nonam-putated side. The chest strap terminates posteriorly with its attachment to the proximal end of the elbow flexion/terminal device control cable. Vertical suspension of the chest strap and prosthetic socket is augmented by the use of an elastic suspensor strap. The anterior suspensor originates posteriorly on the chest strap ( Fig 6B-31. ,B). Passing over the shoulder on the amputated side along a diagonal path, the suspensor terminates with its attachment to the proximal surface of the shoulder cap. In addition to assisting with vertical support, the anterior suspensor helps to prevent external rotation of the socket on the shoulder during use of the prosthesis. Biscapular abduction is usually strong enough to produce sufficient cable tension for fully operating the elbow and terminal device of a shoulder disarticulation prosthesis. Abduction of the scapulae is, however, a poor body motion for generating adequate cable excursion. Very few shoulder disarticulation amputees are capable, through biscapular abduction, of creating enough cable excursion to permit complete elbow and terminal device operation. Since biscapular abduction is a good source for generating cable tension but a poor source of cable excursion, shoulder disarticulation harnesses frequently require the addition of an excursion amplifier ( Fig 6B-32. ). A simple excursion amplifier consists of a small pulley attached near the posterior end of the chest strap of the harness. 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. With this type of amplifier each 2.5 cm (1 in.) 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.). Consequently 5.6 cm (2 in.) of chest expansion produces the 11.3 cm (4 in.) of cable excursion required for full elbow and terminal device operation. It should be noted that although the incorporation of a pulley in the harness system doubles the cable excursion, it also doubles the input force required for elbow flexion and/or terminal device operation. Since biscapular abduction is a good source of force generation, this increased force requirement does not generally pose a major problem for most adult shoulder disarticulation amputees. Nevertheless, an effort should be made to maximize the mechanical efficiency of the cable system by reducing friction to its lowest possible level. Depending on factors such as body build, availability of adequate range of scapulothoracic motion, and the neuromuscular coordination of the amputee, locking and unlocking of the elbow unit of a shoulder disarticulation prosthesis can be effected in one of several different ways. The preferred method involves the incorporation of the elbow lock control strap as an anterior extension of the chest strap. In this method the anterior attachment of the chest strap is bifurcated ( Fig 6B-33. ). The upper leg of the split strap consists of nonelastic webbing. 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. A nonelastic elbow lock control strap originates at the chest strap, passes laterally between the two legs of the split strap, and attaches directly to the proximal end of the elbow lock control cable. With this harness arrangement, cable tension for locking and unlocking the elbow is created by scapular adduction on the amputated side. 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. An alternative arrangement for elbow lock control requires the use of a waist belt ( Fig 6B34. ). The waist belt serves to anchor the distal end of the elbow lock control strap. 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. With the waist belt system, the primary body control motion for cycling the elbow unit is shoulder elevation on the amputated side. A third option for achieving elbow lock control requires the use of a nudge control mounted
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on the an-teroproximal surface of the prosthetic shoulder cap ( Fig 6B-35. ). The nudge control for locking and unlocking the elbow is operated by force exerted by the amputee's chin. Nudge control is usually reserved for severely disabled persons such as bilateral shoulder disarticulation amputees. Realistically, the functional expectations for persons with acquired bilateral shoulder disarticulation amputations are extremely limited. With the help of adaptive equipment, environmental modifications, modifications of clothing, and a unilateral prosthetic replacement, it may be possible to achieve a reasonable degree of partial independence in the basic functions of personal hygiene, dressing, and eating. There is no such thing as a "standard" harness for bilateral shoulder disarticulation amputees. Although most authorities agree that fittings should be unilateral rather than bilateral, the specifics of the harness and control system are left to the experience and ingenuity of the prosthetist, therapist, physician, patient, and members of the patient's family. The unilateral prosthesis should permit active operation and passive prepositioning of a lightweight terminal device, active or passive flexion of the wrist unit, active flexion and locking of the elbow unit, passive external and internal rotation of the humeral section, and passive prepositioning of the shoulder joint in flexion and abduction. Absence of the humeral heads narrows the girth of the shoulder girdle and reduces the effectiveness of biscapular abduction as a work source. 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, thereby preserving this important control source ( Fig 6B-36. ). 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. Shoulder elevation on the amputated side may be used for elbow lock control. Harnessing patterns for the forequarter amputation do not differ significantly from those used in the shoulder disarticulation, except that the efficiency of operation is less. Most persons with high-level amputations benefit from the use of externally powered (electronic) componentry, as discussed in Chapter 6C and Chapter 6D.
Chapter 6B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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/chap06-03.asp[21/03/2013 21:53:42]
6C: Components for Adult Externally Powered Systems | O&P Virtual Library
distinct device functions. For example, the Otto Bock "digital two site" myoelectric controller is also described in the text as a two-site, two-function controller to indicate that two separate and independent muscle sites are required to operate the controller and that two functions (e.g., "open" and "close") can be controlled voluntarily. The "off" condition is generally assumed, unless noted otherwise, because it is not practical to have a battery-powered device continuously "on" in the absence of a control signal. In the case of control by means other than muscle signals or in cases where myoelectric control is one of several options, the more general term "source" is used in place of "site." In keeping with the intention of this section as a component review, techniques for incorporating components into prosthetic systems and for fabrication of prostheses are not covered. The reader is referred to the technical manuals and courses offered by the various manufacturers. 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. These are areas of specialization that warrant separate and detailed treatment. However, integrated systems that are provided by a manufacturer as a specific option are described.
PREHENSION MECHANISMS
Electric-powered prehension devices are available in a variety of forms, some of which resemble the anatomic hand while others do not and several of which are interchangeable. It is important to note that, appearances aside, 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. None of the devices offer independent movement of individual fingers, and all have fixed prehension patterns. Early work on electric-powered prehension devices emphasized preservation of a handlike This preferential effort grew out of two broad, mutually reinforcing appearance. considerations. First, from the cultural vantage point, was a sensitivity to the sociological, symbolic, and aesthetic qualities associated with the human hand, qualities that can be powerful shapers of individual perceptions. The second consideration was a general expectation that in an environment of objects manufactured to be handled by human hands, a device with handlike characteristics would offer the best prehension function, an expectation that was taken literally with the adoption of shape as a principal characteristic. Both of these considerations are as valid today as they were in the early years of electric hand design. Although quality of appearance can vary considerably, the cosmetic function of a prehensor with a handlike shape continues to be a strong determinant of personal In addition, the broad contact surfaces of the electric hand and frictional acceptance. properties of the cosmetic glove offer good grasp and retention of held objects. (Other significant factors cited for the acceptance of handlike prehensors-higher prehension force, reduced operating effort, increased comfort associated with the absence of control harnessing in myoelectri-cally controlled prehensors, 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.) Electric hand prehensors have not, however, proved to be the ideal prosthetic solution that early developments were thought to foreshadow. 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, especially with regard to control. Fidelity to a handlike shape entails engineering compromises that diminish not only the prehensile function but also the overall mechanical function of electric prehensors. 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. 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, and it cannot be compensated by changing the orientation of the fingers. The electric hand's size and shape can visually obstruct the object being grasped or the work area in general. Shape constraints have also limited the form and arrangement of structural frames and finger armatures, and these parts can be damaged by heavy use. 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, inks, and other materials. Power is lost in compressing and stretching the cosmetic plastic forms and gloves enclosing
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the mechanisms, and this contributes to the degradation of overall performance. As a result of these observations, 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. prostheses with hook-type prehensors is frequently cited in association with use of electricpowered prostheses. Additionally, adaptors and tools that can be held within the electric hand and mechanical tools that can be interchanged with the hand prehensors are available. More recently, 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.
Prehension Force
Force is a relatively easy characteristic to quantify. Therefore, it is often cited as a "figure of merit" for a prehension device. However, little is known about how prehension force capacity, frictional properties of the surfaces in contact, and conformability to surface features contribute to adequate grip. It is generally recognized that changes in either of the latter two characteristics can significantly alter the effectiveness of the applied force. Force should not, then, be considered in isolation from the other prehensile characteristics when drawing comparisons between particular devices. Rationales for force requirements of prosthetic pre-hensors are typically based on physiologic performance. A study, done at the University of California, Los Angeles (UCLA), of human prehension force indicated that adult males could produce maximum mean forces of 95.6 newtons (21.5 pounds-force [lbf]) for palmar prehension, 103 newtons (23.2 lbf) for lateral prehension, 93.4 newtons (21.0 lbf) for tip prehension, and 400 newtons (90 lbf) for cylindrical More recent studies of larger populations have produced slightly different means grasp. but generally support the UCLA results. 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 3.52 kg (7.75 lb). 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, the greater the force needed to hold the object. 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. Using the UCLA data for maximum palmar prehension
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force, one could expect that the maximum force acting on an object that could be held without slipping could not exceed 47.8 newtons (10.8 lbf) for a low coefficient of friction and 95.6 new-tons (21.5 lbf) for a high coefficient of friction. An unpublished investigation at UCLA indicated that prehension forces to a maximum of 66.7 Peizer et newtons (15 lbf) were necessary to carry out a variety of activities of daily living. reasoning that higher forces could only improve the prehensile utility of a prosthetic al., prehensor, proposed that this be a minimum standard for the maximum prehension force of an electric prehensor. All of the devices in Table 6C-1 and Table 6C-2 have specified maximum prehension forces, some of them approaching or exceeding physiologic levels. However, 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. Consequently, 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. 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. 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. 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, similar to the function of a vise. This is an important feature, essential to the overall performance of a prehensor. Without such a mechanism, it would be necessary to continue to drive the motor in stall to hold an object. During stall, a motor draws high currents, which would deplete a battery supply within a relatively short time. The same mechanism that maintains the applied force also prevents the fingers from being pried open by external forces while an object is grasped. This feature is certainly helpful when using tools and other implements held in the prehensor. For safety and to prevent damage from excessive forces, all of the prehensors incorporate some method for opening the fingers when, for one reason or another, the prehensor does not respond to an opening control signal. Width of Opening In the handling of common objects, Keller et al. determined that 5.1 cm (2.0 in.) of prehensile opening was needed most of the time, but that an 8.2-cm (3.25-in.) opening was occasionally needed. Peizer et al. suggested the 8.2-cm (3.25-in.) opening as a minimum opening, a suggestion that was adopted by the Panel on Upper-Extremity Prosthetics of the National Research Council. Experience by users of prosthetic prehensors with an opening of 11.43 cm (4.5 in.) indicated a preference for the wider opening, although it was not used often. The maximum opening of any prehensor in Table 6C-1 or Table 6C-2 does not exceed 10.2 cm (4 in.) Speed of Movement Based on a study of user's experiences with electric prehensors available at the time, Peizer et al. recommended a minimum closure rate of 8.25 cm/sec (3.25 in./sec), measured at the fingertip. This minimum standard, considered a "high standard" in 1969, is exceeded by all of the prehensors in Table 6C-1 and Table 6C-2 . 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. Assuming a finger length from the metacarpophalangeal joint to the tip of 10 cm (3.9 in.), the maximum velocity at the finger tip would be 400 cm/sec (157 in./sec). These data provide an appreciation for the upper limit on physiologic finger speed, which is far in excess of the speeds attainable by any of the prosthetic prehensors. In the same study, finger velocities were measured for an untimed pick-and-place task involving blocks of various sizes. Average finger velocities in this functional activity were
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considerably less than the maximum and were on the order of 3.0 radians/sec (172 degrees/sec). Only the Synergetic Prehensor, in Table 6C-2 , achieves this speed, which was one of its design criteria. 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. At higher speeds, a proportional relationship between the magnitude of the control signal and the response of the prehensor appears necessary to achieve confident and acceptable operation.
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Several options are available from Otto Bock to supplement the prehension features of the System Electric Hand. A pincer, or tweezer, that is keyed to fit the fingers of the hand prehensor can provide tip prehension for handling small objects. Alternatively, if the prehensor is equipped with a quick-disconnect wrist, it can be removed, and one of a variety of Bock work tools can be connected to the wrist of the forearm for special functions. These tools are not electrically powered. One could also exchange the hand prehensor for a System Electric Greifer (or Steeper Powered Gripper if the control system is compatible). A variety of techniques are available for controlling the System Electric Hand alone. Otto Bock provides three myoelectric controllers as well as switch control. Bock terms the three myoelectric systems "digital two site," "grip force," and "double channel." The "digital two site" system is a two-site, two-function threshold myoelectric controller. When one or the other muscle site generates a myoelectric signal that exceeds the threshold, a control signal is generated to open or to close the prehensor. For the duration that the amplitude of the myoelectric signal is above the threshold, the prehensor will continue to operate, but the degree to which the signal exceeds the threshold does not alter the action of the mechanism. Regardless of the strength of the contraction generating the signal, the prehensor will move at only one speed or generate grip force (in low gear) at only one rate. In effect, the myoelectric signal is activating an electronic switch, and for this reason this type of control has been termed "myoswitch" control. The "grip force" control is also a two-site, two-function system and is a variation on the "digital two site" controller that provides for two thresholds during closing. If the myoelectric signal from the "closing" site is above the lower threshold but below the higher threshold, the prehensor will close and apply force up to a maximum of about 15 newtons (3.4 lbf). To exceed this level, the user generates a stronger myoelectric signal, above the higher threshold, to cause the automatic transmission to downshift and the prehensor to apply higher force. Although two thresholds are involved, the controller is of the myoswitch variety, and the user cannot alter the speed of motion or the rate at which force is increased by varying the myoelectric signal. The higher threshold only provides a means of "manually" shifting the transmission. The third Bock myoelectric system, "double channel," is a one-site, two-function myoswitch controller. The myoelectric signal from one muscle controls both opening and closing of the prehensor, depending on its amplitude with respect to one of two thresholds. When the signal is above the lower threshold but below the higher threshold, the prehensor closes. When the signal is above the higher threshold, the prehensor opens. To be completely accurate in describing either the "grip force" or "double channel" system, it must be noted that the rate at which the myoelectric signal is generated is also important. To effect the function associated with the second threshold of either system, the amplitude of the myoelectric signal must not only exceed the threshold, but it must also do so within a short period of time. 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. For switch control, Otto Bock provides several types of electromechanical switches, including a cable pull switch, a harness pull switch, and a rocker switch. All switches provide operational positions for both opening and closing the prehensor. Other manufacturers of myoelectric controllers have interfaced their systems with a special version of the Bock System Electric Hand that contains no electronics. Both Hosmer Dorrance Corporation and Motion Control provide two-site, two-function proportional myoelectric controllers. 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. Thus, lower signal levels produce slower movements or lower rates of prehension force application, and higher signal levels produce faster movements or faster rates of force application. Universal Artificial Limb Co. also has a twosource, 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.
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by their width across the knuckles: the 3-in. and 3 1/4-in. Electric Hands. For comparison to the Otto Bock adult hand prehensors, the 3-inch Steeper hand prehensor has a circumference at the knuckles of 7 3/8 in. and the 3 1/4 in. hand prehensor has a circumference of 7 3/4 in. The size of the prehensors are determined by the dimensions of the fingers and the enclosures around the drive mechanism. 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.,A). The thumb, index, and middle fingers are molded of hard plastic directly over the armature of the finger assembly and are separate from the shell. The smaller two fingers are molded of pliable plastic and are attached to the plastic shell. For finishing, the shell and fingers are covered by a PVC cosmetic glove. The mechanism, identical for the two sizes, includes a single motor with a gear reducer and drive screw and nut actuator, all held within a support structure ( Fig 6C-1.,B). The first two fingers (as one unit) and thumb are linked to the nut and to the stationary support structure. As the nut travels along the screw, 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). The fingers move at a speed only slightly less than that of the Otto Bock hand prehensors. However, 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, the Steeper Electric Hands achieve less than half the maximum prehension force of the Bock design. A back-lock feature is inherent in the design of the drive screw and nut actuator, and the fingers cannot be forced open in typical usage when the prehensor is not powered. For safety purposes and to prevent damage to the mechanism under excessive forces, the thumb incorporates a breakaway device that allows it to hyperex-tend. Operation of the breakaway does not damage the thumb, and it can be manually reset to its normal position. All models of the Steeper Electric Hands include current sensors that prevent the motor from running in a stall condition that draws high currents. Therefore, users need not consciously monitor their application of prehension force (when handling non-fragile objects) and are prevented from prematurely depleting their batteries. Additionally, a microswitch cuts off motor current when the Electric Hand is opened to its full extent, thereby preventing the motor from running in a stall condition in opening. The thumb and finger arrangement of the Steeper Electric Hands provide both palmar prehension and cylindrical prehension. The PVC glove adds to the effectiveness of the prehension force by increasing the friction between the prehensor and the object being held; however, because of the hardness of the hand shell and molded fingers, the prehension surfaces cannot conform to the shape of the held object. With respect to control, Steeper has two models of their Electric Hands: the "Myoelectric Hand" and the "Servo Hand." The Myoelectric Hand is somewhat of a misnomer since the prehensor model can be operated by means other than myoelectric signals. The Steeper controllers for the Myoelectric Hand include several parts: one or two transducers, a Digital Connector Ring (external to the hand prehensor), and an electronic assembly (in the prehensor itself). All of the control configurations operate the Myoelectric Hands in a switchlike manner, and the user cannot vary the speed of motion or the rate at which prehension force builds while generating the control signal. Several types of transducers are available from Steeper. An Amplifier-Myoelectrode produces a control signal in response to a myoelectric signal that crosses an adjustable threshold. A Touch Activated Switch, similar in appearance to the Amplifier-Myoelectrode, produces a signal in response to a resistance change, such as from skin contact, between two of its metal surfaces. Two electromechanical switches are also available: the Momentary Contact Switch (similar to a push-button membrane switch) and a Single-Action Pull Switch, which is activated by a cable. All of these transducers operate from a single source and produce one control signal. To create a two-source, two-function controller, any two of these transducers are connected to the Digital Connector Ring. For example, one can have a two-site, twofunction myoswitch controller using two of the Ampli-fier-Myoelectrodes. Alternatively, one can configure a two-source, 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. Any combination is possible. For situations where a single control source is all that is available, Steeper offers two options. The first is the One-Action Two-Function Adapter. This adapter accepts input from any one of the four transducers to provide one function, and whenever that control signal is absent, the
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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.
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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.
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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.
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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.
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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.
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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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At present, all elbow controllers available through commercial manufacturers control the velocity of motion, 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. 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. In a related study using tracking experiments, 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 implication for the future is that as elbow mechanisms become faster, it will be necessary to adopt different control strategies (than are now used) to take advantage of the improved response. Furthermore, the work suggests that even present-day elbows could be controlled more effectively by position control. These types of controllers have been used experimentally on the NY-Hosmer Electric Elbow and on the Boston Elbow. None of the available electric elbows approach physiologic performance. There is greater difference between each of the prosthetic elbows and the physiologic elbow than there is among the elbow mechanisms. Therefore, it is not yet possible to truly restore elbow function with these prosthetic components. Consequently, one should consider the many attributes of each of the elbows-including factors such as weight and size, control options, integration into a complete prosthesis, and capacity for being finished in a cosmetically acceptable form-when choosing one for implementation in a fitting.
CONCLUDING REMARKS
The first edition of the Atlas of Limb Prosthetics was published in 1981. Since that time, significant changes have occurred in the types and characteristics of electric-powered upperlimb components. Several devices described in that edition have ceased to be available. Other devices under development then are now commercial items accepted in clinical practice. And still other items have been introduced in the intervening years that were not even conceived a decade ago. Technological reviews are always in danger of becoming out of date. In several years, the devices and systems described here may no longer be available or may be eclipsed by improved versions. This is the hope. No matter how well accepted or how adequately current devices and systems are thought to perform, they fall far short of the physiologic systems they have been developed to replace. It is not, however, inevitable that new developments come into being. 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. 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.
RESOURCE LIST
Hosmer Dorrance Corporation 561 Division St PO Box 37 Campbell, CA 95008 Hugh Steeper (Roehampton), Ltd 237-239 Roehampton Lane London, SW14 4LB England Liberty Mutual Research Center 71 Frankland Rd Hopkinton, MA 01748
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Motion Control, Inc Division of IOMED, Inc 1290 West 2320 South, Suite A Salt Lake City, UT 84119 Otto Bock Orthopedic Industry, Inc 3000 Xenium Lane North Minneapolis, MN 55441 Universal Artificial Limb Co 938 Wayne Ave Silver Spring, MD 20910 University of New Brunswick Prosthetics Research Centre Institute of Biomedical Engineering 180 Woodbridge St Fredericton, New Brunswick E3B 4R3 Canada References: 1. Alpenfels EJ: The anthropology and social significance of the human hand. Artif Limbs 1955; 2:4-21. 2. Billock JN: Upper limb prosthetic terminal devices: Hands versus hooks. Clin Prosthet Orthot 1986; 10:57-65. 3. Chan KM, Lee SY, Leung KK, et al: A medical-social study of upper limb amputees in Hong Kong-a preliminary report. Orthot Prosthet 1984; 37:43-48. 4. Childress DS: Artificial hand mechanisms, report 72-Mech-55, in Proceedings of the Mechanisms Conference and International Symposium on Gearing and Transmissions. San Francisco American Society of Mechanical Engineers, 1972, pp 1-11. 5. Childress DS: An approach to powered grasp, in Gavri-lovic M, Wilson AB Jr (eds): Proceedings of the Fourth International Symposium on Advances in External Control of Human Extremities, 1973. Dubrovnik, Yugoslavia, Yugoslav Committee for Electronics and Automation, 1972, pp 159-167. 6. Childress DS, Grahn EC: Development of a powered prehensor, in Proceedings of the 38th Annual Conference on Engineering in Medicine and Biology. Chicago, The Alliance for Engineering in Medicine and Biology, 1985, p. 50. 7. Childress DS, Strysik JS: Controller for a high-performance prehensor, in Proceedings of the 23rd Annual Rocky Mountain Bioengineering Symposium. Columbia, Missouri, Instrument Society of America, 1986, pp 65-67. 8. Datta D, Kingston J, Ronald J: Myoelectric prostheses for below-elbow amputees: The Trent experience. Int Dis-abil Stud 1989; 11:167-170. 9. Doubler JA: An analysis of extended physiological proprioception as a control technique for upper-extremity prostheses (dissertation). Evanston, Ill, Northwestern University, 1982. 10. Doubler JA, Childress DS: An analysis of extended physiological proprioception as a prosthesis control technique. J Rehab Res Dev 1984; 21:5-18. 11. Doubler J A, Childress DS: Design and evaluation of a prosthesis control system based on the concept of extended physiological proprioception. J Rehabil Res Dev 1984; 21:19-31. 12. Engen TJ, Spencer WA: Development of Externally Powered Upper Extremity Orthotics, Final Report. Houston, Texas Institute for Rehabilitation and Research, 1969. 13. Imrhan SN: Trends in finger pinch strength in children, adults, and the elderly. Hum Factors. 1989; 31:689-701. 14. Jacobsen SC, Knutti DF, Johnson RT, et al: Development of the Utah artificial arm. IEEE Trans Biomed Eng 1982; 29:249-269. 15. Jorgensen K, Bankov S: Maximum strength of elbow flexors with pronated and
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supinated forearm, in Medicine and Sport, vol 6, Biomechanics II, Basel, Switzerland, S Karger AG, 1971. Keller AD, Taylor CL, Zahm V: Studies to Determine the Functional Requirements for Hand and Arm Prostheses. Los Angeles, University of California Department of Engineering, 1947. Kemp MC: Design and development of an electrically powered prosthetic gripper, in Proceedings of the First International Workshop on Robotic Applications in Medical and Health Care. Ottawa, Canada, National Research Council Canada, 1988, pp 19.119.5. Komi PV: Relationship between muscle tension, EMG and velocity of contraction under concentric and eccentric work, in Desmedt JE (ed): New Developments in Electromyography and Clinical Neurophysiology, vol 1. Basel, Switzerland, S Karger AG, 1973. Mathiowetz V, Kashman N, Volland G, et al: Grip and pinch strength: Normative data for adults. Arch Phys Med Rehahil 1985; 66:69-74. Michael JW: Upper limb powered components and controls: Current concepts. Clin Prosthet Orthot 1986; 10:66-77. Millstein SG, Heger H, Hunter GA: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prostheses. Prosthet Orthot Int 1986; 10:27-34. Morrey BF, Askew LJ, An KN, et al: A biomechanical study of normal functional elbow motion. J Bone Joint Surg [Am] 1981; 63:872-877. Northmore-Ball MD, Heger H, Hunter G: The below-el-bow myo-electric prosthesis: A comparison of the Otto Bock myo-electric prosthesis with the hook and functional hand. J Bone Joint Surg [Br] 1980; 62:363-367. Nader, M: The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop 1990; 258:9-17. Palmer AK, Werner FW, Murphy D, et al: Functional wrist motion: A biomechanical study. J Hand Surg [Am] 1985; 10:39-46. Peizer E, Wright DW, Mason C, et al: Guidelines for standards for externally powered hands. Bull Prosthet Res 1969; 10:118-155. Pertuzon E, Bouisset S: Maximum velocity of movement and maximum velocity of muscle shortening, in Medicine and Sport, vol 6, Biomechanics II. Basel, Switzerland, S Karger AG, 1971. Prout W: The New York Electric Elbow, the New York Prehension Actuator, and the NU-VA Synergetic Prehen-sor, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1989. Ring ND, Welbourn DB: A self-adaptive gripping device: Its design and performance, in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, Proceedings 1968-1969, vol 183. London, The Institution of Mechanical Engineers, 1969. Safaee-Rad R, Shwedyk E, Quanbury AO, et al: Normal functional range of motion of upper limb joints during performance of three feeding activities. Arch Phys Med Rehabil 1990; 71:505-509. Schlesinger G: Der Mechanische Aufbau der kanstlichen Glieder, in Ersatzglieder und Arbeitshilfen, part 2. Berlin, Springer-Verlag, 1919. Sears HH, Andrew JT, Jacobsen SC: Clinical experience with the Utah artificial arm, in The Canadian Association of Prosthetists and Orthotists Yearbook, 1984, pp 30-33. Sears HH, Andrew JT, Jacobsen SC: Experience with the Utah Arm, hand, and terminal device, in Atkins DJ, Meier RH, (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag, NY, Inc, 1989. Simpson DC: Functional requirements and systems of control for powered prostheses. Biomed Eng 1966; 1:250-256. Simpson DC: The functioning hand, the human advantage, J R Coll Surg Edinb 1976; 21:329-340. Tanenbaum SJ: The Boston Elbow - Health Technology Case Study 29, Report OTAHCS-29. Washington, DC, U.S. Congress, Office of Technology Assessment, 1984. Taylor CL: Control design and prosthetic adaptations to biceps and pectoral cineplasty, in Klopsteg PE, Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill International Book Co, 1954. Taylor CL: The biomechanics of the normal and of the amputated upper extremity, in Klopsteg PE, Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill International Book Co, 1954. Uellendahl J, Heckathorne CW, Krick H, et al: Four-function hybrid arm prosthesis incorporating an electric wrist rotator and prototype electric prehensor, in Proceedings
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of the 13th Annual RESNA Conference. Washington, D.C., Resna Press, 1990, pp 167-168. 41. van Lunteren A, van Lunteren-Gerritsen GHM, Stassen HG, et al: A field evaluation of arm prostheses for unilateral amputees. Prosthet Orthot Int 1983; 7:141-151. 42. Westling G, Johansson RS: Factors influencing the force control during precision grip. Exp Brain Res 1984; 53:277-284. 43. Williams TW: The Boston Elbow. SOMA 1986; 1:29-33.
Chapter 6C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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. However, little will be found in engineering books regarding the control approaches that are currently used with limb prostheses and discussed here. This section attempts to place prosthetics control in the wider context of general control applications. Briefly, 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, control concerns how to create inputs that will cause an artificial limb to behave in a desired way. If the inputs are generated independently of outputs, we call it "open-loop" control. If the input is, at least partially, a function of the systems output variables, as is the case with most control systems, we call it "closed-loop" or "feedback" control. 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. With arm prosthesis systems, the primary feedback method is visual feedback of output position to the prosthesis user, who is the input decision maker. This concept is shown in Fig 6D-1. for both electric-powered and body-powered prosthetics systems. A more complete view of feedback relationships in prostheses has been described by Childress.
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Human-Machine Systems
If we regard an upper-limb artificial arm as a machine that helps someone manipulate his environment, then we can consider a human-prosthesis system as a human-machine system. Human-machine systems (e.g., airplanes, automobiles, spacecraft, and other human-operated systems) have been extensively studied in the field of "human factors engineering," and many of the ideas of that field relate, at least partially, to human-prosthesis systems. Sheridan and Ferrell have written definitively on this topic, and their book deals with many of the issues of human-machine systems, particularly from an engineering viewpoint. One aspect of prosthesis control that makes it unique when compared with typical human-machine systems is the modality of human control. While in almost all human-machine systems the operator interacts with the machine with the hands or feet, this is not the case with most humanprosthesis systems. Therefore, prosthesis systems are a subset of human-machine systems that may be classified as having "nonmanual control" modalities, as opposed to the so-called manual control systems.
Manipulators
The class of complex human-machine systems used in industry and elsewhere, that most nearly resemble complex human-artificial arm systems are master-slave manipulators (teleoperators). With these systems the human operator remotely controls manipulators that, for example, handle radioactive materials or that work in hostile conditions like those in outer space. Manipulator arms are somewhat similar to artificial arms and hands. A main difference is that the controls of the manipulator are activated through movement and forces of the operator's hands, arms, and/or feet. Additional differences come from the engineering constraints that prostheses and manipulators are designed under. Prostheses, because they must be carried about with the user, must be light in weight; restricted in size, shape, and appearance (somewhat like a human hand/arm); energy efficient so that they can operate all day on a relatively small battery; and quiet in operation. Manipulator design is usually not constrained nearly as much by power, weight, shape, noise, or appearance requirements. Consequently, solutions to manipulator problems often do not solve prosthesis problems. However, 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, and these concepts should not be ignored, even though they may not be applicable directly. Conversely, solutions to prosthetics problems may have points out that bilateral users of cable-actuated prosthetic manipulator applications. Murphy arms appear to be able to perform many tasks considerably quicker than what is typical with manipulators. He attributes this to the basic design philosophy of arm prostheses. Another similarity of manipulators with prostheses is that the first master-slave manipulators that were designed were entirely cable controlled, just as most arm prostheses have been cable controlled. Direct cable control provides good proprioceptive and force feedback in manipulators, as it does in prostheses. As manipulators increasingly incorporated power into their designs, 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. became available for prosthesis design, but the trend may now be in that direction. Teleoperators that provide proportional force and position feedback to the site of control are often called "telechirs." As tele-operator technology advances to more remote applications, such as in outer space or under the sea, 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. Some of these advances may be useful in limb prosthetics.
Robots
Solutions to problems in robotics seldom have an impact on prosthesis design, partially for the same reasons that manipulator designs have not had much impact. However, manipulators are at least human-machine systems. Robots are usually under the supervision of digital computers and so are less similar to human-prosthesis systems than manipulator systems. Consequently, even though knowledge of manipulator and robot design is surely of assistance to designers of humanprosthesis systems (artificial arms), not many ideas can be translated directly between the fields without considerable modification.
The use of powered mechanisms is a common experience of everyday life, and the control systems used in these devices are often similar to those used in powered prostheses. Practical control systems for artificial limbs are, by and large, rather simple systems. Some are so simple that when we experience them in daily life we often do not identify them as control systems. Hand-operated bicycle brake systems are familiar cable-operated control systems that are similar to the cable control mechanisms of body-powered prostheses, except that the prosthesis systems are not operated with the hands. In the bicycle brake example, applying the brakes (gripping the rim of the wheel) is analogous to pulling the cable of a voluntaryclosing prehension mechanism to grip an object. The Bowden cable was invented in 1885 by Bowden, the founder of the Raleigh bicycle company, and it is probably not by chance that the Wright brothers, the builders of the first airplane, owned a bicycle shop. Cable controls have been used extensively in the bicycle and aircraft industry and also in the smaller field of limb prosthetics. 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. Pushing the control switch down causes the window to be lowered. Pushing it the other way causes the window to elevate. The window will stop whenever the switch is released. Consequently, the human operator is the feedback link for positioning the window. By operating the switch and by watching the window as it moves, the operator can position the window in almost any desired vertical position. The upand-down operation of an electric-powered projection screen is another example of this kind of control. It is "on-off" switch control where the switch is often mechanical in construction, but which could be electronic and operated in a multitude of ways ranging from capacitive touch to breaking a light beam of a photodiode. On-off control is a widely used approach to the control of prostheses, with the control ranging from mechanical switches to electronic switches operated by myoelectric signals. 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.g., prosthetic joint or car window). 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. Hence, 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. The same is true in prosthetic systems that use "on-off" control. Lighting systems frequently use "on-off" control. Some lights have a proportional controller so that the position of a dial determines the level of light intensity. In proportional control, the output intensity is proportional to an input setting. For example, in a lighting system, 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. This is a kind of position control input. In another kind of lighting system, the intensity may be set in the same way an electric car window is run up and down. Pushing a switch one way causes the light intensity to go up; pushing it the opposite direction causes the intensity to go down. This allows a graded response in intensity, but it is not proportional control. Since intensity is related to the time the switch is activated, this is similar to the "velocity control" already described. In prosthetics, this method is sometimes called proportional-time control because the intensity is related to the time the switch has been activated, but it should be noted that this is not conventional use for the term "proportional." Powered drills, powered screwdrivers, and other portable powered tools are about as close to simple powered prosthesis systems and components (e.g., electric hands, elbows, etc.) as any systems that we commonly experience in our daily lives. They are self-contained and portable, contain rechargeable batteries, use dc motors, produce rotational velocity and torque, are reversible, have interchangeable end components, and have their own control systems. Drills or screwdrivers with inexpensive control systems may use "on-off" switch control. More sophisticated devices may have proportional control in which the velocity of output rotation is proportional to position or pressure at the input. In addition, some of these devices have control mechanisms that automatically try to keep the output velocity constant for a given input setting, even when external loading is increased or decreased at the output. This is an automatic control adjustment that occurs without the knowledge of the operator but that helps with accurate control of the device. Automobile powered steering is a kind of "boosted" power system in which the mechanism of
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control is similar to the nonpowered case. 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. Velocity of turning of the wheels is directly related to steering wheel velocity, and forces on the wheels are reflected into the steering column. The powered system works in the same way as its nonpow-ered equivalent, 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. The ideas behind powered steering appear to have considerable application in control of upper-limb prostheses, where a similar kind of "boosted" power, used in combination with cable control, enables cable force and excursion to be matched to the physical abilities of the amputee using the system. Such a system maintains the proprioceptive qualities of cable-actuated systems while also providing the benefits of powered components. The author has called this "powered cable steering." In this control approach, a cable is used to "steer" a powered prosthesis joint through use of a position control system. This approach is closely related to the concepts of "extended physiologic proprioception" as proposed by D.C. Simpson for the control of powered prostheses. 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. Airplane flight surface controls have traditionally been body powered through cables. In fact, the development of cable-operated arm prostheses after World War II was considerably influenced by this cable technology through aircraft companies (e.g., Northrup Corp.) and by aeronautical engineers. Cable-actuated systems give pilots a good "feel" for the plane just as cable-operated prostheses provide "feel" for the prosthesis. The larger, faster planes that were developed after World War II often had "boosted" power for their cable controls. As noted already, in the discussion about manipulators and automobile powered steering, new prosthesis controllers may follow this same trend. More recent advanced aircraft systems, the so-called "fly-by-wire" systems, connect the pilot to the control surfaces through electrical wire connections. Nevertheless, an effort has been made to continue to give the pilot "feel" in the control stick. Home heating and cooling systems are in our common experience. They are a class of control systems that are called regulators and attempt to keep some variable constant (e.g., inside temperature) in the face of external changes, for example, outside temperature fluctuations. This kind of controller is automatic; however, it is designed to maintain a fixed state that is set by a constant input. Regulator-type control is not generally used in limb prosthetics. On the other hand, position servomechanisms are designed so that the output tracks or follows a time-varying input. Such systems are designed so that the output position responds quickly to input position changes. The Steeper hand position controller is an example of this kind of system as applied to prosthetics. A position of the body is sensed and translated into a position of hand opening. Control systems of this kind are not too common in everyday experience. 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. 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. 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. Consequently, significant differences may exist between the input position indicator and the antenna while the antenna is powered to a new position. This is in contrast with automotive power steering, already discussed, 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.
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1. Low mental loading or subconscious control. This means that the prosthesis can be used without undue mental involvement. Successful control systems enable the users to use their artificial limbs almost subconsciously, the way people commonly use their limbs. In other words, the prosthesis should serve the user; the user should not be a servant to the prosthesis. The user should be able to think about other things, even while using the prosthesis. This kind of control may require proprioceptive and sensory feedback of the right modality in order to be achieved. 2. User friendly or simple to learn to use. This feature is closely related to feature 1. It means that learning to control the prosthesis should be intuitive and natural. If this is true, the user should be able to learn to use the prosthesis quickly and easily. 3. Independence in multifunctional control. Control of any function should be able to be executed without activating or interfering with the other control systems of a multifunctional prosthesis. For example, a person with prostheses on both arms should be able to use each limb independently. Operation of a function of one prosthesis should not cause any activity of the prosthesis on the opposite side. A common example where independent action is not achieved is in typical cable-operated, bodypowered transhumeral prostheses with a voluntary-opening hook. If the user attempts to lift a heavy load, the hook tends to open during the lifting. 4. Simultaneous, coordinated control of multiple functions. This is the ability to coordinate multiple functions simultaneously in effective and meaningful ways and, of course, without excessive mental effort (attribute 1). It also implies attribute 3 in that it allows independent control of any function or any combination of functions. 5. Direct access and instantaneous response. All functions, if possible, should be directly accessible to the user and without time delay. Prosthetic systems should respond immediately to inputs, if possible. 6. No sacrifice of human functional ability. The control system should not encumber any natural movement that an amputee can apply to useful purposes. In general, it is not wise to sacrifice a useful body action for the control of a prosthesis. The prosthesis should be used to supplement not subtract from available function. 7. Natural appearance. If possible, the control system should be operated in ways that have a nice aesthetic appearance. Likewise, the mechanical response should be graceful, if possible. Control methods that allow aesthetically pleasing action (e.g., smooth, flowing, graceful movement) are important to prosthetic appearance, just as are shape and color. Movements that appear mechanical in nature may not be pleasing to the eye.
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1. 2. 3. 4.
There are many situations (e.g., pushing) where it is advantageous for a prosthetic arm to be completely rigid (all joints positively locked). There are other instances where the joints should be free (e.g., during walking). When we think of control we usually think of grasping or of positioning and lifting. However, the ability to make joints rigid or free is also an important function to be controlled in practical arm prostheses. In the future it may be advantageous to continuously control the impedance of joints from the free to the locked condition. However, that is not done in practical prostheses used by amputees today, and it will not be discussed here. It is currently practical to control the "free" and "locked" conditions, and this kind of joint impedance control will be emphasized in this chapter. It should be pointed out that friction joints, particularly for high-level amputees, do not function well because when an amputee wants to position a joint, the friction needs to be low, and when he wants the joint to remain fixed in position under load, the friction needs to be high. It is difficult if not impossible to meet both of these needs with a single friction setting. Therefore, locking/unlocking joints are often recommended, even though they may complicate control since the locking state must be controllable.
Biomechanical Input
Biomechanical inputs of the kind described above have been used fairly extensively for the control of non-powered prostheses. These same inputs can be used with some powered prostheses. In fact, 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. The ways in which biomechanical inputs can be used for control are, for the most part, intuitive and will not be discussed here in detail. Basically, the force or movement of a body part (e.g., the chin/head) is used to move a mechanical switch lever, to activate an electronic switch, to activate a cable attached to a switch or instrumented element, to push on a pressure-sensitive transducer, or to otherwise operate some kind of position, force, or touch/proximity transducer.
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. It is not the intent here to discuss the many transducers that are available commercially. In fact, only those transducers that are used in presently available prosthesis control systems will be discussed. These are mechanical switches that require both force and excursion to turn on or off, pressure-sensitive transducers that change their resistance with force applied but with essentially no excursion (isometric), and excursion transducers that measure distance but with essentially no force required. Most of the suppliers of control systems, as described in Chapter 6C, supply switch controllers and myocontrollers. Universal Artificial Limb Co.
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supplies pressure transducers, and Hugh Steeper, Ltd., supplies an excursion transducer. Switches are applicable to most systems, and with a number of the control systems they can be used interchangeably. 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. Correct voltage amplitude, voltage polarity, electrical impedance, and electrical connections must often be observed when interconnecting transducers with control systems. Bocker and push-button switches are commonly used switch types that can easily be operated by pressing against them with a body movement. Switches are easy to use, simple, and inexpensive. Also, their assembly into a whole prosthesis is fairly intuitive. Unfortunately, switch control is not always sufficient for good prosthesis control. Switches also can provide more than one function from one source. For example, a frequently used pushbutton switch produces one function when pushed in a short distance and another function when pushed in a greater distance. In this way, the two functions of a powered prosthetic joint or prehensor can be controlled with the switch and activated by only one control source. Switch inputs can be arranged (with some electronics) so that multiple activations could be used to produce certain prosthetic functions. For example, a simple code (like a few of the simple letters of the Morse code) could be input to produce a specified output. This is not done. It is mentioned here only to hint at the wide variety of control schemes that are possible with simple switches and electronics. Many kinds of control systems and transducers could be used with prosthetics systems. With each system, questions must be asked. Are they reliable and simple to incorporate into a system, and more importantly, do they offer some or many of the desirable attributes of prosthetics control that have already been discussed?
Myoelectric Control
By definition, myoelectric control is the control of a prosthesis or other system through the use of "muscle electricity." In this kind of control, the control source is a small electric potential from an active muscle. 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, which in turn drives the prosthetic system (e.g., hand or elbow). Muscle electricity is a by-product of muscular action, just as mechanical noise is a by-product of an internal combustion engine. 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. 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. Hence, they must be benign to the skin and tissues. The surface method of detection of muscle activity is nicely illustrated in the standard electrocardiogram (ECG), which is the electromyogram (EMG) of the heart muscle. A gel-type electrolyte is usually applied to the skin during ECG procedures to lower the electrical resistance of the skin. However, with prosthesis control, gel electrolyte is not recommended on the electrodes because of possible skin irritation with long-term usage. Consequently, inert metal (e.g., stainless steel) electrodes are usually used in myoelectric prostheses. They are often called "dry" electrodes because of the absence of electrode paste (conductive gel). Actually, 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.
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Just as with an ECG, special care must be taken to negate the influence of interfering electrical signals from the environment (e.g., broadcast waves, fluorescent lights, motor arcing, power lines, etc.) that may cause the prosthesis to operate inadvertently. These potential interference signals may be many times larger than the myoelectric signal itself. A typical surface EMG may have a peak-to-peak amplitude of around 100 V (0.0001 V), whereas the noise signals may be a thousand times greater in magnitude. The electrical noise can be eliminated, for the most part, by good electronic circuitry that features differential amplification, filtering, and thresholding and by good electrode positioning and design techniques. To reduce electrical noise pickup, the electronic amplifiers are often packaged together with the metal electrodes to make the connecting wires extremely short between the electrodes and the amplifiers. The reader should refer to Fig 6D-2. to see the electrodes, as drawn diagram-matically. When the electronic amplifier or the amplifier and processor electronics, as shown, are put into a single package with the metal electrodes on the outside, the whole package is often called an electrode; however, from a technical viewpoint it should be remembered that only the metal parts that interface with the user's skin are the actual electrodes. Amplifiers or other circuitry at the electrode site are part of the electronic amplifying and processing system. It is impossible to cover myoelectric control comprehensively in this chapter. The characteristics of myoelectric signals and the processing of myoelectric signals for use in prosthesis control have been described extensively in many places. 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. Scott has written an elementary introduction to myoelectric prostheses, including control, and Scott and have prepared a comprehensive bibliography concerning myoelectric control of Childress limb prostheses. The use of myoelectric control in arm prostheses has greatly increased in the United States and elsewhere during the last decade. Consequently, some may consider this technique a result of "space age electronics." In reality, the first myoelectric control system was built in Germany about 1944. The physical concept is therefore nearly 50 years old, older than the solid-state electronics that made the method ultimately practical. The early German system and an early British system were designed with vacuum tube electronic technology. British were instrumental in advancing the concepts of myoelectric control early on and scientists constructed some novel circuitry. Soviet scientists were the first to design a transistorized myoelectric system that could be carried on the body. Collaboration between a German company, Otto Bock, and an Austrian hearing aid company, Viennatone, led to the first transradial myoelectric system that could be commercially purchased in the United States. Many other commercial myoelectric systems have followed (see the current listing in Chapter 6C). Although myoelectric control will not be discussed here in great detail, 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. Since there are no systems within our common daily experience that are analogous to myoelectric control, it seems appropriate to describe it more fully than was the case with biomechanical control approaches, which are more intuitive. Electricity from skeletal muscles can be created by voluntary muscle action. In fact, this voluntary control is one of the excellent attributes of myoelectric control. A myoelectrically controlled system will only work when the amputee wills it by voluntary muscle action. Such a system is immune to influence from external forces, prosthesis location, or body position/motion. Similarly, except for very exceptional cases, the prosthesis should be free from influence by environmental electrical noise. 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. 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. This kind of random-like electric wave can only be described statistically because its amplitude and frequency are constantly varying, even when a person is holding his muscular action as constant as possible. However, one can use a "rule of thumb" to remember the general range of amplitude and the dominant frequency of a typical surface signal. The rule of thumb is to remember the number 100 for amplitude and for frequency- 100 |xV for amplitude and 100 Hz for frequency. A typical surface EMG amplitude on the forearm, under moderate muscle action-which can be measured in a number of ways (peak to peak, root mean square (RMS), etc.)-is often in the neighborhood of
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100 V, or on the order of a million times less than the voltage of electrical wiring in American homes. Of course, this voltage can usually be made larger by increased muscle action, or it can be reduced all the way to zero when the muscle is inactive. The frequency components of the EMG that have the most energy are in the neighborhood of 100 Hz (cycles/sec). There is very little energy in a surface EMG above about 400 Hz. 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. Consequently, we can see by our "rule of thumb" that an amplification of 10,000 to 100,000 is needed (1.0/0.0001, or 10.0/0.0001) to accomplish this increase. To avoid noise amplification as much as possible, 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. No amplification is necessary above about 400 Hz for control purposes since the signal above this frequency is relatively low. It should be noted that additional bandwidth is necessary for instrumentation purposes (e.g., up to 1000 Hz). 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, which may be of special importance with "dry" electrodes. 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. All electrodes should remain in contact with the skin at all times during prosthesis usage. If electrodes lose contact with the skin, a lack of control or interference may result. 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 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. The body acts as an antenna and picks up electrical noise from the environment. Consequently, touching the exposed electrodes with the fingers-so called "tipping"-introduces electrical noise through the fingers to the electrodes and into the electronics. There are no myoelectric signals in the fingertips. Also, this response should not be interpreted to mean that the electrode is a touch sensor or a pressure sensor during regular use; it is not. It merely means that when touched the myoelectric system responds to the stray electrical noise present on the fingertip. "Tipping" the electrodes is often used as a way of demonstrating the general action of the prosthesis when it is not on the body. However, it must be remembered that an expected response to touching the electrodes does not necessarily mean that the myoelectric system is completely functional. Malfunctioning amplifiers may still respond to "tipping" even when they no longer function correctly as myoelectric amplifiers. Therefore, a correct "tipping" response is a necessary but not a sufficient test to determine whether a myoelectric prosthesis is functioning properly. In a myoelectric system, amplification is followed by electronic processing that usually turns the myoelectric signal, an ac potential, into a dc potential of a given polarity (positive in Fig 6D-2.). 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. Electronic logic circuitry can be designed such that if the dc potential is greater than some threshold voltage (e.g., 1.0 V), then the circuit will turn on an electronic switch that allows electric power to flow to the prosthesis motor. Therefore, the result of contracting a muscle to a certain level results in power delivery to the driving motor of the hand or arm. If the dc potential falls below the threshold, 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, not the electricity from muscles. The myoelectric signal is used only for activation or control purposes. The system illustrated in Fig 6D-2. represents the essence of myoelectric control of a prosthesis motor-a kind of generic myoelectric control module. In actuality, the electronics of myoelectric control systems from each manufacturer take on different forms and designs. Some have circuits that enable the power to be applied to the motor in a manner proportional to the myoelectric signal amplitude. Some can turn the motor on and also reverse its direction of action (polarity/rotation) while using only one myoelectric control site. Others use two or more myoelectric control sites to effect action of a motor or motors. Fig 6D-3. shows a typical transradial myoelectric prosthesis and a generic design for a two-site, two-function myoelectric control system for it. Myoelectric control of a hand or other prehensor is particularly applicable to transradial amputation levels since people with acquired amputations usually have a "phantom
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sensation" of their missing hand. When they think of moving their phantom hand, the muscles remaining in their limb are naturally activated. Therefore, 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. Likewise, the original finger flexor muscles can be used (usually in conjunction with wrist flexor muscles) for the signal site to "close" the prosthetic hand. As a consequence, there can be a rather natural relationship between thinking about operating the phantom limb and actual operation of the hand prosthesis. Also, 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, how fast it is moving through space, and what external forces are acting upon it. Consequently, transradial myoelectric prosthesis control is usually performed well.
Myoacoustic Signals
Myoacoustic signals (auditory sounds when muscles are active), a phenomenon observed long ago but only recently reinvestigated in much depth, have been shown to have potential for the control of prostheses. Myoacoustic control systems are very similar in structure to myoelectric systems, and there does not appear, at this time, to be any compelling reason to move from myoelectric control to myoacoustic control. Myoacoustic controls primary advantage over myoelectric control could be that the acoustic sensor does not have to be in direct contact with the skin. Its main disadvantage concerns potential difficulty with elimination of extraneous mechanical noises. When a prosthesis strikes an object in the environment or rubs against something in the environment, large mechanical vibrations can be created. 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.
Neuroelectric Control
Neuroelectric control, where microelectrodes interface directly with nerves and possibly with This method of neurons, remains a control possibility that may have future applications. control requires indwelling components of some kind (e.g., telemetry implants) because neuroelectric signals are, in general, too weak to be picked up on the surface of the skin. 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. Nevertheless, the method is experimental and only has "potential" for practical applications. Nervous tissue is rather sensitive to mechanical stresses, and so it may be difficult to maintain long-term neuroelectrodes. The practicality and effectiveness of this kind of humanmachine interconnection will remain an open question until it can be tried extensively. Another surgical possibility with nerves is to surgically connect the cut ends of nerves to prepared muscle sites. This has been suggested by Hoffer and Loeb and experimentally The concept, for example, investigated in basic studies of animal preparations by Kuiken. would be to take a muscle like the latissimus dorsi, which may not be a functionally critical muscle for a shoulder disarticulation amputee, remove its normal innervation, and reinnervate it at multiple places with nerves that formerly went to the hand and forearm. The muscle, after reinnervation, might be a good source of multiple myoelectric sites or other kinds of control sources for prosthesis control. This technique has the benefit of not requiring implants. Andrew (see Chapter 9B) has apparently fitted some transhumeral amputees with myoelectric control who had had successful nerve transfer following brachial plexus injury. The decade from 1965 to 1975 was one of unprecedented research on the control of artificial limbs. The research, particularly that conducted in Europe, was stimulated by limb absences at birth that resulted from use of the drug thalidomide during pregnancy. 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. The Swedish Board for Technical Development sponsored a workshop on control of prostheses and orthoses in 1971, is a landmark publication on prosthesis control and the proceedings of that meeting research.
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should be. Surgeons can play an important role in assisting with control of limb prostheses. Unfortunately, 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. For control of limb prostheses to advance along a broad front, advancements in surgery and surgical techniques are as necessary as technical advancements. In fact, technological advancements and surgical advancements in prosthetics should be integrated, synergistic activities. Techniques in orthopedic surgery, vascular surgery, plastic surgery, and neurosurgery have advanced rapidly over the last 20 years; unfortunately, many of the new techniques have not had as much impact on prosthesis control as they could have had if surgeons, pros-thetists, and engineers had consistently worked together on limb control problems. Surgical procedures in general are handled in other parts of the Atlas, but objectives of surgery in assisting with control sites and function are considered here.
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they offer a unique way for surgeons to create control sources. New surgical techniques and the wide availability of powered prostheses may lead to a revival of this procedure. The technique is being reconsidered in Europe. In recent years Baumgartner, Biederman, Krieghoff et al., among others, have written about the utility of this control technique. In the United States, 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. Liicke et al. have discussed the use of cineplasty in connection with modern introduced a new cineplasty-like, "tendon electronic prosthesis technology. Beasley exteriorization" procedure that shows much promise. Tendon exteriorization does not traumatize the muscle itself and therefore is thought to have minimal influence on a muscle's circulation and neurologic mechanisms. This procedure demonstrates the possibility for surgical creation of a number of such control sources on the forearm that could, in the future, enable amputees with long transradial limbs to gain coordinated control of individually powered prosthetic fingers. Also, 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. Direct muscle control through tunnel cineplasties is particularly attractive in both cases because of the proprioception they naturally provide to the user. 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. Powered prostheses make it possible for tunnel cineplasty control sources to be used even when they can develop only small forces or small excursions. It appears that the combination of powered prostheses and electronic position control systems, in conjunction with new surgical techniques and procedures, may open up a new era of control based on the older, but still vital ideas of tunnel cineplasty. Adherence of the skin to underlying muscle is a less direct method of using a muscle as a control source. Skin adherence brings about skin motion when muscular contraction causes movement. This method of control has been demonstrated by Seamone et al. Surgical transfer of muscles to the amputated limb is possible for improvement of arm control, but this has not been done in large enough numbers for generalizations to be made about the utility and indications for muscle transfer procedures. Joint control, myoelectric control, or tunnel cineplasty control may all be possible applications for muscle transfers. Finally, 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. It presents options. Some users may choose to use the Krukenberg limbs in the privacy of their homes because of the good sensory and motor qualities, but they may prefer to use prostheses over their arms when they are in public venues. Even though this procedure has normally been used primarily with blinded bilateral hand amputees, the procedure may, in certain circumstances, have applications with sighted and unilateral amputees. Activation of pressure-sensitive transducers by the Krukenberg limb is one way to use it to control a hand. Myoelectric control is another option. Finally, 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. 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. Surgery can be very beneficial in assisting with the control of prostheses. This is of particular importance for high-level bilateral amputations, but may also be important for less difficult cases where a number of control sources are needed for multifunctional prostheses. Sometimes the surgical procedures designed to assist with prosthesis control can be performed at the time of original amputation, but often such surgical intervention will necessarily need to be done at a later date.
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wear a prosthesis. Professionals connected with prosthetics fitting need to support amputees' decisions about the use of prostheses. Nonetheless, 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. 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. Also, an amputee's true feelings and desires may take time to mature and to emerge. Likewise, an amputation often leads to job changes and other changes that require time to be sorted out. The prosthesis takes its place amid many life changes, and this makes initial prescription difficult. These factors suggests that diagnostic and temporary prostheses may be very useful for initial and early fittings.
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way to use this elbow design is to place a two-position switch in series with the cable that controls the elbow. When the elbow is unlocked, cable operation is normal. When the elbow is locked, pulling the cable lightly will activate the first position of the switch and close the hand. Pulling the cable with greater force will activate the second position on the switch and open the hand. In both cases the idea is to reduce the number of control sources needed. However, simultaneous control of both functions is impossible with this control approach. 3. 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. This approach, shown in Fig 6D-4.,B, is a kind of "boosted" cable control. Since the cable is directly connected to the elbow's output position, the body's position cannot get ahead of the corresponding position of the elbow and forearm. Therefore, it is a form of "unbeatable" position controller that is similar in operation to automobile powered steering, mentioned earlier in this chapter. The approach is based on D.C. Simpson's principles of extended physiologic proprioception. Heckathorne et al. have reported on this technique for a clinical fitting. 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. The principles and details behind this particular control approach have been described by Doubler and Childress. 4. For transhumeral amputees who cannot operate a body-powered elbow well (e.g., have trouble with the locking and unlocking function), a powered elbow can be used, often myoelectrically controlled (biceps-flexion, triceps-extension). The prehensor can be cable controlled and body powered. This is thought to be an effective work prosthesis if a totally cable-driven system cannot be used. It is an approach that has been promoted for use with the Liberty Mutual electric elbow. 5. For transhumeral amputees who do not want to use the harness needed for cable control or who cannot tolerate a harness (e.g., because of skin grafts) or for amputees with a relatively short limb (weak glenohu-meral leverage), the controls can be completely myoelectric, as with the Utah arm fitting shown in Fig 6D-5.. This is a twosite myoelectric control system that can be used to control the elbow proportionally. If the elbow is held stationary at a position for a short period of time, the elbow automatically locks, and this action transfers the myoelectric proportional control to the hand. A quick cocontraction of the biceps and triceps muscles is used to transfer control back to the elbow. This is a form of two-site, four-function control in which all functions are not directly accessible. Control can be alternated between the hand and the elbow.
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be contoured so that the shoulder is free to move up and down and back and forth, to a limited degree, within the prosthesis. This relatively free motion can be used effectively for control. The author feels that position servo control of the elbow, interfaced with up and down movement of the shoulder (up for elbow flexion), proportional force control of the prehensor mediated through shoulder protraction (the prehensor closes with a force proportional to the shoulder force), and retraction movements against pressure-sensitive transducers would be a desirable control scheme. However, many other schemes would work effectively, and the differences in overall performance of the unilateral amputee, as a whole, would probably not be discernible with many other control approaches (e.g., mechanical switches operated by the shoulder movements), particularly with most currently available electric elbows and prehensors.
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well with body-powered, cable-controlled systems. The functional dexterity possible at this level with this kind of control can be extraordinary. People fitted in this manner fly airplanesjust one way they manifest their excellent control capabilities. The transradial side would normally be considered the dominant side fitting. Another scheme, if the transhumeral stump is reasonably long, would be to use cable control on the transradial side and a cablecontrolled, body-powered elbow on the transhumeral side in conjunction with myoelectric control of an electric prehensor (as described for the long unilateral transhumeral amputation). When the transhumeral limb is short in this situation, a powered elbow should be considered. Two transhumeral amputations frequently lead to the use of external power on one side or the other, although totally body-powered, cable-controlled systems can be functional at this level. 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, cablecontrolled system on one side, usually the side with the longest residual limb but possibly on the side of the individual's original dominance, if the residual limb length is adequate. A single cable control of four body-powered functions has been found to be very functional. This is a technique pioneered by Mr. George Robinson at Robin Aids Prosthetics (Vallejo, Calif) and applied there currently by Mr. James Cay-wood. Their system has been redesigned somewhat to make it more modular and easier to apply. 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. However, with four-function control, two additional functions that can be locked (like the elbow) are added. These are a locking/unlocking wrist rotator and a locking/unlocking wrist flexor. As long as the elbow, wrist rotation, and wrist flexion units are all locked, the primary cable will pull the voluntary-opening hook prehensor open. If the elbow is unlocked, this cable controls flexion/extension. If the wrist rotation unit is unlocked by pushing a lever mechanism (e.g., lever on the forearm), activating the primary control cable supi-nates the prehensor if all other joints are locked. If the primary cable is relaxed, a spring connected to the wrist rotator pronates the prehensor. Therefore, the rotator can be unlocked, positioned to a new rotation angle by the primary control cable, and then locked again. The wrist flexor operates in a similar way. The amputee pushes a lever to unlock it (e.g., chin-operated lever). A rubber band causes it to move toward its extended position. Pulling on the primary control cable flexes the wrist unit. It may be locked at the desired position (in this case, three positions). If both the wrist rotator and the wrist flexion unit are unlocked, they move together. The prehensor will move to the extended and pronated position if the primary cable is relaxed. Pulling this cable under this condition brings the prehensor to a flexed and supinated position. This technique is shown on the right prosthesis of Fig 6D-6. (note the lever on the medial aspect of the forearm and the chin lever that is obscured under the shirt). The technique is also shown in Fig 6D-7. on the right prosthesis, except that in this case one chin lever locks/ unlocks the elbow and the other lever locks/unlocks the wrist rotator. The flexion wrist is unlocked by pushing the lever on its medial side in this case. The single control cable, 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. A body-powered elbow and myoelectrically controlled prehensor can be fitted to the nondominant side if the residual limb is fairly long. An electric elbow with myoelectric or rocker-switch control may be useful if the limb is short. This kind of fitting is illustrated in Fig 6D-6.. Short transhumeral and bilateral shoulder disarticulation amputations are cared for in our center with similar components as in the previous case, 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. As in the previous case, we like to use a four-function, body-powered, cable-controlled system on the dominant side. The nondominant side is fitted with a powered elbow, a powered prehensor, and a powered wrist rotator. 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. This kind of fitting is illustrated in Fig 6D-7. . Heckathorne et al. have described the complementary function of bilateral hybrid prostheses of this nature. The user can don and doff the prosthesis independently and uses it effectively in activities of daily living. Nevertheless, he has found it useful to also modify his home environment to simplify function. 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. In other words,
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forces and motions to activate the body-powered side do not activate the electric system on the opposite side. Likewise, operation of the electric prosthesis does not activate the bodycontrolled system. This automatic decoupling allows the amputee to concentrate on the prosthesis he is operating without having to consider both simultaneously. Initially, all joints except at the shoulder had positive locks, so the user does not have to worry about them slipping under loads. The shoulders had friction joints that were pre-positioned and set to high friction (see Fig 6D-7. ,A). Later the shoulder joints were converted to positive locking joints (MICA, from M. Collier, Longview,Wash) that have positive locking/unlocking in flexionextension and friction in abduction-adduction. One of these is shown installed on the right shoulder in Fig 6D-7. ,B. The three locking levers and two electric rocker switches shown in this figure are operated easily and unobtrusively by the amputee. Chin control appears to be integrated nicely into control of a multifunctional prosthesis. Nevertheless, 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. We also believe that electric-actuated, poweredlocking mechanisms will, in the future, ease the effort now involved with locking and unlocking the joints of the body-powered prosthesis with the mechanical levers. The author believes that provision for natural, subconscious control of multifunctional limbs in meaningful and coordinated ways is one of the great challenges of the medical engineering field. A reasonable medical engineering (human-prosthesis) goal, for persons who require bilateral limbs at the shoulder disarticulation level, is for them to be able to manipulate their environment as well as the best foot users do who have similar arm amputation levels. Of course, if that goal can be achieved, it would mean that we will have also been able to make similar or superior achievements at the less severe amputation levels.
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"proportional" velocity control. On the basis of these observations and others, on the basis of the objective studies, and on the basis that the cable-operated, 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, 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, joint velocity corresponds to prosthesis velocity, and joint force corresponds to prosthesis force. Gow, and others have also worked on this kind of prosthesis control. This Carlson, control method is relatively simple to implement and has been illustrated in Fig 6D-4.,B. To a great extent this principle suggests that powered prostheses should be controlled in much the same way that body-powered systems are controlled. As with powered steering on a car, required force and excursion can be matched to the force and excursion available by the human operator. The extended physiologic proprioception control approach realizes feedback of important information in a form that is naturally received by the human operator. 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. supplemental sensory feedback, as suggested by Childress, 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), if the place of stimulus on the prosthesis is represented by a particular place mapping on the body (position-to-position correspondence), and if the velocity of movement of stimulus on the prosthesis corresponds to velocity of stimulus movement on the body (velocity-to-velocity correspondence). has speculated that direct muscle action can provide the same kind of control Childress that is available from joint position inputs. 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, muscle velocity corresponds to prosthesis velocity, and muscle force corresponds to prosthesis force. The use of tunnel cineplasties (or variants) for control is an example of direct muscle action control. We know that from a control standpoint, these have been successful. New possibilities now exist for expanding the use of this kind of control input, as we have already noted in this chapter. This kind of control may even make it possible in the future to control individual prosthetic fingers in coordinated and meaningful ways. This has always been a hope of many hand amputees. The myoprehension principle has been described as the natural relationship between muscular contractions and prehension. This is easily illustrated by gripping an object tightly. As the prehension force is increased, muscles of the body that are quite distant from the hand are contracted in reaction to the holding forces being generated. For this reason, it seems natural for the body to relate prehension with muscular effort to some extent regardless of where the muscle is located. Therefore, an EMG signal, which can be related to muscle effort, is a signal that the body can relate to the gripping function. Consequently, the principle suggests that myoelectric control can be somewhat naturally connected with the control of prehension. This is intuitive if the muscles involved are in the forearm but not so obvious if the muscles are proximal to the elbow. The principles presented can be used as a guide to prescription, provided that the components that are needed are available. We know that good theories tend to fit what is known and can also be used for prediction of new kinds of control schemes. If we apply the principles outlined, they suggest that myoelectric control is good for the transradially amputated limb because the intact elbow, with the prosthesis extension, provides extended
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physiologic proprioception control of the artificial prehensor in space and the EMG signals independently control prehension (myoprehension). In like manner, for the transhumeral stump, 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, if not unanimous following as a good solution for this amputation condition. In general, 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, force control through pressure transducers, or possibly a direct muscle input be used for control of prehension. The principles suggest that there are many cases where limbs can be used effectively as rigid extensions of the body, and this implies the need for locking/unlocking of joints. The concepts presented should also be applicable to the lower limb and to other rehabilitation situations where human-machine interactions occur. As a note of caution, although theories can help guide our decision-making process, in the final analysis they cannot be the final arbiter for prosthesis control decisions, even when they are known to be valid. The final arbiter is the user. 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, if possible) control strategy under given conditions, based on experience or upon theory. If a control strategy based on a theory is in fact good-possibly best-it should also be successful in clinical practice. However, that would only be the case for a large number of fittings. As in statistics, what holds on average may be quite different for a given individual. Theoretical constructs, even when valid, must yield to the will of the individual in deciding the control method finally used, if any. This, of course, does not diminish the usefulness of the theoretical construct unless it happens in a high percentage of cases, in which case the theoretical construct would have to be questioned and re-examined.
SUMMARY
Although many factors need to be considered at the time of prosthesis prescription and during subsequent follow-up, 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. The theoretical framework that has been presented seems to be congruent with much that we know from previous experience. If it or some modification thereof is valid, it can become an effective guide for prescription. It also appears predictive, which makes it potentially valuable in directing research and development efforts with regard to prosthesis control. Many of the approaches presented in this chapter do not correspond to the theoretical ideas presented at its end. 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. Commercially available systems are not available to implement some of the approaches described in the theoretical construct. Also, as already noted, many complex factors are ultimately involved in prescriptions, with a theoretical framework being only one factor. Also, 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. We have a long way to go before we can say that we have built an "artificial arm" or an "artificial hand." In fact, Beasley and de Bese have said, "There is no such thing as an artificial hand, and the term should be dropped from use as it is misleading." They suggest that "prostheses meet only very specific and limited objectives." By extension of this idea we might say that the upper-limb prostheses currently in use are not worthy of the title "artificial arms." Nevertheless, we can see that progress has and is being made. Powered limbs have perhaps not brought the big advances originally envisioned, but they have taken on significant and practical roles in upper-limb prosthetic procedures, and that demonstrates important progress. We seem to be learning how to integrate them appropriately into practical prosthesis systems. Progress in science and technology is normally not a linearly increasing function of time. We must continue to seek insights that may result in "breakthroughs" that will yield very rapid improvement of the control of replacement limbs. Short of these "hoped-for breakthroughs," we need to keep making the kind of incremental progress that has brought us to the present state of development.
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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. He would also like to thank his associates Mr. Craig Heckathorne and Mr. Edward Grahn, who assisted and influenced him significantly. In addition, the author wants to acknowledge the clinical assistance of Dr. Yeongchi Wu and Mr. Jack Uellen-dahl, C.P.O., of the Rehabilitation Institute of Chicago, who have been open to use new upper-limb control concepts and who provided a rich clinical environment for this work. References: 1. Abul-Haj CJ, Hogan N: Functional assessment of control systems for cybernetic elbow prostheses-Part I: Description of the technique. IEEE Trans Biomed Eng 1990;37:1025-1036. 2. Abul-Haj CJ, Hogan N: Functional assessment of control systems for cybernetic elbow prostheses-Part II: Application of the technique. IEEE Trans Biomed Eng 1990; 37:1037-1047. 3. Barry DT, Cole NM: Muscle sounds are emitted at the resonant frequencies of skeletal muscle. IEEE Trans Biomed Eng 1990; 37:525-531. 4. Battye CK, Nightingale A, Whillis J: The use of myoelectric currents in the operation of prostheses. J Bone Joint Surg [Br] 1955; 37:506-510. 5. Baumgartner R: Moglichkeiten und Grenzen der Prothe-senversorgung der oberen Extremitat. Biomed Technik 1985; 30:340-344. 6. Basmajian J, DeLuca C: Muscles Alive. Baltimore, Williams & Wilkins, 1985. 7. Beasley RW: The tendon exteriorization cineplasty. In-ter-Clin Info Bull 1966; 5:6-8. 8. Beasley RW, de Bese GM: Prostheses for the hand, Evarts CM (ed): in Surgery of the Musculoskeletal System, ed 2, vol 2. New York, Churchill Livingstone Inc, 1990. 9. Bejczy AK: Sensors, controls, and man-machine interface for advanced teleoperation. Science 1980; 208:1327-1335. 10. Biedermann WG: 1st der Sauerbrucharm noch aktuell? Orthop Technik 1981; 32:156161. 11. Billock J: Upper limb prosthetic management: Hybrid design approaches. Clin Prosthet Orthot 1985; 9:23-25. 12. Bottomley AH: Myo-electric control of powered prostheses. J Bone Joint Surg [Br] 1965; 47:411-415. 13. Bottomley AH, Kinnier Wilson AB, Nightingale A: Muscle substitutes and myoelectric control. J Br Inst Radio Eng 1963; 26:439-448. 14. Carlson LE: Position control of powered prostheses. Proceedings of the 38th Annual Conference of Engineering in Medicine and Biology. Chicago, 1985, p. 48. 15. Childress DS: Biological mechanisms as potential sources of feedback and control in prostheses: Possible applications, in Murdoch G, Donovan R (eds): Amputation Surgery ir Lower Limb Prosthetics. New York, Blackwell Scientific Publications, 1988, pp 197-203. 16. Childress DS: Closed-loop control in prosthetic systems: Historical perspective. Ann Biomed Eng 1981; 8:293-303. 17. Childress DS: Control philosophies for limb prostheses, in Paul JP, et al. (eds): Progress in Bioengineering. Adam Higler, 1989, pp 210-215. 18. Childress DS: Historical aspects of powered limb prostheses. Clin Prosthet Orthot 1985; 9:2-13. 19. Childress DS: Powered limb prostheses: Their clinical significance. IEEE Trans Biomed Eng 1973; 20:200-207. 20. Childress DS, Krick H, Heckathorne CW, et al: Positivelocking components and hybrid fitting concepts for persons with high level bilateral arm amputations. Presented at the 12th Annual RESNA Conference, 1989, pp 296-297. 21. Doubler JA, Childress DS: Design & evaluation of a prosthesis control system based on the concept of extended physiological proprioception. J Rehabil Res Dev 1984; 21:19-31. 22. Gow GW, Dick TD, Draper ERC, et al: The physiologically appropriate control of an electrically powered hand prosthesis. Presented at ISPO IV World Congress. London, 1983. 23. Heckathorne CW, Uellendahl J, Krick H, et al: Achieving complementary manipulative function with bilateral hybrid upper-limb prostheses (abstract). Arch Phys Med Rehabil 1990; 71:773.
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24. Herberts P, Magnusson R, Kadefors R, et al (eds): The Control of Upper-Extremity Prostheses and Orthoses. Springfield, Ill, Charles C Thomas Publishers, 1974. 25. Hoffer JA, Loeb GE: Implantable electrical and mechanical interfaces with nerve and muscle. Ann Biomed Eng 1980; 8:351-360. 26. Kovacs GT, Storment CW, Jemes B, et al: Design and implementation of twodimensional neural interfaces. Presented at the 10th Annual Conferences of the IEEE Engineering in Medicine and Biology Society, New Orleans, 1988, pp 1649-1650. 27. Krieghoff R, Bruckner L, Richter KW: Der aktuelle Stel-lenwert Sauerbruch-Prothese bei der Rehabilitation des Armamputierten. Med Orthop Technik 1990; 110:145-147. 28. Kuiken T: The Hyper-Reinnervation of Rat Skeletal Muscle (dissertation). Northwestern University, Evanston, Ill, 1989. 29. Leal JM, Malone JM: VA/USMC Electric Hand with be-low-elbow cineplasty. Bull Prosthet Res, 1981; 10:52-56. 30. Liicke R, Marquardt E, Carstens C: Kineplasty according to Sauerbruch-The fresh indication pectoralis canal in amputations in the region of the shoulder girdle (abstract). Presented at the Sixth World Congress of ISPO, Kobe, Japan, 1989, p 200. 31. Marquardt E: The operative treatment of congenital limb malformation-Part I. Prosthet Orthot Int 1980; 4:135-144. 32. Michael JW: Upper limb powered components and controls: Current concepts. Clin Prosthet Orthot 1986; 10:66-77. 33. Murphy EF: In support of the hook. Clin Prosthet Orthot 1986; 10:78-81. 34. Parker PA, Scott RN: Myoelectric control of prostheses. Crit Rev Biomed Eng 1986; 13:283-310. 35. Popov B: The bio-electrically controlled prosthesis. J Bone Joint Surg [Br] 1965; 47:421-424. 36. Reiter R: Eine neue Elektrokunsthand. Grenzegebiete Med 1948; 1:133-135. 37. Ryder RA: Occupational therapy for a patient with a bilateral Krukenberg amputation. Am J Occup Ther 1989; 43:689-691. 38. Scott RN: An introduction to myoelectric prostheses, in U.N.B. Monographs on Myoelectric Prostheses. University of New Brunswick Bio-Engineering Institute, Can42. ada, 1984. 39. Scott RN, Childress DS: A bibliography on myelectric control of prostheses, in U.N.B. Monographs on Myoelec- 43. tric Prostheses. University of New Brunswick BioEngineering Institute, Canada, 1989. 40. Seamone W, Schmeisser G, Hoshall H: A powered cable drive for prosthetic-orthotic systems, in Gavrilov M, Wilson AB Jr (eds): Proceedings of the Fourth International 44. Symposium on Advances in External Control of Human Extremities. Dubrovnik, Yugoslavia, Yugoslav Committee for Electronics and Automation, 1973, pp 736-755. 41. Sears HH, Shaperman J: Proportional myoelectric hand control: An evaluation. Am J Phys Med Rehabil 1991; 70:20-28. 42. Sheridan TB, Ferrell WR: Man-Machine Systems: Introductory Control and Decision Models of Human Performance. Cambridge, Mass, MIT Press,1974. 43. Simpson DC: The choice of control system for the multi-movement prosthesis: Extended physiological proprioception, in Herberts P, et al (eds): The Control of UpperExtremity Prostheses and Orthoses. Springfield, Ill, Charles C Thomas Publishers, 1974, pp 146-150. 44. Thring MW: Robots and Telechirs: Manipulators With Memory; Remote Manipulators; Machine Limb for the Handicapped. Chichester, England, Ellis Horwood Ltd, 1983.
Chapter 6D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
HAND FUNCTION
The primary objective of hand surgery is the restoration of function to an injured hand. It is therefore important that the basics of hand function and their evaluation be understood prior to repair or reconstruction. There are a number of standard tests now used to assess hand function. These evaluate the musculoskeletal components, sensation, and functional capacity. An adequate method of evaluating function is necessary to assess the extent of the injury and the outcome of reconstructive efforts. The musculoskeletal components are evaluated by measuring muscle strength and joint range of motion, while sensory function is evaluated through tactile sensitivity. Functional capacity is assessed by observing a patient's ability to manipulate objects and use the hand. The joint ranges of motion are important in assessing function; the impairment as a result of lost motion is well outlined in the American Medical Association Guides to the Evaluation of Permanent Impairment.8-11 Prehensile activities involve power and precision grips, which are evaluated by grip strength The hand grip and, in the case of precision grips, by a movement profile as well. dynamometer provides the most consistent measure of power grip strength. It is assessed by ( Fig 7A-1.). There are three types of precision grip: tip, averaging three separate trials three-jaw chuck, and lateral-pinch grip. These involve the thumb and second and third fingers ( Fig 7A-2.). Tip pinch is used in picking up objects such as paper clips, the three-jaw chuck in grasping objects more firmly, and lateral pinch in holding a key. 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, temperature, Normal static two-point discrimination at the vibration, and two-point discrimination. Moving two-point discrimination can also be used to test fingertips is approximately 6 mm. the mechanoreceptors in the hand. 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.). These are a Pressure sensitivity can be evaluated by Semmes-Weinstein monofilaments. 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. Pressure sensation does not correlate with twopoint discrimination. Point localization, tactile object recognition, and su-domotor function are also important in
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evaluating sensory defects. Point localization is the ability to accurately localize a point of stimulation of the skin. This test is performed by touching with a probe in one or two separate locations and asking the patient to identify those locations. Tactile object recognition, also known as tactile gnosis or stereognosis, is the ability to recognize an object placed in the hand. The time the patient takes to identify the object is also recorded. Su-domotor function is evaluated by the Ninhydriri sweat test or the wrinkle test. When a peripheral nerve is cut, innervation to the sweat glands is lost, and the skin becomes dry. The return of sudomotor function closely follows the return of tactile sensibility. The wrinkle test is performed by placing the hand in warm water (42 C) for 20 to 30 minutes. If the skin is denervated, it will not wrinkle. In order to more fully evaluate functional activities of the hand, a number of tests have been devised that involve manipulating small objects or the performance of activities of daily living. The only objective measurement in these tests is the time it takes to perform the tasks. These tests are important because they require a combination of functions measured by all the previous methods, thus measuring the ability to execute certain tasks by the hand. At present, there are no better instruments to evaluate hand function as a whole.
FINGERTIP INJURIES
Fingertip injuries are very common in industry and also in children. The industrial worker, usually working with a circular saw, gets distracted, and the saw amputates the finger at the midnail area. Children have their fingertips amputated in doors that are forcefully slammed on the digit. The action taken for treatment is different depending on whether the patient brings the amputated part or not. If an adult brings the part and it is clean, the best treatment is the application of a full-thickness defatted skin graft taken from the part. If there are losses in the nailbed on the remaining finger, a full-thickness graft can be taken from the amputated part to restore the nail matrix of the remaining digit. In the case of the child, no defatting is done, 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 amputated part is not brought in or is dirty and therefore unusable, one must proceed with reconstruction. There are basically four modes of reconstructing the fingertip to avoid amputation of the distal phalanx. These are fat advancement and splitor full-thickness skin grafting, V-Y-plasty, cross-finger flaps, and distant flaps. These are well described in standard texts ( Fig 7A-4. and Fig 7A-5.).
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function of each individual digit may not be improved over that of a single digital replantation, 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. these cases, unless it is severely impaired, may add significantly to the width and strength of the hand. Indications for replantation of a single digit, except the thumb, are more controversial. Replantations distal to the flexor superficialis insertion, i.e., middle phalanx, usually do well. They exhibit significantly better range of motion, approximately 80 degrees of proximal interphalangeal joint motion, than do replants at the metacarpal level. Digits replanted proximal to the flexor superficialis insertion have decidedly limited proximal interphalangeal found the total joint motion that averages approximately 35 degrees. Scott and associates active motion of replants through the proximal phalanx to be poor (averaging 120 degrees) in 84% of their patients. Joint stiffness combined with limited sensibility may seriously limit the use of a replanted digit when three normal digits are available for substitution. Even worse, the impaired function of the replanted finger may seriously jeopardize use of the entire hand. Causes of limited use may be decreased sensibility, pain, cold intolerance, and quadriga. 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.). For these reasons, many authors no longer recommend proximal replantation of single digits, except in the occasional patient in whom a full complement of digits is a professional necessity (e.g., a musician) or perhaps in Ring avulsion injuries are a specific subset of single-digit amputations whose care children. Although complete amputations by this mechanism were not has been subject to debate. recommended for replantation, 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. Relative contraindications to replantation include associated life-threatening injury or the presence of systemic disease, particularly any that would affect the patient's vasculature or ability to withstand a prolonged surgical procedure. Factors pertaining to the injury itself, including severe crush or avulsion, gross contamination, the presence of injury at multiple levels, or excessive delay in treating the patient, may also make attempts at replantation inadvisable. The ultimate question to be answered is whether the replanted part will function in a manner that will surpass amputation. Although the strictly medical issues involved in making such a decision are complex enough, the physician must also consider and discuss with the patient the psychological and economic implications of the available options. 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. Once the decision for replantation has been made, survival rates in most recent series approach 80% to 90% or greater at all levels. The major factors influencing survival are age of the patient and experience of the surgeon. Early complications requiring reoperation are related to vascular occlusion in up to 40% of cases. Somewhat fewer than half of the digits requiring early reoperation are salvageable. Infection is a rare occurrence following replantation in the hand. The occurrence of postoperative hemorrhage reported in various series ranges from rare to nearly 50% of cases. The severity of this complication is difficult to quantify, and the incidence of bleeding significant enough to require reoperation is not reported. Postoperative heparinization seems to be associated with higher rates of hemorrhagic complications, 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. Leeches may also be of benefit if there is difficulty with venous drainage. Recovery of sensation following replantation is slightly poorer than that of digital neurorrhaphy in lacerations involving fingers. If nerve repair is delayed or requires the use of grafts, recovery of sensation is not as good as with primary repair. In general, virtually all patients develop protective sensation, while two thirds regain measurable two-point discrimination. Approximately half will exhibit two-point discrimination of 10 mm or less. Gelberman and colleagues have shown a correlation between the return of sensation and restoration of digital vascularity on a quantitative basis. Other late complications include malunion or nonunion, with an incidence of less than 5% in and the almost universal presence of cold intolerance. Urbaniak states that most series, this problem usually resolves spontaneously in the year or two following replantation, although
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it may remain indefinitely as a minor problem in colder climates. Secondary operations are performed on 15% to almost 50% of patients, with tenolysis and release of joint contracture being the most common procedures. Very few patients require late secondary reamputation. Virtually all patients express satisfaction regarding replantation, with few stating that they would have preferred amputation. 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. Data regarding return to work do give some indication of fairly normal functional use, and the ability to do so is of obvious economic, social, and personal significance to the patient. Early return to work should be considered a priority of rehabilitation.
THE THUMB
The thumb is required for both power and precision grip. In order to achieve this, adequate length and sensation must be present as well as stability and the ability to oppose the other fingers. 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. controversy over exactly how much length must be lost before there is a significant impairment. For example, disarticulation through the interphalangeal joint of the thumb is rated as a 20% impairment of the hand. Whatever the amputation level, the patient must have an adequate residuum for pinch and grip to be restored. Once adequate length has been achieved, the sensation of the thumb must be considered. The thumb is involved in tactile perception and two-point stereognosis. Without adequate sensation, it is difficult to recognize an object and localize its position in the hand. In order for function to occur, the thumb must have at least protective sensation. The ability to oppose the thumb and index finger is necessary for grasping and pinching. This motion occurs at the carpometacarpal joint of the thumb. If this joint is destroyed or unstable, it can be fused with the thumb in full opposition, with resultant loss of function. This position enables the fingers to brace objects against the thumb, which serves as a post. Motion at the interphalangeal or metacarpophalangeal joint is not an absolute necessity for normal thumb function. Replantation has become a reliable surgical procedure as microvascular surgical techniques have improved. Restoration of thumb function by replantation has been reliable and well This should be the first consideration when examining a thumb amputation. documented. Only after replantation is not successful or found to be not feasible should other reconstructive procedures be considered. Thumb reconstruction requires assessment of the patient's age, sex, occupation, hand dominance, and the remaining structure and functional status of the injured hand. The level of amputation in the thumb determines which procedures should be considered.
Amputation Through the Midproximal Phalanx and Mid-distal Phalanx of the Thumb
At these levels of amputation, the functional impairment is caused by loss of length, which
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affects pinch and grip strength. The carpometacarpal joint is usually uninvolved, thus giving the thumb good rotation and mobility. The goals are to restore length and sensibility. When this is A free toe transfer satisfies all the requirements of reconstruction at this level. unacceptable to the patient, there are other reconstructive procedures such as "phalangization" of the first metacarpal, which results in a deepened first web space that can improve grip and pinch. The web space procedures available include Z-plas-ties, both simple and four flap, and dorsal rotational or remote pedicle flaps. These are best performed when the underlying soft tissues are minimally scarred and there is good joint mobility. When there are contractures of the muscles and scarring with loss of mobility, then a pedicle from uninjured tissue must be utilized. This can be obtained by cross-arm flap, free flap, or reverse radial artery flap coverage into the web space. By deepening the web space and releasing contracted tissue, the thumb is effectively lengthened ( Fig 7A-7., Fig 7A-8., Fig 7A-9.).
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. Reconstructive options are essentially limited to pollicization and island or free digit transfers. If the carpometacarpal joint is intact due to a residual portion of metacarpal, a digit transfer to the thumb can be performed with minimal loss of mobility. If the entire first metacarpal is absent, 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. This is the only technique capable of restoring function when only metacarpals are remaining after amputation.
RAY AMPUTATIONS
These amputations are rarely performed emergently. 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, infection, or failed replantation. If function is severely impaired secondary to the injury and especially if the function of adjacent digits is impaired, the removal of the entire ray should be considered in an effort to improve function of the hand as a whole. Each ray resection has its own special considerations for preventing complications such as painful neuromas, closing the gap created between rays, and minimizing cosmetic deformities. Index ray resection has two complications associated with it that need attention ( Fig 7A-11. ). The first is debilitating pain occurring from excessive mobilization of the radial digital nerve when performing the amputation. This complication appears in the first 8 weeks following surgery, and reoperation is not usually successful. 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. This
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procedure is not necessary, and the resultant deformity will further hinder hand function. When performing a long-ray resection, there may be difficulty in closing the space between the ring and index rays ( Fig 7A-12. and Fig 7A-13. ). 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. 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. Ring-ray resections are similar to those of the long ray but usually close the remaining gap more easily ( Fig 7A-14. ). If there is difficulty in reducing the space, the fifth metacarpal base can be allowed to slide radially if the entire base of the fourth metacarpal is excised. The fifth metacarpal can also be transposed to the base of the remaining fourth metacarpal after amputation, but this is rarely necessary. 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. ). 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.
RECONSTRUCTION
Following single or multiple digital amputations in which replantation is not feasible, attention is focused on reconstruction of the remaining hand so that a prosthesis can be worn. In addition, preservation of the general function of the hand has to be considered fundamental to reconstruction. In the case where the patient has retained a "basic" hand including the thumb and at least one of the digits, consideration has to be given to the space between them. Is that space adequate? Is there a painful neuroma in the midpalmar area that would inhibit function? Is
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there adequate skin coverage? Is there good sensation? If a contracture exists, that area should be reconstructed with a long-lasting, soft piece of skin, ideally a distant free flap with sensation. If the patient presents with a thumb and no other digit, reconstruction of an opposing finger is a priority. A toe with its neurovascular bundle may be transferred from the foot to the hand to provide an opposing digit. 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. When coverage must include subcutaneous tissue and sensation, potential donor procedures are the free lateral arm flap and the radial artery fasciocutaneous flap. 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. This is also true for the radial artery flap, where the superficial radial nerve can provide innervation. These flaps are capable of withstanding the use of a prosthesis very nicely. Other donor sites are available but do not provide as good a sensory component as these flaps (see Fig 7A-10. ).
COMPLICATIONS
Numerous complications can occur following amputation in the hand. Although much has been written concerning solutions to these problems, particularly the painful neuroma, few authors have attempted to examine their true nature and incidence. The incidence of complications varies considerably in published reports, depending somewhat upon how diligently they are sought. The reported need for reoperation following amputation ranges from 2% to 25%. The largest number of complications involve the presence of pain and is therefore at least partially subjective in nature. The patient's attempt to come to terms with an amputation involves a complex and interrelated series of physical, psychological, emotional, aesthetic, economic, and cultural adaptations. To say that well-motivated amputees do better may be trite, but it is also quite true. A review of surgeons with amputations involving the hand revealed few of these complications, a high level of acceptance, and almost universal return to preamputation activities. 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. Painful amputations due to adherent or excessive scarring, poor padding, or protuberant bone are much more common in the digits than at the metacarpal level. These are usually the result of an injudicious attempt to save length at all costs. Although maintenance of length is of concern, such residua seriously jeopardize function of the entire hand. Tension-free closure with appropriate shortening or tissue transposition should be performed initially. Late treatment of such a problem is usually best managed by more proximal amputation, although occasionally local flap coverage may be considered for specific indications. The incidence of painful neuroma following amputation in the hand has been reported to range from less than 1% to 25% or greater. The number of treatments proposed to prevent or manage a painful neuroma is large. Occasionally, nonoperative methods such as desensitization, transcutaneous nerve stimulation, or neural blockade may prove to be Tupper and curative, but an established painful neuroma often requires a surgical solution. 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. Other authors have had significantly less success with this technique. Transposition of the intact neuroma to a better-padded, preferably dorsal location seems to The most promising provide the most consistent and significant long-term relief of pain. new technique that may be considered when adequate local soft-tissue for transposition is not present is that of centrocentral nerve union, whereby two proximal nerve ends are joined with intervening graft. 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. Deformity more distal in the nail may be treated similarly; however, reconstruction with grafts of sterile or germinal matrix may be considered. The hooked nail resulting from the loss of distal
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phalangeal support is exceptionally difficult to treat, with resorption of distally located bone grafts and recurrence of deformity being the norm. Quadriga or profundus tendon blockage may limit motion of adjacent unaffected digits following amputation. 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. Scarring of these tendons within the amputated digit or in the palm may limit excursion of the adjacent digits. Early and full active motion of the intact fingers postoperatively usually prevents this complication. Once present, surgical correction by release of the adherent profundus tendon is quite successful. 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. Interconnections of the profundus tendons in the palm and the relatively greater strength of the flexor system make this "lumbri-cal-plus" deformity uncommon. When encountered, division of the lumbrical tendon is curative. Median nerve compression following retraction of the profundus tendon and its lumbrical into the carpal tunnnel is another rare complication. Cold intolerance following amputation is quite common, although this usually resolves over time without treatment. The dysvascular residuum, which is painful, nonfunctional, and prone to repeated trauma and ulceration, is generally best treated by more proximal amputation. Occasionally, pharmacologic treatment or local sympathectomy by excision of vessel adventitia may prove effective, although long-term benefits are uncertain. References: 1. Aulicino PL, DuPuy TE: Clinical examination of the hand, in Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand, ed 2. St Louis, Mosby-Year Book, 1984, pp 25-48. 2. Barton NJ: Another cause of median nerve compression by a lumbrical muscle in the carpal tunnel. J Hand Surg 1979; 4:189. 3. Bell J: Sensitivity evaluation, state of the art, in Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand, ed 2. St Louis, Mosby-Year Book, 1984, pp 101-132. 4. Brand PW: Clinical Mechanics of the Hand. St Louis, Mosby-Year Book, 1985, pp 61191. 5. Brown PW: Complications following amputations of parts of the hand, in Boswick JA (ed): Complications in Hand Surgery. Philadelphia, WB Saunders Co, 1986. 6. Brown PW: Less than ten-surgeons with amputated fingers. J Hand Surg 1982; 7:31. 7. Conolly WB, Goulston E: Problems of digital amputations: A clinical review of 260 patients and 301 amputations. Aust N ZJ S 1973; 43:118. 8. Dellon LA: Evaluation of Sensitivity and Re-education of Sensation in the Hand. Baltimore, Williams & Wilkins, 1981, pp 95-139. 9. Dellon LA: The moving two-point discrimination test: 10. Clinical evaluation of the quickly adapting fiber/receptor system. J Hand Surg [Am] 1978; 3:474-481. 11. Engleberg A: Guides to the Evaluation of Permanent Impairment, ed 3. Chicago, American Medical Association, 1988, pp 20-21. 12. Fess EE: The need for reliability and validity in hand assessment instruments. J Hand Surg [Am] 1986; 11:621-623. 13. Fisher GT, Boswick JA: Neuroma formation following digital amputations. J Trauma 1983; 23:136. 14. Gelberman RH, Urbaniak JR, Bright DS, et al: Digital sensibility following replantation. J Hand Surg 1978; 3:313. 15. Gellis M, Pool R: Two-point discrimination distances in the normal hand and forearm. Plast Reconstr Surg 1977; 59:57-63. 16. Glas K, Biemer F, Duspiva KP, et al: Long-term follow-up results of 97 finger replantations. Arch Orthop Trauma Surg 1982; 100:95. 17. Gorkisch K, Boese-Landgraf J, Vaubel E: Treatment and prevention of amputation neuromas in hand surgery. Plast Reconstr Surg 1984; 73:293. 18. Grant GH: Methods of treatment of neuromata of the hand. J Bone Joint Surg [Am] 1951; 33:841. 19. Greenseid DZ, McCormack RM: Functional hand testing: A profile evaluation. Plast Reconstr Surg 1968; 42:567-571. 20. Hallin RG, Wiesenfeld Z, Undblom U: Neurophysio-logical studies on patients with
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38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53.
sutured median nerves: Faulty sensory localizations after nerve regeneration and its physiological correlates. Exp Neurol 1981; 73: 90-106. Harvey FJ, Harvey PM: A critical review of the results of primary finger and thumb amputations. Hand 1974; 6:157. Herndon JH, Eaton RG, Littler JW: Management of painful neuromas in the hand. J Bone Joint Surg [Am] 1976; 58:369. Jebsen RH, Taylor N, Trieschmann RB, et al: An objective and standardized test of hand function. Arch Phys Med Rehabil 1969; 50:311-319. Jones L: The assessment of hand function: A critical review of techniques. J Hand Surg [Am] 1989; 14: 221-228. Kay S, Werntz J, Wolff TW: Ring avulsion injuries: Classification and prognosis. J Hand Surg [Am] 1989; 14:204. Kevins S, Pearsall G, Ruderman RJ: Von Frey's method of measuring pressure sensitivity in the hand: An engineering analysis of the Weinstein-Semmes pressure aes-thesiometer. J Hand Surg 1978; 3:211-216. Komatsu S, Tamai S: Successful replantation of a completely cut off thumb. Plast Reconstr Surg 1968; 42:374. Laborde KJ, Kalisman M, Tsai T: Results of surgical treatment of painful neuromas of the hand. J Hand Surg [Am] 1982; 7:190. Leung PC: An analysis of complications in digital replantations. Hand 1980; 12:25. Louis D: Amputations, in Green DP (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988, pp 61-119. May J, Rohrich R: Microvascular great toe-to-hand transfer for thumb reconstruction, in Green DP (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988. May JW: Digit replantation with full survival after 28 hours of cold ischemia. Plast Reconstr Surg 1981; 67:566. McPhee SD: Functional hand evaluation: A review. Am J Occup Ther 1987; 41:158163. Moberg E: Objective methods for determining the functional value of sensitivity in the hand. J Bone Joint Surg [Br] 1958; 40:454-476. Morrison WA, O'Brien BM, Macleod AM: Evaluation of digital replantation-a review of 100 cases. Orthop Clin North Am 1977; 8:295. Murray JF, Carman W, MacKenzie JK: Transmetacarpal amputation of the index finger: A clinical assessment of hand strength and complications. J Hand Surg 1977; 2:471-481. Mutniowetz V, Hashman N, Volland G, et al: Grip and pinch strength: Normative data for adults. Arch Phys Med Rehabil 1985; 66:69-74. Neu BR, Murray JF, MacKenzie JK: Profundus tendon blockage: Quadriga in finger amputations. J Hand Surg [Am] 1985; 10:878. O'Brien BM, Franklin JD, Morrison WA, et al: Replantation and revascularization surgery in children. Hand 1980; 12:12. Omer GE: The painful neuroma, in Strickland JW, Stei-chen JB (eds): Difficult Problems in Hand Surgery. St Louis, Mosby-Year Book, 1982. Onne L: Recovery of sensitivity and sudomotor activity in the hand after nerve suture. Acta Univ Scand Suppl 1962; 300:1-69. O'Riain S: New and simple test of nerve function in the hand. Br Med J 1973; 3:615616. Owen JE: Sensitivity testing, in Owen GE, Spinner M (eds): Management of Peripheral Nerve Injuries. Philadelphia, WB Saunders Co, 1980, pp 3-80. Poppen NK, McCarroll HR, Doyle JR, et al: Recovery of sensitivity after suture of digital nerves. J Hand Surg 1979; 4:212-226. Schmidt RT, Toews JV: Grip strength as measured by the James dynamometer. Arch Phys Med Rehabil 1970; 52:321-327. Scott FA: Complications following replantation and revascularization, in Boswick JA (ed): Complications in Hand Surgery. Philadelphia, WB Saunders Co, 1986. Scott FA, Howar JW, Boswick JA: Recovery of function following replantation and revascularization of amputated hand parts. J Trauma 1981; 21:204. Semmes J, Weinstein S, Ghent L, et al: Somatosensory Changes After Penetrating Brain Wounds in Man. Cambridge, Mass, Harvard University Press, 1960, pp 4-11. Smith HB: Hand function evaluation. Am J Occup Ther 1973; 27:244-251. Smith JR, Gomez NH: Local injection therapy of neuromata of the hand with triamcinolone acetonide. J Bone Joint Surg [Am] 1970; 52:71. Strickland J: Thumb reconstruction, in Green DP (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988, pp 2175-2261.
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54. Strickland JW: A rationale for digital salvage, in Strickland JW, Steichen JB (eds): Difficult Problems in Hand Surgery. St Louis, Mosby-Year Book, 1982. 55. Tamai S: Digit replantation: Analysis of 163 replantations in an 11 year period. Clin Plast Surg 1978; 5:195. 56. Tupper JW, Booth DM: Treatment of painful neuromas of sensory nerves in the hand: A comparison of traditional and newer methods. J Hand Surg 1976; 1:144. 57. Urbaniak J: Other microvascular reconstruction of the thumb, in Green DP (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988. 58. Urbaniak JR, Evans JP, Bright DS: Microvascular management of ring avulsion injuries. J Hand Surg 1981; 6:25. 59. Urbaniak JR, Roth JH, Nunley JA, et al: The results after amputation of a single finger. J Bone Joint Surg [Am] 1985; 67:611. 60. 57.Weinstein S: Intensive and extensive aspects of tactile sensitivity as a function of body part, sex, and laterality, in Henshals DR (ed): The Skin Senses. Springfield, Ill, Charles C Thomas Publishers, 1968, pp 195-222. 61. 58.Whipple RR, Unsell RS: Treatment of painful neuromas. Orthop Clin North Am 1988; 19:175. 62. 59.Wynn Parry CB: Peripheral nerve injuries: Sensation. J Bone Joint Surg [Br] 1986; 68:15-19.
Chapter 7A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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. Those who elect to wear a prosthesis do so for specific reasons, and the foundation for successful prosthetic-orthotic design is therefore careful Although a variety of approaches assessment of the amputee's expectations and needs. are possible, the simplest device necessary to meet the identified needs will provide the greatest measure of acceptance and patient satisfaction. Due to the space constraints dictated by the remnant hand, few devices can provide both a cosmetic appearance and strong prehension simultaneously. Thus, it may well be necessary to prescribe more than one device to meet all of the amputee's needs.
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Aesthetic Loss
One common concern of partial-hand amputees is the disfigurement that an anomalous hand presents. It should be noted that the degree of physical loss is not at all indicative of the degree of emotional loss, which varies according to cultural and personal values. Prescription of a prosthesis to restore the external appearance is common, and such devices Although it is true that covering the remnant are generally well accepted by the amputee. hand with a rubberized glove reduces sensory input and increases perspiration, neither factor is of great consequence for the unilateral amputee. Chapter 7D discusses the aesthetic prosthesis in detail. 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. 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
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not identical to) the patient's hand. Although these latter prostheses are much less expensive than custom-sculpted restorations, they are not as durable nor as well matched in color or contours and are therefore satisfactory only in selected cases ( Fig 7B-1.). It should be noted that passive restorations should not be considered to lack function. Most allow a fixed grasp, many provide a source of opposition for mobile hand remnants, and partial-digit extensions frequently restore the ability to type, play keyboard instruments, and the like. 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.
Protection
Another indication for prosthetic use, in addition to restoring a more normal appearance, is to protect hypersensitive or fragile areas. This is frequently necessary during the early postoperative stages while healing is occurring. 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.,A). 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.,B). In some cases, grafted skin or hyperesthesias will require long-term protection by a prosthetic device ( Fig 7B-3.). Particularly for the manual laborer, such protective devices may be required to permit a return to gainful employment ( Fig 7B-4.).
Prehension
The final justification for prosthetic-orthotic fitting is to improve prehension. 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, sensate, and prehension-capable limb deficiency will likely be encumbered by a prosthesis that attempts to augment grasp, although some prefer an aesthetic restoration. The one exception is the limb without digits that retains carpal or carpal-metacarpal motion. An orthotic post may improve grasp by providing a platform for the mobile, sensate metacarpal "pad" to oppose. The three-position design developed at the Child Amputee Prosthetics Program (CAPP) is particularly useful ( Fig 7B-5.).
STATIC DEVICES
Most prosthetic devices used to restore grasp following partial-hand amputation have static configurations. Particularly for use under the rugged conditions of factory work or manual labor, static designs have the advantage of durability. Some are formed from stainless steel, individually shaped to the anomalous hand, and covered with a pink-colored plastic (Plastisol) to increase the friction when gripping objects ( Fig 7B-6.). Other devices are made of laminated plastic formed over balsa wood ( Fig 7B-7.) or over lightweight aluminum armatures covered with polyurethane foam ( Fig 7B-8.). It is also possible to use thermoplastics to form partial-hand devices ( Fig 7B-9.). Some amputees choose to retain the simple utensil cuffs provided early in their rehabilitation training because they find this approach adequate for their needs. The common denominator in all these prostheses is that they must be individualized carefully to perform the specific tasks desired by the amputee. For example, the configuration to permit a landscape worker to handle shovels, rakes, and the like will differ significantly from the contours necessary to permit a chef to use cooking utensils. It is usually helpful to have the amputee bring examples of the objects he wishes to handle with the prosthesis to the initial fitting. This permits the prosthetist to reconfigure the prosthesis to provide as many grasp patterns as possible prior to finishing the device.
DYNAMIC DEVICES
Articulated or dynamic devices powered by residual motions at the wrist or palm may also be developed to enhance grasp. Although technically much more difficult to fit than static designs, articulated partial-hand prostheses usually offer a wider range of openings, thereby ( Fig 7B-10. ). 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. ). Body power transmitted from biscapular abduction is generally used to open the device,
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but wrist motion ( Fig 7B-12. ) or other body motions may sometimes be used ( Fig 7B13. ). It is also possible to utilize a voluntary-closing terminal device ( Fig 7B-14. ). It is sometimes possible to combine a wrist-driven orthosis with prosthetic fingers and thumb to result in a somewhat cosmetic hand prosthesis, particularly when covered with a modified ( Fig 7B-15. ). This approach has been difficult to replicate due to numerous cosmetic glove technical constraints but is worthy of further investigation. Myoelectric control of fingers driven by individual motors is the most advanced technique yet attempted. Researchers at Northwestern University have developed demonstration prototypes (see Chapter 12D), although many barriers must be overcome before such technology can become clinically available.
SUMMARY
In summary, partial-hand prostheses are highly individualized devices designed to meet such specific needs as cosmetic appearance, protection of tender areas, and augmentation of active grasp. In traumatic cases, 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. Devices to restore active grasp are best described as "tools" and are most readily accepted for manual tasks or factory occupations. Many amputees prefer one device to provide cosmetic restoration and another for specific tasks where appearance is unimportant. Since every prosthetic device reduces sensory feedback to some degree, many individuals will choose to function without any devices at all. References: 1. Baumgartner R: Active and carrier-tool prostheses for upper limb amputations. Orthop Clin North Am 1981; 12:953-960. 2. Beasley RW: General considerations in managing upper limb amputations. Orthop Clin North Am 1981; 12: 743-750. 3. Beasley RW: Surgery of hand and finger amputations. Orthop Clin North Am 1981; 12:763-804. 4. Bender LF: Prostheses for partial hand amputations. Prosthet Orthot Int 1978; 2:8-11. 5. Bender LF, Koch RD: Meeting the challenge of partial hand amputations. Orthot Prosthet 1976; 30:3-11. 6. Blair SJ, Kramer S: Partial hand amputation, in American Academy of Orthopaedic Surgeons (ed): Atlas of Limb Prosthetics: Surgical and Prosthetic Principles St Louis, Mosby-Year Book, 1981; pp 159-172. 7. Brown RD: An alternative approach to fitting partial hand amputees. Orthot Prosthet 1984; 38:64-67. 8. Buckner HE: Cosmetic hand prosthesis-A case report. Orthot Prosthet 1980; 34:41-45. 9. Bunnell S: The management of the nonfunctional hand- Reconstruction vs. prosthesis. Artif Limbs 1957; 4: 76-102. 10. Cole DP, Davis GL, Traunero JE: The Toledo tenodesis prosthesis-A case history utilizing a new concept in prosthetics for the partial hand amputee. Orthot Prosthet 1985; 38:13-23. 11. Dobner D: A simple cosmetic partial-hand prosthesis. J Hand Ther 1988; 1:209-212. 12. Herring HW, Rommerdale EH: Prosthetic finger retention: A new approach. Orthot Prosthet 1984; 38:64-67. 13. Kirk NT: Amputations, in Lewis DDL (ed): Practice of Surgery, vol 3. Hagerstown, Md, WF Prior Co Inc, 1944. 14. Kramer S: Partial hand amputation. Orthopedics 1978; 1:314. 15. Law HT: Engineering of upper limb prostheses. Orthop Clin North Am 1981; 12:929952. 16. Malick MH: A preliminary prosthesis for the partially amputated hand. Am J Occup Ther 1975; 29:479-482. 17. Pillet J: The aesthetic hand prosthesis. Orthop Clin North Am 1981; 12:961-970. 18. Schottstaedt ER, Robinson GB: Functional bracing of the arm. J Bone Joint Surg [Am] 1955; 38:477-499. 19. Swanson AB: Restoration of hand function by the use of partial or total prosthetic replacement. Part 2. Amputation and prosthetic fitting for treatment of the function-less, asensory hand. J Bone Joint Surg [Am] 1963; 45:284-288. 20. Tomaszewska J, Kapczynska A, Konieczna D, et al: Solving individual problems with partial hand prostheses. In-ter-Clin Info Bull 1974; 13:7-14.
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21. Wedderburn A, Caldwell RR, Sanderson ER, et al: A wrist-powered prosthesis for the partial hand. J Assoc Child Prosthet Orthot Clin 1986; 21:42-45.
Chapter 7B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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In the senior author's experience, unilateral distal congenital amputees almost never ask spontaneously for a functional prosthesis. In the very rare exceptions encountered, it has been relatively easy to discern the influence of parents or family practitioners, both equally misinformed. When one is treating a congenital amputee, it is common to commit a dual error by considering him as a disabled person and by assuming that he must have a prosthesis. He is not a true amputee but rather has an imperfect development because of a congenital deformity. He has established his own perception of his body, which differs from our perception of it. He sees himself as being complete and normal. 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. 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 even just as quickly and just as well. To require fitting a prosthesis for a patient with unilateral agenesis, however perfect the prosthesis may be, is tantamount to encumbering a normal person with a third hand. In fact, this was the reaction of such a patient when I asked why he did not have a functional prosthesis. "Doctor," he said, "what would you want with a third hand?" Congenital unilateral amputees are therefore disabled chiefly by our perceptions. Whatever their ages, they typically manage all activities of daily living without any prostheses. They may use a technique that differs from ours. Naturally they have some frustration from not being able to do certain things, and this varies from one person to another. However, giving them insensitive prostheses will not automatically make them any more dexterous. In the 16th century, Ambroise Pare, the "father of French surgery," reported seeing "an armless man do almost all the things anyone else could do with his hands." Aesthetic Needs Unlike the traumatic amputee, an agenetic person is not subject to the initial emotional shock of losing a hand. Only gradually does he come to realize that he is not like other people. The realization is not spontaneous, but rather is a result of those around him. Generally speaking, awareness of their anomaly begins when they start their school days and new friends show their curiosity. They begin to fear medical checkups and gym. Finally, the hurdle of adolescence is most important. A young person often tends to blame his malformation for all his teen-age troubles. The congenital amputee considers himself from the outset as being normal from a functional point of view, but he often suffers from feeling "different." These patients may have the same aesthetic need felt by the amputee who has had a traumatic loss.
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correspond to the normal skin in all details and match the color as precisely as possible. The material of the prosthesis must be strong and repairable if torn. It must not stiffen at low temperatures within the normal climatic range and must also be heat resistant ( Fig 7C-1.). It must not be stained by ordinary materials such as newsprint and, if soiled, must be easily cleaned by washing in water with a mild soap ( Fig 7C-2.). It must not irritate the skin. Fingernail details are especially important: consistency, translucency, color, and the nail and lunula length must be similar to the opposite side. A lack of all these qualities has been the reason for dissatisfaction with the commonly used polyvinylchlo-ride (PVC) gloves. Polymers of dimethyl siloxane (silicones) allow copying of the natural hand in every detail. The opposite hand of the amputee is cast in the silicone, and from this design, a replica of the hand is made. Fixation of the prosthesis must be secure, comfortable, and simple. When fixation is perfect, attempts at removal create a negative pressure, 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. Amputations at this level require a thimble-like prosthesis extending to the middle phalanx, with the proximal interphalangeal joint left free. The proximal edge of the prosthesis is feathered to a thin edge without pigmentation, and this makes the skin juncture relatively inconspicuous. The most beautiful result is achieved when the length of the prosthesis is extended over the proximal interphalangeal joint to the proximal phalanx, even though some restriction of flexion results. By extending the digit to its normal length, the most common type of precision grip is
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improved. The pulp of the thumb can now oppose the pulp of the prosthetic digit, as when picking up a pencil. The prostheses can also be used in typing and playing a musical instrument. The socket provides some flexibility for comfort. When a person's job requires that he uses his prosthesis hard, i.e., computer operator, a small dorsal thermoplastic splint can be worn over the prosthesis during work for mechanical strength and stability. If the distal interphalangeal joint develops a fixed flexion contracture from scar formation, stiffens in a position of nonfunction, or has a spatulate appearance, surgical revision may be indicated. Experience has shown that it is much better, both functionally and aesthetically, to undergo amputation at the distal interphalangeal joint than to keep a longer but stiff stump in flexion.
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Metacarpal Amputations
Metacarpal amputations can be transverse, central, or oblique. In the case of transverse amputations, the prosthesis is essentially a total hand terminating 2 to 4 cm proximal to the ulnar styloid. A watchband or tennis bracelet in summer can be worn to cover the juncture between the prosthesis and natural skin. When only a portion of the thumb remains, it is generally covered with a total-hand prosthesis that extends the length of the thumb and provides it with a natural-looking fingernail. 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. The fingers are made firm in a semiflexed position to serve as opposition posts for the mobile thumb. When a normal thumb has been preserved, 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 latter method presents the problem of disguising the opening in the glove, but for most activities having a sensate thumb outside the glove is so functionally superior that it is generally recommended. When a useful small finger remains after an oblique metacarpal amputation in which all or most of the thumb is lost, it is best that the second metacarpal be surgically resected and the small finger fitted into the ring finger of the prosthesis. This not only is more functional, with the single finger having a better working relation to the thumb post, but also allows the prosthesis to be fabricated to the exact size of the other hand. When a metacarpal amputation is central and involves the index, middle, and ring fingers, i.e., a punch press injury, both the thumb and small finger are preserved. Functionally, it is best to leave both the thumb and small finger protruding from the prosthesis if they are normal. The small-finger juncture can be easily covered with an ordinary ring. Prosthetic fitting of partial-hand amputations is a most difficult problem. The variety of physical problems encountered is enormous, and potential solutions must be carefully weighed against the needs of the patient, which are almost as variable. The absence of any perfect solution gives rise to a great variety of possibilities that one must carefully consider.
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. Fixation by suction eliminates the need for a complicated harness or suspension system. 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. Once locked into position, it enables the amputee to use the prosthesis as a stabilizer as well as functional assist in bilateral activities. Flexibility of the prosthetic digits allows the amputee to hold light objects placed in the hand.
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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. The stump should be conical in shape and firm, with bone extending the full length. If the tissues are soft, a shoulder prosthesis will be required. A stump that is too fat requires surgical revision prior to fitting of the prosthesis.
Shoulder Amputation
Shoulder disarticulation is less disfiguring than the forequarter amputation since the contour of the shoulder remains. The prosthesis for the shoulder disarticulation patient is very similar in design to that for the forequarter amputation, except for the extent of the shoulder cap. Forequarter amputations leave a distressing aesthetic and functional defect. It is often difficult to fit and train these amputees in the use of a satisfactory active prosthesis. 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.,A), thus improving the appearance of clothing, and to which an aesthetic forearm and wrist unit are attached. The prosthesis is secured to the patient by means of webbing straps ( Fig 7C-5.,B)
PREPROSTHETIC MANAGEMENT
The considerations when applying a prosthesis are many and varied. Each case must therefore be evaluated individually so that psychological, social, vocational, and avocational needs can be determined. Although patients of all ages can be fitted with a prosthesis, the loss of one or more distal phalanges in a child or adolescent does not generally require a prosthesis. Children and teenagers usually manage to overcome the functional loss and in most cases perform all their
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activities. A prosthesis might be functionally more awkward than useful. Many patients who sustain distal amputations are engaged in occupations or hobbies where finger dexterity means the difference between success and failure. A secretary, typist, or pianist who has lost the distal phalanx of any digit may find functional ability enhanced with a prosthesis. In the fingertip amputee, a thimble-like prosthesis may provide the needed length to enable the flutist to play the flute again (Plates 5 and 6). It is necessary to determine the patients motivation for obtaining a prosthesis and whether he has a realistic understanding of the advantages and disadvantages. If the patient is appropriately oriented to the realities of the prosthesis, he is better prepared to accept the limitations of the prosthesis when he receives it. It is important to convey that the prosthesis may impede function and reduce sensation in an area. Also, the patient must realize that the color of his skin varies due to daylight or electric light, emotional status, position of the hand, and many other conditions that can change the blood flow. He must understand that the color of the prosthesis will be the one that most matches the "average normal" color of the skin. To make these differences less noticeable, it is recommended that a ring or small plastic strip bandage be worn at the edge of the prosthesis. Some patients wear their prostheses for years, some only for months. We do not consider this a failure, but rather proof of the effectiveness of the prosthetic treatment that helped the patient through a difficult period of his life. The prosthesis is then considered a temporary treatment discontinued because the amputee feels himself "cured." When the amputee uses his prosthesis all his life, this means that he considers it either a so-cioprofessional accessory or a part of his body image. Then he wears it every day, all day long, and it becomes an integral part of himself.
PHYSICAL ASSESSMENT
Although patients are anxious to obtain their prostheses as soon as possible, it is necessary that sound wound healing be completed and edema controlled. Coban [*Coban. Medical Products Division, Minnesota Mining and Manufacturing Co., St. Paul, Minn.] wrapping helps to reduce edema, promote stump shrinkage, and contour the stump for the prosthesis. Coban is applied firmly distally to proximally, with less tension over joints allowing free use. When volumetric measurements of the stump have stabilized, the patient is ready for fabrication of the prosthesis. A painful stump cannot tolerate a prosthesis. Desen-sitization techniques reduce these paresthesias and help to prepare the stump for the prosthesis. 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. If no progress is made with desensitization techniques after 1 month, surgical revision should be considered.
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motivation or one with unrealistic expectations as to what the device is expected to accomplish. Relative contraindications include instances when such a device may be uncomfortable, result in significant functional loss, or even achieve a poor aesthetic result. For example, with disarticulation of several digits, the prosthesis must cover the hand completely for adequate fixation. Attempts at fixation on very short stumps can result in trophic skin changes that will make the prosthesis unbearable. Multiple digital prostheses on the same hand can interfere with its sensibility as well as its gripping strength. When there are bulky or badly aligned stumps, aesthetically pleasing prostheses may not be feasible without prior surgical revision. It should also be remembered that in bilateral amputations an aesthetic prosthesis should be provided on only one side.
SUMMARY
An aesthetic prosthesis can be equally helpful to the acquired amputee and to a patient whose malformation is attributable to agenesis. 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. Such a prosthesis may fulfill the psychological and functional needs of congenital or acquired amputees to look like everybody else, with two hands, and be able to use them in public without embarrassment. Although the primary aim and purpose of an aesthetic prosthesis is to provide an aspect of normality to a disfigured hand, 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. In cases where the hand has been totally amputated, the prosthesis may be used functionally to hold light objects and, in two-handed grasping activities, as a support or to push objects. Finally, by being aesthetic, the prosthesis encourages the amputee to use his stump for daily activities, which enables him to better integrate into the complex socioeconomic environment of todays society. The prosthesis must conform to very high standards of quality to achieve these goals.
BIBLIOGRAPHY
Dautry P, Pillet J, Apoil A, et al: A la recherche d'une main perdue. Rev Practicien 1971; 21:603. Dufourmentel C: La Substitution Prothetique de L'ongle, vol 9. Paris, GEM Monographic 1978; pp 108-112. Iselin M, Pillet J: Possibilites actuelles de la prothese plas-tique. Association a la chirurgie dans les mutilations de la main. Presse Med 1953; 82:1-1767.
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Pillet J: Prosthetic requirements of the congenital unilateral amputee, in Boswick J Jr (ed): Current Concepts in Hand Surgery. Philadelphia, Lea & Febiger, 1983, pp 212-213. Pillet J: Digital and hand prosthetic fitting, in Urbaniak JR (ed): Microsurgery for Major Limb Reconstruction. St Louis, Mosby-Year Book, 1987, pp 46-50. Pillet J: La Chirurgie Secondaire Dans les Mutilations de la Main. Toulouse, France, Souquet Mansat, 1989, p 141. Pillet J: La Prothese Dans les Amputations des Extremites Digitales, ed 2, vol 9. Paris, GEM Monographic, 1981, pp 123-127. Pillet J: La prothese plastique et restauratrice chez les amputs partiels du membre superieur. Acta Chir Belg 1958; 57:319-322. Pillet J: The aesthetic and functional replacement, in Landi A, De Lucia S, Desantis, G (eds): Reconstruction of the thumb. London, Chapman & Hall Ltd, 1989. Pillet J: The aesthetic hand prosthesis. Orthop Clin North Am 1981; 12:961. Pillet J, Biteau O: La prothese plastique du membre superieur. Gaz Med Fr 1969; 87:34213425. Pillet J, Guyaux MC, Le Gall CA: Protheses ungueales. Ann Dermatol Venereol 1987; 114:425-428. Pillet J, Mackin E: Aesthetic hand prosthesis-its psychological and functional potential, in Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand, ed 2. St Louis, Mosby-Year Book, 1984, pp 801-807. Pillet J, Mackin E: Prosthetic contribution to distal amputations, in Foucher G (ed): Fingertip and Nailbed Injuries. New York, Churchill Livingstone Inc, 1990. Pillet J, Mantero R: in Piccin (ed): Rivista di Chirugia Delia Mano. Padova, Piccin Editore, 1986, pp 217-220.
Chapter 7C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Surgical Principles
Elizabeth Anne Ouellette, M.D. In the upper limb, the etiology of 90% of amputations is trauma. This occurs predominantly in the 20- to 40-year-old age group, with males involved four times as frequently as females and the left side affected as often as the right. All other causes of amputation are less common, including peripheral vascular disease, neurologic disorders, malignant tumors, The most common congenital infections, contractures, and congenital deformities. amputation, however, is at the short transradial (below-elbow) level. With the advent of limb salvage procedures, a malignant tumor no longer automatically leads to an amputation. Microvascular surgical techniques have also aided in the preservation of limbs after trauma. Despite these advances, there are still situations in which amputation is the final outcome. Amputation levels are now chosen not by the prosthesis, but by the level of injury or involvement by the disease process. If the cause is trauma, there must be adequate debridement of nonviable tissue, but primary amputation closure is contraindicated to prevent infection. Length of the amputation can be preserved by coverage with split grafts over muscle or with free vascularized flaps. Indications for elective shortening of residual limbs are rare. The ultimate goal of amputation surgery is to provide a pain-free residual limb that is functional.
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.
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.,A-C). Regional anesthesia is ideal. The use of a tourniquet allows for clear identification of tissues and reduces blood loss. Exsanguination by an elastic bandage prior to elevating the tourniquet is indicated except in cases of tumor and infection. In these situations, limb elevation alone is recommended. Palmar and dorsal flaps in a 2:1 ratio are developed to provide adequate tissue for closure ( Fig 8A-2.,A and B). These flaps extend down to deep fascia. Hemostasis should be achieved as these flaps are developed. The styloid processes need to be contoured enough to create a symmetrical limb for fitting of the prosthesis. The triangular fibrocartilage complex must be preserved because it provides for stability and hence painless motion of the distal radioulnar joint. The dorsal and volar
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tendons are transected and stabilized under physiologic tension when the vascular supply permits. Blood vessels may be controlled by coagulation or ligation. The main vessel groups that must be identified are the ulnar, radial, and anterior and posterior interos-sei. The nerves that must be identified are the median, ulnar, posterior interosseous, and radial sensory. These should be cut under moderate tension and allowed to retract proximally into the soft tissues to avoid entrapment in the incisional scar. Specifically, 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. A minor cosmetic drawback is that the active prosthesis for this level will result in a longer forearm on the prosthetic side.
Transradial Amputation
As long a residual limb as possible should be saved, commensurate with the diagnosis. The longer it is, the stronger the lever arm will be, and the more completely pronation and supination will be preserved ( Fig 8A-3.). 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. Very short residual limbs, however, may have difficulty tolerating the weight of a myoelectric prosthesis. The same surgical principles apply to forearm amputations as to wrist disarticulation. The bone is transected after the periosteum has been incised. The bone edges are then carefully smoothed. Myodesis or myoplasty is performed to stabilize the muscle mass, which may be helpful in later myoelectric fitting. If the amputation must be very proximal, then an ulna 3.8 to 5 cm long is still adequate to preserve the elbow joint. In order to fit this very short residuum with a prosthesis, it may be helpful to detach the biceps and reattach it to the ulna. 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. Rather than decrease prosthetic function by shortening the longer bone, it may be preferable to create a one-bone forearm. Skin coverage is best achieved by local flaps with care taken to avoid adherence to underlying bone. If skin coverage is a problem, a split graft, free flap, or abdominal flap can be used to obtain coverage and preserve length. Split grafts will require extra care from the patient until the grafts mature but should do well with time. Revision surgery is necessary in approximately one third of transradial amputees. Every effort should be made during revision surgery, however, to preserve even a very short transradial level so long as active range of motion of the elbow will be preserved.
KRUKENBERG OPERATION
The purpose of this operation is to give an amputee a sensate, active pincer by using the ulna and radius. It is a valuable procedure in patients whose contralateral hand has been lost or severely damaged, as well as for those patients without access to prosthetic limbs, as in some developing nations. It is particularly useful for the blind bilateral transradial amputee since it uses sensation to enhance grasp, something no prosthesis can offer. 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. The sensation of the tips can approach normal finger sensibility when the operation is performed in children. Adults usually achieve protective sensation and the ability to identify objects. To perform this operation, there must be good skin coverage and muscles in the forearm, so it is usually contraindicated in burn patients (see Chapter 36A). Because the appearance of the Krukenberg limb may be objectionable in some circumstances, it can be easily fitted with a prosthesis if desired. Myoelectric, body-powered, and passive cosmetic fittings are possible. This will allow the amputee the option of using his Krukenberg limb or prosthesis as the situation dictates.
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a rigid dressing include better control of postsurgical edema and protection of the wound from external trauma. With the addition of prosthetic prehension and suspension components to a rigid postoperative dressing, the patient can begin to use this temporary prosthesis within 1 or 2 days, thus preserving two-handed grasping patterns ( Fig 8A-4.). Elastic bandages may be used if rigid techniques are not feasible. Even pressure must be applied, with care taken to avoid flap necrosis. References: 1. Baumgartner RF: The surgery of arm and forearm amputations. Orthop Clin North Am 1981; 12:805-817. 2. Burkhalter WE, Mayfield G, Carmona LS: The upper extremity amputee, early and immediate post surgical prosthetic fitting. J Bone Joint Surg [Am] 1976; 58:46-51. 3. DeSantolo A: A new approach to the use of the Krukenberg procedure in unilateral wrist amputations, an original functional-cosmetic prosthesis. Bull Hosp Joint Dis Orthop Inst 1984; 44:177-187. 4. Louis D: Amputations, in Green DL (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988, pp 61-119. 5. Rees MJ, UeGens JJ: Immediate amputation stump coverage with forearm free flaps from the same limb. J Hand Surg [Am] 1988; 13:287-292. 6. Sarmiento A, McCollough NC, Williams EM, et al: Immediate post surgical prosthetic fitting in the management of upper extremity amputees. Artif Limbs 1968; 12:14-16. 7. Tooms RE: Amputations, in Crenshaw A (ed): Campbell's Operative Orthopaedics, vol 1, ed 7, St Louis, Mosby-Year Book, 1987, pp 597-637. 8. Tubiana R: Krukenberg's operation. Orthop Clin North Am 1981; 12:819-826. 9. Wood MR, Hunter GA, Millstein SG: The value of stump split grafting following amputation for trauma in the adult upper and lower amputees. Prosthet Orthot Int 1987; 11:71-74.
Chapter 8A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Prosthetic Principles
Carl D. Brenner, C.P.O.
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
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The first prosthesis to be considered when attempting to provide early intervention is either the immediate or early postoperative prosthesis. An immediate postoperative prosthesis is applied in surgery at the time of final closure, while an early postoperative procedure is one that is performed anytime between surgery and suture removal. There appears to be no significant difference in the long-range outcomes between immediate and early postoperative application. However, it can be argued that an immediate application can provide additional psychological benefits to the patient and the patient's family. Essentially, both immediate and early procedures are done by utilizing the same technique. This begins with the application of two separate layers of stockinette directly over the dressing ( Fig 8B-1.), followed by distal padding that can be made of either lamb's wool, sterile fluffs, or a reticulated urethane foam pad. Over this is applied a thin cast/socket fabricated of plaster or fiberglass casting tape ( Fig 8B-2.), which will come up to the level of the epicondyles but leave the elbow free. 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.). This is followed by a similar application of tape in order to affix the flexible elbow hinges, which are connected to the triceps pad. A standard Bowden cable assembly is applied, and either a shoulder saddle harness or, more typically, a figure-of-8 harness is employed for suspension and terminal device control. Once all the components have been taped to the cast/socket, a final covering of either Coban or Elastoplast can be applied in order to reinforce the fixation of the components ( Fig 8B-4.). It is important to note that no synthetic casting tape or plaster is used to attach the components to the inner socket. This ensures easy removal of the components when it becomes necessary to change the cast/socket. The two stockinette socks, applied at the beginning, allow easy removal and application of the postoperative prosthesis, which facilitates wound However, the patient and the nursing staff should be advised inspection and management. that removal should only be done for very short periods of time so that edema control can be maintained. 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. postoperative prostheses are as follows: (1) decreased edema, (2) decreased postoperative pain and phantom pain, (3) increased prosthetic use, (4) improved proprioceptive/prosthetic transfer, and (5) improved patient psychological adaptation to amputation.
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prove most functional, then the elements of an appropriate prescription become self-evident. However, there are several things that should be considered when developing definitive specifications. Among these factors are socket configuration, elbow joints, wrist components, and harness designs.
Socket Designs
For the mechanical prosthesis, the choice of sockets lies either with a harness-suspended or self-suspended design. As a general rule, the longer the residual limb, the lower the proximal trim line of the socket can be. When the patient has a significant amount of natural pronation and supination available after surgery, the proximal trim line of the socket should be cut low enough to preserve at least 50% of the active pronation and supination. Although there are several self-suspended sockets that are now available for wrist disarticulation and long belowelbow (transradial) levels, most of these designs cannot provide maximum benefit to the patient as long as some form of suspension/control harness is necessary. 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. socket,
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, which can be made out of either triplethickness Dacron webbing ( Fig 8B-6.) or flexible metal cable. When socket rotation around the residual limb becomes a problem secondary to a very short bone length, the use of single-axis elbow joints is the most effective measure to provide stability. In those rare instances where the patient has very limited elbow flexion, the use of step-up hinges may prove beneficial, particularly in the case of the bilateral amputee.
Wrist Components
The three most commonly used wrist units are the standard friction wrist, the quickdisconnect/locking wrist, and the flexion wrist unit. 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 quick-disconnect/locking wrist has proved to be the most useful for adult unilateral amputees. In those cases where normal functional performance of the contralateral upper extremity has been compromised, 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.
Harness Designs
There are three basic harness designs, including the figure-of-9, the figure-of-8, and the shoulder saddle harness with a chest strap. The figure-of-9 harness is used primarily with a self-suspended socket that requires a harness only to provide terminal device operation. 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 shoulder saddle harness is beneficial to those amputees who will be doing an unusual amount of heavy lifting. It also provides relief from some of the axilla pressure exerted by a figure-of-9 or figure-of-8 harness. However, 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.
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prosthetics. This has led to increasing complexity and a much broader array of options to be considered when prescribing prostheses for the upper-limb amputee. However, a practical method to simplify the decision-making process has slowly evolved throughout the past several years. 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, the different design and component options before coming to a final conclusion. preparatory/ training electronic prosthesis should be considered a separate and distinct procedure in the total evaluation process of the upper-limb amputee's needs. Components and Technique Although a preparatory electronic prosthesis should be fitted with the same care as any definitive prosthesis, the fabrication process and the components used provide a very costeffective way of analyzing the patient's needs. What follows will be a brief description of the actual process involved in fitting and fabricating a preparatory/training electronic prosthesis. As previously stated, 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. This ensures that the experience of the patient, while wearing the prosthesis, will compare very closely with a similar experience in a more costly definitive electronic limb. The same techniques are used for taking the negative plaster mold of the residual limb and subsequent modification as with a definitive fitting. A transparent test socket is then made over the modified plaster model, and this is used to both evaluate the suspension and stability of the socket design as well as establish electrode sites. The test socket is then filled with plaster to create the final positive master model over which the preparatory electronic socket will be fabricated. Once the socket has been fabricated, it is then possible to attach a simple fitting frame ( Fig 8B-7.) to provide a means by which the electronic components can be installed in the prosthesis. This entire complex is then covered with some form of temporatory material, either rigid or semiflex-ible, that provides protection to the wiring and various electronic components during the time that the patient will wear the prosthesis ( Fig 8B-8.). Finally, a standard protective outer glove is applied over the prosthesis to cover the inner shell of the electronic hand. It is very important that the patient receive preprosthetic signal training prior to the start of the prosthetic fitting and fabrication. Following the fitting, the patient should continue with occupational therapy that stresses the specific activities that relate to that patient's daily routine, both on and off the job. Although most electronic prostheses use myoelectric signals as the primary control format to command the prosthesis, there are three other electronic control modes that may also be utilized in a preparatory or a definitive electronic prosthesis. These include electronic servo controls, electronic switch controls, and It is not uncommon for a prosthesis to have a combination of one electronic touch controls. or more electronic controls in addition to one or more mechanical controls. Under such a scheme, the design of the prosthesis is designated as a hybrid system. Although multiple combinations are seen primarily in amputation levels above the elbow and higher, a hybrid combination may very definitely be indicated for a patient with marginal elbow function, which may require a step-up mechanical hinge in conjunction with either a switch-controlled or myoelectrically controlled terminal device and/or wrist rotator.
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amputee, the preparatory/training electronic prosthesis also adheres to the three general goals of preparation, evaluation, and training. By way of preparation, the preparatory electronic prosthesis provides for (1) the establishment of ideal definitive myoelectric signal sites, (2) the opportunity to improve marginal myoelectric signals, and (3) the conditioning of the tissues contained within a self-suspended socket. In terms of evaluation, the four specific objectives to be addressed are (1) validation of the socket design and selected electronic components, (2) an assessment of the patients motivation and commitment to derive maximum benefit from an electronic prosthesis, (3) providing the patient with the opportunity to determine the actual functional value of the electronic prosthesis when compared with other options, and (4) the development of clinical evidence to substantiate a cost-vs.-benefit comparison between various alternatives. 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.
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health care insurance to cover the cost of these procedures. In addition, 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. As a result, 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. A secondary concern involves the maintenance and corresponding downtime that may be associated with the continuous operation of a sophisticated electronic system. In recent years, the use of electronic prostheses has increased, and it has been possible to evaluate and compare maintenance schedules among mechanical and electronic prostheses. For the most part, electronic prostheses appear to require maintenance at approximately the same level of However, the issue of downtime for maintenance can frequency as mechanical prostheses. 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. 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. 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.
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. Each system can provide a unique perspective on the potential solution and eventual outcome for each individual amputee. Although circumstances may not permit or necessitate the use of all five basic procedures in every case, the use of two or three of these techniques is almost always possible and indicated. In following the above model, the patient, the patient's family, clinicians, care givers, 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. References: 1. Billock JN: The Northwestern University supracondylar suspension technique for below elbow amputations. Or-thot Prosthet 1972; 26:16-23. 2. Billock JN: Upper limb prosthetic management: Hybrid design approaches. Clin Prosthet Orthot 1985; 9:23-25. 3. Brenner CD: Funding sources for electronic upper limb prostheses. Presented at the 1989 University of New Brunswick Myoelectric Controls Course and Symposium, Fredricton, New Brunswick, August 1989. 4. Brenner CD: Patient management experience with Myo-bock controls. Presented at the Scientific Program of the American Orthotic and Prosthetic Association, Quad
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Regional Meeting, Denver, June 1989. 5. Burkhalter WE, Mayfield G, Carmona LS: The upper-extremity amputee: Early and immediate post-surgical prosthetic fitting. J Bone Joint Surg [Am] 1976; 58:46-51. 6. deBear P: Functional use of myoelectric and cable-driven prostheses. J Assoc Child Prosthet Orthot Clin 1988; 23:60-61. 7. deBear P: Myoelectric training for upper limb amputees. Presented at the 1989 University of New Brunswick Myoelectric Controls Course and Symposium, Fredricton, New Brunswick, August 1989. 8. Epps CH: Externally powered prostheses for children- 1984. Clin Prosthet Orthot 1985; 9:17-18. 9. Hubbard S: Myoelectrics for the acheiria and partial hand amputee. Presented at the Scientific Program of the 1987 Annual Meeting of the Association of Children's Prosthetic-Orthotic Clinics, Vancouver, British Columbia, June 1987. 10. Kritter AE: Current concepts review: Myoelectric prostheses. J Bone Joint Surg [Am] 1985; 67:654-657. 11. LeBlanc MA: Patient population and other estimates of prosthetics and orthotics in the U.S.A. Orthot Prosthet 1973; 27:38-44. 12. Malone JM, Childers SJ, Underwood J, et al: Immediate postsurgical management of upper extremity amputation: Conventional, electric and myoelectric prosthesis. Orthot Prosthet 1981; 35:1-9. 13. Malone JM, Fleming LL, Roberson J, et al: Immediate, early, and late postsurgical management of upper limb amputation. J Behabil Res Dev 1984; 21:33-41. 14. Michael JW: Upper limb powered components and controls: Current concepts. Clin Prosthet Orthot 1986; 10:66-77. 15. Millstein SG, Heger H, Hunter GA: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prostheses. Prosthet Orthot Int 1986; 10:27-34. 16. Morawa LG: Early intervention with immediate and early post-surgical prostheses. Presented at the Seminar on Myoelectronic Upper Extremity Prosthetics, Rehabilitation Institute, Detroit Medical Center, October 1987. 17. Nichol WR: Electronic touch controls for prostheses. J Assoc Child Prosthet Orthot Clin 1986; 21:33. 18. Northmore-Ball MD, Heger H, Hunter GA: The below elbow myo electric prosthesis with the hook and functional hand. J Bone Joint Surg [Br] 1980; 62:363-367. 19. Sauter W: Three-quarter-type Muenster socket. J Assoc Child Prosthet Orthot Clin 1985; 20:34. 20. Supan TJ: Transparent preparatory prostheses for upper limb amputation. Clin Prosthet Orthot 1987; 11:45-48.
Chapter 8B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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level of choice, however, for juvenile amputees. The high incidence of bony overgrowth requiring stump revision in the case of transhumeral amputation in the child is avoided, 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. that internal elbow mechanisms occupy approximately 4 to 6 cm of length. Although functionally equivalent to shoulder disarticulation, amputation through the surgical neck of the humerus has the significant cosmetic benefit of leaving shoulder width and axillary borders intact, which makes prosthetic suspension somewhat easier when compared with shoulder disarticulation. High transhumeral amputations also provide more stable electromyographic sites for the myoelectric wearer and improved range of motion for body-powered function. It must be recognized that the deltoid tuberosity is the most proximal level at which shoulder joint control is effective.
TECHNICAL CONSIDERATIONS
Skin
Equal anterior and posterior flaps are the norm; however, unconventional flaps should be used whenever necessary to preserve residual-limb length. The ultimate position of the scar is not critical with modern total-contact sockets. Be aware that the skin in the region of the medial epicondyle is thin and wears poorly; therefore, a long medial flap is the least desirable. Although preservation of length is important, 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.
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. Neuroma formation is the normal and expected consequence of nerve division, and the goal is to locate the cut nerve end away from areas of contact and cicatrix so that it will be asymptomatic. Nerves should be gently withdrawn from the wound, sharply divided, and allowed to retract under cover of proximal soft tissue. It has been suggested that because of their close proximity, the median and ulnar nerves be divided in such fashion that their stumps do not come to lie at the same level, although this is not of proven benefit.
Blood Vessels
Use of a pneumatic tourniquet greatly facilitates more distal amputations. As has often been emphasized, exsanguination of the distal portion of the limb should not be performed in cases of tumor or infection, and the tourniquet should always be deflated and careful hemostasis achieved prior to wound closure. Tourniquet deflation also allows for proper muscle tensioning. Major vascular structures are doubly ligated proximally, and cautery alone should not be relied upon to control larger collaterals. Postoperative wound drainage is essential to prevent hematoma formation and delayed wound healing, which can adversely affect early prosthetic training.
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During elbow disarticulation, epicondylar prominences may be reduced medially and laterally to prevent areas of pressure concentration within the socket. This must, however, be done conservatively to avoid negating the inherent suspension and rotational control value of elbow disarticulation. The articular cartilage is left undisturbed. Transhumeral amputations should be performed with minimal periosteal stripping to prevent the occurrence of ring sequestra or bony spurs. If myodesis is performed, care should be taken not to devitalize a large segment of bone. Rough edges should be removed with a file or rongeur, although beveling of the bone is unnecessary. The wound should be thoroughly irrigated following bone contouring. 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. References: 1. Abraham E, Pellicore RJ, Hamilton RC, et al: Stump overgrowth in juvenile amputees. J Pediatr Orthop 1986; 6:66. 2. Aitken GT: Surgical amputation in children. J Bone Joint Surg [Am] 1963; 45:1735. 3. Baumgartner RF: The surgery of arm and forearm amputations. Orthop Clin North Am 1981; 12:805. 4. Brown PW: The rational selection of treatment for upper extremity amputations. Orthop Clin North Am 1981; 12:843. 5. Burkhalter WE, Mayfield G, Carmona LS: The upper extremity amputee: Early and immediate post-surgical prosthetic fitting. J Bone Joint Surg [Am] 1976; 58:46. 6. Glynn MK, Galway HR, Hunter G, et al: Management of the upper limb deficient child with a powered prosthetic device. Clin Orthop 1986; 209:202. 7. Heger H, Millstein S, Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation. J Bone Joint Surg [Br] 1985; 67:278. 8. Jaeger SH, Tsai T, Kleinert HE: Upper extremity replantation in children. Orthop Clin North Am 1981; 12:897. 9. Jones NF, Hardesty RA, Goldstein SA, et al: Upper limb salvage using a free radial forearm flap. Plast Reconstr Surg 1987; 79:468. 10. Malone J, Fleming L, Robertson J, et al: Immediate, early and late postsurgical management of upper limb amputation. J Rehabil Res Dev 1984; 21:33. 11. Marquardt E, Neff G: The angulation osteotomy of above-elbow stumps. Clin Orthop 1974; 104:232. 12. Schmidt R, Springfield D, Dell PC: Extended forearm flap. J Reconstr Microsurg 1987; 3:189. 13. Tooms RE: Amputations of upper extremity, in Crenshaw AH, (ed): Campbell's Operative Orthopaedics, ed 7. St Louis, Mosby-Year Book, 1987. 14. Whipple RR, Unsell RS: Treatment of painful neuromas. Orthop Clin North Am 1988; 19:175. 15. Wood MB, Cooney WP: Above elbow limb replantation: Functional results. J Hand Surg [Am] 1986; 11:682. 16. Zuker RM, Stevenson JH: Proximal upper limb replantation in children. J Trauma 1988; 28:544.
Chapter 9A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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PHYSICAL FACTORS
There are several factors that are crucial when designing and optimizing transhumeral and elbow disarticulation prostheses, including the following: 1. 2. 3. 4. Length of the bony lever arm Quality and nature of soft-tissue coverage Shape and muscle tone of the residual limb Flexibility, range of motion, and stability of the proximal joints
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.
While severe trauma does not always leave the surgeon many options, optimization of these factors will significantly aid the amputee by facilitating his prosthetic rehabilitation and minimizing the need for revision surgery. 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. In the transhumeral case, if the adult humerus is transected 10 cm (4 in.) above the olecranon tip, all available elbow options can be utilized successfully, including external power. Elbow disarticulation, on the other hand, will require the use of outside locking joints located on either side of the humeral epicondyles external to the socket. Although this level may add active rotary control and the possibility of a self-suspending socket, both component durability and cosmesis are reduced. The functional advantages of disarticulation make it especially valuable to the bilateral upper-limb amputee, who must use the residual limb for self-care. It is also preferred over the transhumeral level in children since the epiphysis is preserved and bony overgrowth is prevented. 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.). Length due to redundant tissue is functionally useless and serves only to complicate the prosthetic fitting. Myoplasty helps to firm the residual limb, helps prevent redundancy, and provides improved electromyographic (EMG) potential for use in myoelectrically controlled prostheses. Scar lines, drains, and skin grafts should be placed away from cut bones and away from the axilla whenever possible. In these prostheses the anterior, lateral, 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. In this author's experience, 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. Latissimus transfers seem Innervated pectoralis-to-biceps transfer has also resulted in a to be the most common. very functional bicepslike EMG control site for use with a myoelectric prosthesis ( Fig 9B-2.). 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.). 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.
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Another somewhat successful alternative has been the use of progressive distraction and callus formation via an external fixator (the Ilizarov technique). While such techniques are certainly not the answer for every short transhumeral stump, the potential benefits are significant. One of our patients, after lengthening via a fibular graft, now has a long, strong transhumeral residual limb capable of operating both an externally powered Utah Arm and a fully functional cable-powered prosthesis ( Fig 9B-4.).
IMMEDIATE/EARLY MANAGEMENT
Much has been written on the subject of immediate and early postsurgical prosthetic fitting. Advantages include control of edema and postamputation pain by containing the remnant limb in a snug dressing. Circulation seems to be improved by the lack of edema, thereby promoting quicker healing of the limb. The patient has an improved outlook since he has a usable replacement immediately following amputation and can maintain two-handed grasp patterns. It has been suggested that EMG signals seem to be improved when a limb is contained in a rigid dressing. Despite these potential benefits, however, upper-limb immediate fittings have never enjoyed widespread popularity. This may be simply due to the infrequency of this level of amputation. Biofeedback training or muscle re-education using functional electrical stimulation has been shown to be an effective technique to enhance myoelectric control. Other important preprosthetic considerations include exercise to maintain strength and range of motion and careful determination of the amputee's vocational and avocational goals. 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. months, it appears that the amputee becomes more and more adept at one-handed work patterns. Once this occurs, learning to use a prosthesis can become a much more frustrating and difficult experience. If immediate fitting has not been possible, early fitting within a few weeks of amputation is strongly recommended.
SOCKET ALTERNATIVES
Prosthetic socket design is largely determined by the physical characteristics of the residual limb. In the case of elbow disarticulation, intimate fitting at and above the condyles provides rotational control and suspension. Socket design alternatives are analogous to those for the knee disarticulation or Syme ankle disarticulation level and include the following : 1. 2. 3. 4. Soft insert with an integral supracondylar wedge Fenestration with a cover plate ( Fig 9B-5.) Flexible bladder variants for the less bulbous remnants "Screw-in"type sockets ( Fig 9B-6.)
Marquardt has described a clever approach for providing rotary control via humeral osteotomy. See Chapter 36A for more information on this technique, which is generally reserved for cases with bilateral upper-limb congenital absences. He has also successfully fit patients with elbow disarticulation and very short transradial remnants with a unique "socketless" design. This technique utilizes an open mediolateral framework, supracondylar pads, and circumferential straps placed superior and inferior to the biceps. While the supracondylar pads provide suspension, the combination of pads and straps allows humeral rotation control of the prosthesis. The fact that there is no encompassing socket results in a lighter, cooler prosthetic interface as well as excellent tactile sense ( Fig 9B-7.). 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. Amputees report that the thin, flexible socket is cooler than conventional rigid alternatives. The pliability of the inner socket also allows for contour and volume changes that occur with normal muscle expansion, thereby increasing comfort and proprioception ( Fig 9B-8.).
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disarticulation except for the loss of humeral rotary control and condylar suspension. In the transhumeral prosthesis, these last two functions must be provided by the socket design and harnessing. Dynamic load bearing is also a function of socket design. The goal is to provide uniform and comfortable pressure along the humerus throughout the range of abduction and flexion of the prosthesis. Primary control of the prosthesis is by the humerus with additional control offered by scapular motion. As humeral length diminishes, both leverage and power decrease significantly. Soft-tissue coverage also affects prosthetic function since painful, adherent scarring may limit the force that the amputee can comfortably generate. Conversely, too much tissue makes donning the prosthesis more difficult and often compromises prosthetic humeral length and cosmesis. Guillotine amputations are difficult to fit either conventionally or myoelectrically due to the instability in the soft tissue from a lack of distal attachment. Amputation in the proximal third of the humerus (proximal to the deltoid insertion) is particularly challenging prosthetically. Primary control is by scapular motion with assistance from the humerus. Due to the obvious reduction in strength and leverage at this level, conventional cable-powered prosthetic control is severely limited. Body-powered systems require up to 5 in. 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. 2 to 3 in. of excursion when using biscapular abduction, externally powered components are usually necessary for full function. Numerous combinations of body-powered and externally powered components have proved successful. Common examples include using an electric elbow with a body-powered terminal device ( Fig 9B-9.). 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. It is also quite possible to use body power for elbow flexion in combination with an electric terminal device ( Fig 9B-10. ). Since myoelectric control can provide a very If precise yet powerful grip, this hybrid approach is particularly useful for hand users. suitable sites for myoelectric hand control exist, they can often be adapted for myoelectric elbow control as well ( Fig 9B-11. ). The precise component configurations must be individualized for each amputee and the relative importance of function, reliability, cosmesis, weight, and cost weighed for each alternative.
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are eliminated. The elastic "V" provides improved suspension by functioning as a shoulder saddle while also providing elastic recovery for the body-powered elbow locking cable.
FOLLOW-UP
Follow-up could be considered to be the most important aspect of prosthetic rehabilitation and yet may be the most often neglected. Three important tasks must occur during the period following prosthetic fitting: 1. Maintenance of socket fit, suspension, and comfort despite limb volume changes 2. Monitoring to ensure that the patient fully understands and masters the functions of his prosthesis in his home and work environment 3. Re-evaluation of socket style, harness design, 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. There are continuing questions to be answered and new skills to be mastered. The fit, comfort, and function of the prosthesis must be maintained and optimized over time as the amputee alters and refines his initial goals and aspirations. Successful long-term use of an upper-limb prosthesis depends primarily on its comfort and its perceived value to the amputee. Innovative design and careful custom adaptation of socket and harness principles, careful attention to follow-up adjustments, and prescription revisions based on the amputee's changing needs are the essential factors for successful prosthetic rehabilitation. References: 1. Billock JN: Upper limb prosthetic terminal devices: Hands versus hooks: Clin Prosthet Orthot 1986; 10:57-65. 2. Bray JJ: Prosthetic Principles: Upper Extremity Amputations (Fabrication and Fitting Principles), ed 3. Los Angles, Prosthetics Orthotics Education Program, University of California Press, 1989. 3. Burgess EM: Postsurgical management, in Surgery of the Musculoskeletal System, vol 4. New York, Churchill Livingstone Inc, 1983, pp 130-161. 4. Ilizarov GA: Possibilities offered by our method for lengthening various segments in upper and lower limbs. Basic Life Sci 1988; 48:323-324. 5. Jentschura G, Marquardt E: Fitting with preserved epi-condyles, in Malformations and Amputations of the Upper Extremity: Treatment and Prosthetic Replacement. Orlando, Fla, Grune & Stratten, 1974. 6. Lister G: Personal communication. 7. Malone JM, Childers SJ, Underwood J, et al: Immediate postsurgical managment of upper extremity amputation: Conventional, electric and myoelectric prostheses. Orthot Prosthet 1981; 35:1-9. 8. Malone JM, Fleming LL, Leal JM, et al: Immediate, early and late postsurgical management of upper extremity amputation. J Rehabil Res Dev 1984; 21:33. 9. Malone JM, Leal JM, Underwood J, et al: Brachial plexus injury management through upper extremity amputation with immediate post operative prosthesis. Arch Phys Med Rehabil 1982; 63:89-91. 10. Marquardt VE: Die Winkelosteotomie an Oberarms-tiimpfen: Indikation, Operationstechnik, Prosthesen und bisherige Resultate (The Angulation Osteotomy in Above-Elbow Stumps: Indications, Operative Techniques, Prostheses and Results), vol 2, Medizinisch-Orthopdische Technik. Stuttgart, West Germany, AW Gentner Verlag, 1975, pp 26-28. 11. Marquardt E: Pneumatische und bioelektrische Prosthesen, Ersdrienen in des Medizinhistorischen Schriffen-reihe. Mannheim, West Germany, Boehniges Mannheim, 1968. 12. Marquardt E: Steigerung der Effektivitat von Oberarm-prosthesen durch Winkelosteotomie. Rehabilitation 1972; 4:244-248. 13. Marquardt E: Versuche des Ersatzes und der Ausnut-zung von Oberflachen-Sensibilitat bei Armprosthesen. Arch Orthop Unfallchir 1961; 53:64-71. 14. Marquardt E, Neff G: The angulation osteotomy of above-elbow stumps. Clin Orthop 1974; 104:232-238. 15. Maxwell GP, Manson PN, Hoopes JE: Experience with 13 latissimus dorsi free flaps.
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Surgery 1979; 64:1. 16. Otto Bock Prosthesen-Kompendium: Prosthesen fur die obere Extremitat. Biederstadt, West Germany, Schile & Schon, 1976. 17. Pentland JA, Wasileif A: An above elbow suction socket. Orthot Prosthet 1972; 36:40. 18. Reddy MP: Nerve entrapment syndromes in the upper extremity contralateral to amputation. Archives of Physical Med Rehabil 1984; 65:24-26. 19. Sears HH, Andrew JT, Jacobsen SC: Clinical experience with the Utah artificial arm, in Yearbook of the Canadian Association of Prosthetists and Orthotists. Toronto, Ontario, 1984. 20. Sears HH, Andrew JT, Jacobsen SC: Experience with the Utah arm, hand, and terminal device, in Atkins DJ, Meier RH III (ed): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1989. 21. Zych G: Personal communication, 1984.
Chapter 9B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 10A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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.
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With this in mind, the surgeons goal should be a mobile, strong, and painless but shortened limb ready for early prosthetic prescription.
Skin
Sufficient sensate skin with adequate subcutaneous tissue for padding and normal vascularity is seldom a problem at this level, save in the traumatic amputee. In cases of trauma, the lessons of military surgery must be well remembered and primary wound closure performed rarely, if at all. Despite the superficial osseous structures of the shoulder girdle and chest wall, split-thickness skin grafting of these areas can often be tolerated beneath a prosthetic socket. Excision of previous biopsy scars or skin involved with tumor can usually be accomplished by the design of unconventional flaps, the ultimate location of the scar being of little consequence with modern socket construction. 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. Such nonconventional use of otherwise discarded portions of the amputated limb should always be considered.
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, none of amputation neuromas. them are uniformly successful. All severed nerves form neuromas, and the prime objective is to locate this normal neural reaction in an area where it will not be symptomatic. 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, sharp division, and its retraction under proximal cover away from the end of the residual limb and the cutaneous scar. Overzealous distal traction may produce interstitial failure of the neural elements and formation of a more proximal symptomatic neuroma in continuity. Vasa nervorum that are large enough to be evident are best controlled by gentle dissection from the surface of the nerve and bipolar electrocoagulation.
Blood Vessels
Major arteries and veins should be dissected separately and doubly ligated proximally. This includes collateral vessels, which in this region may be quite large. Cautery should not be relied upon for their control. Skin and muscle flaps are large, and wound drainage should be used routinely. A postoperative compression dressing is carefully applied to stabilize the flaps and control shear without strangulation.
SURGICAL TECHNIQUES
The details of surgical technique are well delineated in the standard textbooks and monographs on amputation. There are two major techniques for performance of the forequarter amputation. Suggested skin incisions are depicted in Fig 10A-3. and Fig 10A-4..
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In the anterior technique of Berger ( Fig 10A-3.), clavicular osteotomy is performed at the outset, and the lateral portion of the clavicle may be removed from the field by disarticulating the acromioclavicular joint. Following release of the pectoralis major from the humerus and the pectoralis minor from the coracoid process, the major neurovascular structures are exposed and controlled. Anterior dissection is completed by release of the latissimus dorsi from its humeral insertion. 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, including the trapezius, omohyoid, levator scapulae, rhomboids, and serratus anterior. is found by many to be technically easier and to involve Littlewood's posterior approach less blood loss ( Fig 10A-4.). Dissection begins posteriorly with transection of the trapezius and latissimus dorsi muscles in line with the medial border of the scapula. The superior and medial borders of the scapula are then freed by division of the levator scapulae, rhomboids, and serratus anterior. The clavicle is exposed subperiosteally and divided. The scapula and upper limb are rotated laterally and displaced anteriorly to allow for identification and control of the neurovascular structures, which are thus placed under tension. Division of the pectoralis major and minor muscles anteriorly then allows the limb to fall free. References: 1. Adar R, Schramek A, Khodadadi J, et al: Arterial combat injuries of the upper extremity. J Trauma 1980; 20:297. 2. Adinolfi MF, Hardin WD, O'Connell RC, et al: Amputations after vascular trauma in civilians. South Med J 1983; 76:1241. 3. Anderson-Ranberg F, Ebskov B: Major upper extremity amputation in Denmark. Acta Orthop Scand 1988; 59:321. 4. Baumgartner RF: The surgery of arm and forearm amputations. Orthop Clin North Am 1981; 12:805. 5. Burkhalter WE, Mayfield G, Carmona LS: The upper extremity amputee: Early and immediate post-surgical prosthetic fitting. J Bone Joint Surg [Am] 1976; 58:46. 6. Glynn MK, Galway HR, Hunter G, et al: Management of the upper limb-deficient child with a powered prosthetic device. Clin Orthop 1986; 209:202. 7. Hall CB, Bechtol CO: Modern amputation technique in the upper extremity. J Bone Joint Surg [Am] 1963; 45:1717. 8. Heger H, Millstein S, Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation. J Bone Joint Surg [Br] 1985; 67:278. 9. Jaeger SH, Tsai T, Kleinert HE: Upper extremity replantation in children. Orthop Clin North Am 1981; 12:897. 10. Jones NF, Hardesty RA, Goldstein SA, et al: Upper limb salvage using a free radial forearm flap. Plast Reconstr Surg 1987; 79:468. 11. Layton TR, Villela ER, Marrangoni AG: Traumatic fore-quarter amputation. J Trauma 1981; 21:411. 12. Littlewood H: Amputations at the shoulder and at the hip. Br Med J 1922; 1:381. 13. Malone J, Fleming L, Robertson J, et al: Immediate, early and late postsurgical management of upper limb amputation. J Rehabil Res Dev 1984; 21:33. 14. Moore TJ: Amputations of the upper extremities, in Chapman MW (ed): Operative Orthopaedics. Philadelphia, JB Lippincott, 1988. 15. Moseley HF: The Forequarter Amputation. Philadelphia, JB Lippincott, 1957. 16. Schmidt R, Springfield D, Dell PC: Extended forearm flap. J Reconstr Microsurg 1987; 3:189. 17. Sim FH, Pritchard DJ, Ivins JC: Forequarter amputation. Orthop Clin North Am 1977; 8:921. 18. Tooms RE: Amputation surgery in the upper extremity, Orthop Clin North Am 1972; 3:383. 19. Tooms RE: Amputations of upper extremity, in Crenshaw AH (ed): Campbell's Operative Orthopaedics, ed 7. St Louis, Mosby-Year Book, 1987. 20. Whipple RR, Unsell RS: Treatment of painful neuromas. Orthop Clin North Am 1988; 19:175. 21. Wood MB, Cooney WP: Above elbow limb replantation: Functional results. J Hand Surg 1986; 11:682.
Chapter 10A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 10B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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. Each of these groups present a separate and quite distinct clinical picture that affects prosthetic management. When considering the congenital group ( Fig 10B-1.), it should be noted that the clavicle and scapula are often misshapen, may be fused, and are usually foreshortened with the lateral These features create a prominent and usually very mobile bony aspects swept upward. spur. The remainder of the shoulder area is often fleshy and has the potential for weight support, but the lack of bony structures tends to make stability a problem. The shoulder profile drops away quite sharply from the bony point of the glenoid area, and the incorporation of a prosthetic shoulder joint presents no great cosmetic or technical difficulty. In the acquired group ( Fig 10B-2.), the amputation site is likely to be rather elevated laterally, with surfaces that are capable of bearing some weight unless they are scarred by the trauma. It is unusual for the remnant shoulder musculature to be atrophied, although some muscle bulk may have been lost during the trauma or surgery. The major prosthetic problems are therefore prosthesis stability and cosmetic appearance, in particular, retention of a natural shoulder profile. In addition, when trying to provide for a functional device, it is sometimes difficult to decide whether or not a prosthetic shoulder joint should be included and, if so, what type of component is appropriate. In addition, the two groups can be further subdivided to include cases in which other factors must be considered. 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. In the congenital group one might wish to include individuals with digits at the shoulder or with similar longitudinal defi-cits.
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.
SOCKET DESIGN
In clinical practice two types of sockets are commonly fitted at this level. These can be classified as those that enclose the shoulder and are formed to its contours ( Fig 10B-3.) and those incorporating some type of perimeter frame ( Fig 10B-4.) that encompasses the shoulder and provides structural mounting points for the prosthesis and location and reference points for a variety of controls. When providing an enclosed socket, two factors must be taken into account: first, 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. It is therefore important that the edges and surfaces of the socket that interface with the amputee be rounded and relieved very carefully. For example, 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. Alternatively, it is possible to make the whole socket interface from a soft material,
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supported by stiffening where appropriate. A range of materials may be employed for this purpose. With few exceptions, the socket is generally made of plastic. This may be a laminate using silicone or poly-urethane resins and a woven reinforcement, or it may be one of a number of soft thermoplastics such as certain forms of polyethylene that can be drape-formed. A second point to note is that with such a high-level loss the effects of perspiration may cause difficulties. Although an intimate fit is necessary to provide optimal stability, it may be desirable to provide some form of ventilation or moisture-permeable surface next to the skin. If this is necessary, the prosthetist must take care to make, an appropriate allowance on the positive model in addition to relief for bony structures. Where a user with a congenital deficiency is to be fitted, it is often convenient to manufacture a frame socket. This approach uses suitably padded metal strips brazed together to form a (e.g., carbon fiber reinforcement) can be frame. Alternatively, a high-stiffness laminate made. The frame covers very nearly half the torso, extends down to about the fifth rib to within an inch or so of the anterior and posterior center lines, and passes over the shoulder near the neck. In the case of a bilateral fitting, a hinge is provided to link the posterior frames, and a mouth-positioned Velcro fastener is provided at the front.
CASTING
As with all prosthetic procedures the manufacturing process is built upon the foundation of accurate measurement, information recording, casting, and modeling. This process starts by a determination of the dimensions of the prosthesis based either on the remaining limb or, in the case of a bilateral loss, on estimates of these dimensions related to general physique. Care must be taken to estimate the amount of shoulder elevation remaining once the weight of the prosthesis is being carried. One must not be misled by the position of the axilla because surgery or scarring may distort the tissue in the axillary area. 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. This may be done by extending the normal plaster cast over both shoulders, high up onto the neck, and over the upper part of the chest and back by using plaster of paris slabs. A second cast of just the amputation site is then obtained, with care taken to mark the likely trim line of the socket and accentuate the bony contours. The shoulder should be depressed slightly to allow for the weight of the prosthesis. A photographic record may also be helpful.
FABRICATION
In preparing the positive cast, after the outlined contours are smoothed and rectified, they should be built up by using plaster or the appropriate thickness of closed-cell foam stapled to the cast. 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. 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. It will usually be necessary to remove material from the anterior and posterior aspects of the cast to eliminate gaping in these areas; it may also be necessary to remove plaster from the subglenoid lateral aspect to accommodate any shoulder mechanism that is to be attached. The area of the socket superior to the scapuloclavicular joint may have to be removed to allow the prosthetist to achieve a reasonable profile, and this should be taken into account when carrying out these procedures. If a frame socket is to be constructed, the foam technique is a useful way of making channels in which to lay up Kevlar or carbon fiber.
COMPONENTS
The hardware fitted from the humeral rotator downward can be selected from any of the major manufacturers. It is obviously important to provide a relevant prescription that will suit the planned life-style of the individual. Although it is commonly believed that prostheses fitted at this level are likely to be nonfunctional, this does not need to be the case. Active functions can be provided with the judicious addition of appropriate components. While an endoskeletal, lightweight passive arm ( Fig 10B-5.) is frequently supplied to individuals who have a sedentary life-style, a more robust prosthesis can be supplied for manual workers following a traumatic loss. In these cases it may be necessary to custom-make special shoulder units
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with locking functions that will enable tools to be positioned and operated in working environments. For instance, 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.). There are no commercially available units that will survive such rigors. Harnessing and cabling present a difficult challenge in such cases, and this makes one or more powered units a good option. For instance, a Steeper switch-controlled electric lock can be provided at the elbow (Liberty Mutual Research Center, Hopkins, Mass) and modified with an interlock to allow single cable control of both elbow flexion and a Servo Electric hand. A shoulder unit with variable friction in two planes such as the Hosmer Child Amputee Prosthetics Program (CAPP) device (Hosmer Dorrance Corp, Campbell, Calif) is a good addition to this prescription. For some individuals, provision of a powered elbow, a powered wrist, and a powered hand is appropriate. This will provide function without exertion, but the cost must be assessed for the individual concerned, not only in financial terms but also with regard to the weight penalty and the likely difficulties in learning efficient control strategies. If the user finds operation difficult or robotlike, the prosthesis may represent over gadgetization, and it is likely that even with the best technical advice and training the device will be rejected. When a very lightweight limb is required, 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. However, this type of prosthesis may also be rejected as "useless" since it is purely passive. Externally powered components may be either switch controlled or myoelectric. It is important to place the battery holder as high on the prosthesis as is possible, consistent with good cosmesis and practical fabrication for best results.
HARNESSING
The provision of harnessing for the through-shoulder prosthesis ( Fig 10B-7.) has two objectives. First, it is designed to hold the prosthesis in place, minimize slip and movement on the stump, and spread the weight of the prosthesis across the body. Second, by utilizing differential body motion, the harness can provide control inputs with force, speed, and displacement components. The control element also provides some sensory feedback if resistance to the motion is sufficiently large. To meet the first objective, the harness must provide a medial force at two points. These forces counterbalance the effects of gravity, dynamic forces occurring during operation and the forces generated by external loading. The first force is applied just inferior to the point at which the socket edge crosses the clavicle, and the second is applied to the posterior surface, inferior to the spine of the scapula. The simplest harness is a padded strap that passes under the contralateral axilla and connects these two points, possibly with the addition of an elastic element. In some cases, more complex solutions are required. It may be desirable, on occasion, to eliminate the chest strap and replace it with a figure-of-8 harness around the contralateral shoulder. For very lightweight systems fitted to women, all that is required are anterior and posterior ribbons fitted with clips that allow attachment to a brassiere. 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. The switch control elements of the harness are usually linked to the suspension components. This provides fixed points against which force or displacement can be generated. The establishment of the connection points depends on the signal required. Usually, force/ power signals are taken from straps across the back, which takes advantage of biscapular abduction, while control signals are linked to the position of the shoulder or some other small but independent motion. A frame socket is also used when it is desirable to leave the shoulders completely free. This provides complete freedom for the thoracic girdle, either to maximize the ability to operate controls or to minimize discomfort caused by perspiration. With such prostheses, the shoulder can be used to activate simple push switches, which should be suitably perspiration proof, or alternately, the frame can be used as a fixed point against which force and displacement transducers may be operated to control actuators. References:
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1. Aitkin GT: Management of severe bilateral upper limb deficiencies. Clin Orthop 1964; 37:53-60. 2. Brooks MA, Dennis JF: Shoulder disarticulation type prostheses for bilateral upper extremity amputees. Inter-Clin Info Bull 1963; 2:1-7. 3. Cooper RA, et al: Special projects group documentation (unpublished). London, Roehampton Disablement Services Centre, 1978. 4. Hall CB, Bechtol CO: Modern amputation technique in the upper extremity. J Bone Joint Surg 1963; 450:1717-1722. 5. Marquardt E: The Heidelburg pneumatic arm prosthesis. J Bone Joint Surg [Br] 1965; 47:425-434. 6. Meier R: The Comprehensive Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984, pp 267-310. 7. Neff GG: Prosthetic principles in shoulder disarticulation for bilateral amelia. Prosthet Orthot Int 1978; 2:143-147. 8. Ring ND: The Chailey harness with carbon reinforced plastic. Inter-Clin Info Bull 1971; 6:5-8. 9. Simpson DC, Lamb DW: A system of powered prostheses for severe bilateral upper limb deficiency. J Bone Joint Surg [Br] 1965; 47:442-447. 10. Stern PH, Lauko T: A myoelectrically controlled prosthesis using remote muscle sites. Inter-Clinic Info Bull 1973; 12:1-4.
Chapter 10B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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/chap11-01.asp[21/03/2013 21:54:40]
Financial Sponsorship
It is important to identify and explore third-party sponsorship at this time. Specialized prostheses are often costly. Sponsorship must be sought early, and these devices must be adequately described to the payer so that a comprehensive rehabilitation program can be realistically pursued.
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This phase generally occurs 2 to 3 weeks after surgery. Healing has essentially occurred by the 21st postoperative day and should allow a vigorous program for prosthetic preparation.
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Maximizing Independence
Another important element in the preprosthetic phase of care is maximizing functional independence. Instruction in change of dominance and teaching one-handed activities are often indicated when working with the unilateral amputee. The bilateral acquired upper-limb amputation presents a unique challenge to the amputee team. Before receiving his prostheses, this amputee is essentially dependent in all activities of daily living, and this results in very real anxiety and frustration. It is important to express reassurance, support, and realistic optimism to these individuals during this time. Independence can be significantly enhanced by a simple device such as a universal cuff utilized with an adapted utensil, toothbrush, pen, or pencil.
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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. Several steps are required from the time the prosthesis is prescribed to the time it is delivered to the patient. This process should be thoroughly explained to the patient and third-party payer, particularly if the patient lives out of town so that transportation can be arranged for prosthetic fitting and training. This is also an appropriate time to discuss the options of outpatient vs. inpatient hospitalizations. Generally, all unilateral upper-limb amputee patients can be managed on an outpatient basis. It is strongly recommended that all bilateral upper-limb amputees be trained on an inpatient basis. The bilateral upper-limb amputee has not only issues of functional independence to address but emotional issues as well. These can be more closely monitored on an inpatient basis, with the family and patient becoming involved with the social worker or psychologist on the amputee team. Recommended and approximate training time schedules are as follows: Transradial, 5 hours Transhumeral/shoulder disarticulation, 10 hours Bilateral transradial, 12 hours Bilateral transhumeral, 20 hours Ideally this training should be managed on a daily basis for 1 to 2 hours a day. 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. Common reactions, frustrations, and anxieties can be shared. Positive achievements should be stressed, however. It must be remembered that one amputee's experience does not directly parallel another's. 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.
Initial Assessment
During the therapist's first encounter with the amputee patient in therapy, the following issues need to be discussed and documented if they have not already been accomplished.
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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, the assessment will make a significant difference in the therapist's awareness of the individual with whom he is working. The nature of patient-therapist rapport and subsequent success of therapy will be greatly enhanced if this information is gathered before therapy actually begins. 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. Unfortunately, the finished prosthesis is often a disappointment for the patient. It is perceived as "artificial looking," heavy, uncomfortable, and awkward to operate. If the patient is appropriately oriented to the realities of the prosthesis, how it looks and operates, acceptance of the limitations of the prosthesis are more readily achieved following delivery.
Initial Visit
When the upper-limb amputee visits the occupational therapist for the first time, he will probably be carrying the prosthesis in a bag or sack. It is important to understand this awkwardness and reluctance in putting it on with others "watching." A quiet, nondistract-ing room with a mirror plus an atmosphere of acceptance and understanding is preferable. During the first couple of visits the following goals should be addressed: orientation to prosthetic component terminology, independence in donning and doffing the prosthesis, orientation to a wearing schedule, and care of the residual limb and prosthesis.
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Prosthetic Evaluation
Before beginning functional training, it is important to ensure that the prosthesis fits comfortably and that the components function in a satisfactory manner. Ideally this is accomplished with the occupational therapist and prosthetist together. A formal prosthetic checkout form for this purpose is available from Northwestern University. 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.
Controls Practice
A form board is frequently utilized to perfect prepo-sitioning as well as tension control of the terminal device ( Fig 11-5.). Prepositioning involves both manual and active controls to place the prosthesis in the most optimal position for a specific activity. Close attention must be paid to the individual's awkward or compensatory body motions when he approaches an object. Often the amputee will "adjust" his body rather than repositioning the elbow and wrist unit positions. A mirror can be effective in assisting the amputee to see the way his body is positioned. It is helpful to instruct the patient to "think" how his own arm would have been positioned to approach the object. It is often necessary to remind him to maintain an upright posture and to avoid extraneous body movements.
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The five motion elements that are primarily used in hand manipulation are reach, grasp, move, position, and release. A form board can be used in training to orient the individual to approach, grasp, and release objects differing in shape, weight, density, and size. Prehension control can be practiced with a sponge or paper cup. The amputee is instructed to maintain constant tension of the terminal device control cable so as not to crush the object being held. Approach to an object should be such that the stationary hook finger makes contact with the object and the movable finger actually "grasps" it. Flat objects can be moved to the edge of the table and then grasped with the terminal device in a horizontal position. Prehension force is generally controlled by rubber bands, which can be added as tolerated. Springs may be used as an alternative. Controls training for the bilateral upper-limb amputee is an aspect of therapy that may require a period of time to perfect. To learn to separate the controls motion of two prostheses is a complex and coordinated motor process that may need to be practiced frequently. Passing an object back and forth, such as a rule, may help in reinforcing this pattern.
The importance of prepositioning, prior to approaching these tasks, cannot be overemphasized. 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. As a rule, most difficulties in use are a result of improper positioning. A valuable and comprehensive guide in orienting the therapist to the specifics of training the amputee is the Manual of Upper Extremity Prosthetics, ed. 2, 1958 (Santschi W, Winston M, eds.). This is a publication of the Engineering Artificial Limbs Research Project at the University of California at Los Angeles.
Cutting Food
It is easiest to cut food by holding the fork in the hook, 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. The knife is held by the sound hand.
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Using Scissors
When using scissors, the material to be cut should be placed in the terminal device. The scissors are held by the sound hand. To avoid "flopping," the area to be cut should be as close to the area grasped as possible. The material should be repositioned as cutting angles are changed ( Fig 11-6.).
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, snap, or button. The terminal device can "pinch" the fabric at the bottom of the zipper to facilitate zipping with the sound hand. A buttonhook may be used to assist in buttoning cuffs on the sound side ( Fig 11-7.). With the proper preposi-tioning, the cuff can be buttoned rapidly and reliably. Buttonhooks are particularly helpful for the transhum-eral and shoulder disarticulation amputee.
Washing Dishes
To achieve the greatest security of grasp while washing dishes, the dish should be held in the sound hand. Depending on the individuals preference, a dishcloth or sponge is held and manipulated by the terminal device. Submerging the hook in water should be avoided because detergents dissolve the lubricating oils in the hook and wrist units. Periodic cleaning and oiling of the stud threads and bearings may be necessary for the amputee who engages in frequent dishwashing activities. When drying dishes, the sound hand holds the dish while the terminal device grasps the towel.
Driving a Car
Driving a car is an important goal for the individual who has lost an arm. The actual turning of the steering wheel should be done by the sound limb. If the prosthesis has sufficient function, performance can be improved by using the prosthesis to assist the sound arm. A driving ring is available from most prosthetic suppliers. The fingers of the hook are secure in the ring for turning but can easily slip out in emergencies. 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. ).
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Vocational Activities
Discussing vocational needs and expectations with the amputee is very important. Unfortunately, this is an area that is often overlooked or given only brief attention during the rehabilitation process. This discussion should occur later in the training continuum when the individual begins to acknowledge and accept his disability. Although not everyone can return to the exact job held prior to the injury, a review of job responsibilities and expectations can be explored with the therapist. 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. An example of how effective prosthetic hooks can be for drafting is illustrated in Fig 11-12. . If the therapist can do an on-the-job site evaluation, it would be a valuable addition to the amputee's comprehensive rehabilitation.
Home Instructions
At the conclusion of training, a home program of wearing, functional use, and care instructions should be reviewed with the amputee and his family. Specific instructions regarding which team member to contact when a problem arises should also be provided. A follow-up appointment should be arranged, 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 amputee is regularly monitored and reviewed in an outpatient clinic by the rehabilitation team. This is an appropriate time to discuss the amputee's present status and successes as well as problems that may have been encountered. The services of the prosthetist are available for consultation as well as for any repairs and modifications to the prosthesis that may be required. This is a crucial time for the upper-limb amputee, and patterns of prosthetic use and emotional well-being must be carefully re-evaluated at each visit. In an attempt to define prosthetic function in a quantitative manner, the author has designed the following use rating scale. 100%-Wearing all day, using well in bilateral tasks, incorporating well in the body
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scheme. 75%-Wearing all day, using in grossand fine-motor tasks. 50%-Wearing all day (primarily for cosmetic reasons), incorporating in gross activities (used as a leaning surface, i.e., desk/paper tasks). 0%-Not wearing or using the prosthesis. This individual is choosing to be essentially unilaterally independent. 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. In addition to quantifying prosthetic function and wearing patterns, the following goals are equally important to address during the follow-up visit. 1. 2. 3. 4. 5. 6. 7. Maximize prosthetic function. Maintain prosthetic components. Decrease assistive devices. Resume previous vocation or explore new vocational options. Resume avocational interests. Re-enter the family and community environment. Maintain a regular periodic follow-up with rehabilitation professionals.
The first follow-up visit is scheduled approximately 4 weeks after discharge from training. Follow-up visits are then scheduled at wider intervals, e.g., 3 months, 6 months, and eventually an annual visit. For the more complex amputee with specific skin, bone, or pain problems, more frequent return visits may be necessary.
CONCLUSION
The complete rehabilitation process for an amputee is, indeed, a long one. Early fitting is crucial to encourage successful functional outcomes for all upper-limb amputees. Rehabilitation should not be considered complete until a stable, independent life-style has been achieved and the individual's social and occupational niches have been re-established. The amputee's potential is limitless. It is not solely dependent upon the quality of the prosthesis, of medical care, or of therapy. All these areas ideally work in close harmony with one another. Motivation and the desire of the patient to be independent are perhaps the most important ingredients to cultivate and reinforce. 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.
Acknowledgment
The majority of this text, as well as additional information, is published in two chapters entitled "Postoperative and Preprosthetic Therapy Programs" and "Adult Upper Limb Prosthetic Training" in the following: Atkins DJ, Meier RH: Comprehensive Management of the Upper Limb Amputee. New York, Springer Publishing Co Inc, 1989. BIBLIOGRAPHY Northwestern University Medical School: Lower and Upper Limb Prosthetics for Physicians, Surgeons and Therapists- Controls Training. Evanston, Ill, Prosthetic-Orthotic Center, pp 233A-238C, 1986. Occupational Therapy Department: Helpful Hints for the Upper Extremity Amputee. Gainesville, J Hillis Miller Health Center, University of Florida, 1979. Santschi W (ed): Manual of Upper Extremity Prosthetics. Los Angeles, University of California, 1958, pp 241-265. Therapeutic Recreation Systems Inc: TRS Product Catalogue. Boulder, Colorado, 1991.
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Veterans Administration: A Guide for the Arm Amputee. Washington, DC, Veterans Administration, 1952. Wilke HH: Using Everything You've Got! Chicago, The National Easter Seal Society, 1984. References: 1. Atkins D: The upper extremity prosthetic prescription: Conventional or electric components. Phys Disabil Spec Inter OT Newslet 1987; 10:2. 2. Burrough B, Brook J: Patterns of acceptance and rejection of upper limb prosthesis. Orthot Prosthet 1985; 39:40-47. 3. Levy W, Barnes G: Hygienic Problems of the Amputee. Washington, DC, American Orthotics and Prosthetics Association, 1961, p 9. 4. Meier R: Amputations and prosthetic fitting, in Fisher S (ed): Comprehensive Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984, pp 267-310. 5. Meier R: Amputations and prosthetic fitting, in Fisher S (ed): Comprehensive Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984, p 280. 6. Meier R: Amputations and prosthetic fitting, in Fisher S (ed): Comprehensive Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984, pp 303-304. 7. Millstein S, Heger H, Hunter A: Prosthetic use in adult upper limb amputees: A comparison of the body powered and electrically powered prosthesis. Prosthet Orthot Int 1986; 10:27-34. 8. Plainshed L, Friz B: The nurse on the amputee clinic team. Nurs Outlook 1968; 16:3336.
Chapter 11 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library
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Chapter 12A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Special Considerations: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management
John W. Michael, M.Ed., C.P.O. James A. Nunley M.D.
BASIC CONCEPTS
Brachial plexus lesions can result from a variety of causes including birth injuries, gunshot wounds, irradiation, and motor vehicle trauma. These injuries may be divided into open penetrating trauma and closed injuries. Closed injuries produce the majority of cases and may be the result of traction, compression, or traction and compression combined. Traction on the brachial plexus occurs when the head and neck are moved in a lateral direction away from the shoulder. Because the brachial plexus is tethered by the clavicle and scalene muscles, forceful neck motion to the side frequently produces a traction injury to the upper brachial plexus (C5-6). Traction to the brachial plexus may also occur because of arm movement; as the arm is brought up and over the head, traction will occur within the lower brachial plexus (C8-T1). Compression injuries to the brachial plexus occur between the clavicle above and the first rib below. Narakus' "law of seven seventies," based on experience with more than 1,000 patients over an 18-year span, estimates the current demographics: 70% of traumatic brachial plexus injuries (BPIs) are due to motor vehicle accidents. 70% of the vehicle accidents involve motorcycles or bicycles. 70% of the cycle riders have associated multiple injuries. 70% have a supraclavicular lesion. 70% of those with supraclavicular lesions have at least one root avulsed. 70% of patients with root avulsions have the lower roots (C7, C8, Tl or C8, Tl) avulsed. 70% of patients with lower-root avulsions experience persistent pain. 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. Most patients with BPI are males between 15 and 25 years of age. Based on a thorough physical examination, BPI can be divided into preganglionic and postganglionic injuries. This division of injuries has both prognostic and therapeutic implications. Preganglionic injury indicates that avulsion of the nerve root has occurred proximal to the spinal ganglion; there is complete motor and sensory loss in the involved root, and there also will be denervation of the deep paraspinal muscles of the neck. There will be no Tinel sign present, and frequently the patient will have a Horner's syndrome or a fracture of the transverse process of the adjacent cervical vertebra. 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. Postganglionic injuries may be further subdivided into trunk and cord injuries. Treatment recommendations for complete lesions have varied widely over the past 50 years; no one approach has enjoyed widespread success. Following World War II, the standard approach was surgical reconstruction by shoulder fusion, elbow bone block, and finger tenodesis. In the 1960s, transhumeral (above-elbow) amputation combined with shoulder
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
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fusion in slight abduction and flexion was advocated. The classic paper of Yeoman and Seddon noted the tendency to become "one-handed" within 2 years of injury, which led to a dramatic reduction in successful outcomes regardless of the treatment approach. 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. 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. These observations remain valid today.
CURRENT CONCEPTS
Surgery is indicated in nearly every BPI if spontaneous recovery is not expected within a reasonable time interval. Surgical reconstruction of preganglionic lesions will be discussed separately from postganglionic lesions.
NERVE SURGERY
Preganglionic
Depending on the number of roots that have been avulsed, preganglionic BPI generally falls into one of three categories: 1. A completely flail arm with avulsion of all roots (C5-T1) 2. A lower avulsion of the C8-T1 roots 3. An upper lesion in which only the C5 and C6 roots have been avulsed Typically, patients with upper lesions and C5 and C6 root avulsion will have no shoulder function or elbow flexion. There will be finger and wrist extension and hand function. In these patients, the goal of surgical reconstruction would be first to re-establish elbow flexion and then to address shoulder stability. Preganglionic nerve root avulsions are not amenable to direct nerve repair. Tendon transfer procedures are ineffective; the classic pectoralis major and the latissimus dorsi transfer are not possible with a C5-6 avulsion since transfer while these muscles are paralyzed. Transfer of the triceps muscle to achieve elbow flexion, possible, is frequently ineffective since the triceps is usually weak. Transposition of the medial epicondyle from the elbow with the common head of the flexor pronator muscle group is certainly a possibility; however, 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. A Steindler (flexor-pronator) transfer alone in the case of a completely paralyzed shoulder and paralyzed biceps and brachialis is generally unsatisfactory. Our preference for reconstruction of the important function of elbow flexion is through neurotization with intercostal motor nerves. Through a lateral fourth-rib thoracotomy the motor portion of the third, fourth, and fifth intercostal nerves may be transferred subcutaneously into the axilla to be anastomosed to the musculocutaneous nerve ( Fig 12A-1.). This yields an excellent reconstruction of elbow flexion if performed within 12 months of injury ( Fig 12A-2.). Our best results have been where the neurotization is performed within 6 months of injury. If the interval from BPI to reconstruction is delayed beyond 12 months, the results of surgical reconstruction with the intercostal nerves alone have been poor. These poor results have usually been attributed to fibrosis of the motor end plates of the biceps muscle. Under these circumstances, a free innervated gracilis muscle has been used quite successfully to replace the biceps ( Fig 12A-3.). The gracilis is harvested on its neurovascular pedicle with the obturator nerve, artery, and vein. The fibrotic and denervated biceps muscle is excised and the gracilis muscle inserted in its place. Attachment is made proximally with the gracilis origin to the coracoid process and distally to the biceps tendon. After successful vascular anastomosis of the artery and vein, through an ipsilateral thoracotomy, intercostal motor nerves to the third, fourth, and fifth ribs are used to successfully reinnervate the gracilis. Results of this procedure have been particularly gratifying in young patients ( Fig 12A-4.).
Postganglionic
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Postganglionic lesions frequently involve nerve injuries that are directly reconstructible. It has been our practice to follow patients conservatively for up to 3 months to watch for spontaneous motor recovery. In upper-plexus injuries, if the biceps muscle has not recovered within 3 months, then surgical exploration of the brachial plexus is indicated. If spontaneous recovery occurs, then the patient is monitored until the recovery plateaus, at which point a decision is made as to whether exploration or other reconstruction is indicated. Exploration of postganglionic lesions will frequently show combined injuries in which a neuroma in continuity can be identified along with a complete nerve rupture. By using the operating microscope, it is possible to surgically separate intact fascicles from damaged fascicles at a very proximal level. If complete transection of the brachial plexus has occurred, the results of nerve grafting for upper-trunk lesions have been reasonable. Following nerve grafting for lower-trunk injury, 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 exploration reveals a lesion of the lower brachial plexus (C8 to Tl) that can be re-established with nerve grafting, nerve grafting should certainly be performed; however, a later tendon transfer may still be required.
RECONSTRUCTIVE PROCEDURES
Shoulder
To be able to use the hand successfully, the patient's shoulder must be stable to allow positioning of the hand and forearm in space. In the majority of BPIs, insufficient muscles remain for successful tendon transfer about the shoulder. In the upper BPI in which rotator cuff, deltoid, and biceps function have been lost, tendon transfer of the trapezius and the levator scapulae has been tried. Although the shoulder will no longer interiorly subluxate, active function in forward flexion and abduction is not generally possible. Thus, the majority of these patients should benefit from shoulder fusion. Shoulder fusion works best when scapular control has been preserved through the function of Occupation is also a factor; employment the serratus anterior and the trapezius muscles. as a manual laborer suggests consideration of shoulder fusion. However, 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.
Elbow
Restoration of elbow flexion is of primary importance for all patients with BPI. Even if the patient has a flail and completely anesthetic arm, restoration of active elbow flexion will allow the patient to have a transradial (below elbow) amputation. The transradial prosthesis, combined with voluntary elbow flexion, is certainly easier to use and better tolerated than a transhumeral prosthesis. Elbow flexion can be restored by intercostal neurotization or tendon transfer. When the pectoralis major and latissimus dorsi are available for transfer, superior results can be anticipated. The Steindler (flexor-pronator) transfer is only utilized when the patient has weak, but present elbow flexors.
CLINICAL PATTERNS
It is possible to summarize the functional deficits associated with particular lesions to simplify our understanding in this area. However, normal anatomic variations frequently result in clinical findings that differ from these theoretical types. The clinical picture is further complicated since many lesions are incomplete or have been surgically repaired. Due to these limitations, careful assessment of residual function provides the best rationale for orthotic/prosthetic intervention. C5-6 type results in complete loss of voluntary shoulder and elbow control, although many can still extend the wrist by using finger extensors and the extensor carpi ulnaris. Thumb and index finger sensation will be impaired. 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, sometimes with an elbow hinge that can be locked in several positions.
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Shoulder subluxation is reportedly reduced by such an orthosis as well ( Fig 12A-5.). C5-7 type adds radial palsy to the above picture. Not only does the sensory loss in the hand increase, but all active extension at the wrist, hand, and fingers is lost as well. It is possible to add either static or spring-assisted wrist, hand, and finger extension to the previous orthosis ( Fig 12A-6.). C7-S, Tl type has good shoulder and elbow function but loses finger flexors, extensors, and intrinsics. Surgical reconstruction is often of particular value to this group. Those who sustain a concomitant traumatic transradial amputation should be able to operate a body-powered or switch-controlled terminal device. Loss of forearm innervation eliminates myoelectric control sites below the elbow. C8, Tl type enjoys the greatest percentage of orthotic success since motor rather than sensory loss is significant. Although finger flexors and intrinsics are paralyzed, sensory loss is limited to the ring and small digits, which are not involved in pinch prehension. The complete plexus type has the greatest loss. Not only is the arm totally flail and anesthetic, but chronic pain is frequently present as well. Virtually all authors agree that this group has the lowest long-term success rate regardless of treatment. When direct surgical reconstruction is not feasible, transhumeral amputation plus shoulder fusion is the most common recommendation in the literature.
PROSTHETIC OPTIONS
Transhumeral amputation plus shoulder fusion is still a viable approach to complete and untreatable plexus lesions, although many authors have noted that a significant percentage Leffert's excellent text notes that arthrodesis of the flail discard their prostheses over time. or weak shoulder is widely accepted because it is both predictable and uncomplicated. However, fusion increases the leverage on the scapula from the weight of the arm plus prosthesis/orthosis. Leffert suggests that trapezius and serratus anterior strength must be good (or preferably normal) in order to provide sufficient control; motion will be smoother if the levator scapulae and rhomboids are also functioning. Rowe has noted that shoulder fusion attitudes originally intended for pediatric poliomyelitis survivors are not optimal for BPI. Fig 12A-7. illustrates Rowe's recommendations. Fusion in this attitude permits scapular motion, when combined with elbow motion, to allow the patient to reach all four major functional areas: face, midline, perineum, and rear trouser pocket. Numerous harnessing variants have been developed to maximize the limited excursion remaining after BPI (See Chapter 6B). Although complicated harnessing may make donning or doffing the prosthesis independently more difficult, some patients find the bodypowered components a good choice. Unlocking the elbow mechanism is often inconsistent due to limited shoulder movement, so a friction elbow or nudge control may be utilized ( Fig 12A-8.). limited body excursion With the widespread availability of externally powered components, is now less problematic. Microswitch control requires only a few millimeters of motion and can ( Fig 12A-9.). be utilized to operate an electric hand, an electric elbow, or both Myoelectric control may also be feasible since even very weak muscles may generate sufficient signal to operate an externally powered device. It can be argued that myoelectric control for the terminal device is preferable for precise grasp ( Fig 12A-10. ). It may also be possible to utilize myoelectric control for both elbow and hand function (and perhaps for wrist rotation as well), but control sites will likely be on the chest or back ( Fig 12A-11. ). 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. Whether this will result in increased long-term utilization remains to be documented. In the presence of lesions that spare some elbow function, transradial amputation is sometimes performed. 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. shoulder or elbow. Dralle reported a case with good shoulder control and elbow flexors but no When the amputee attempted to operate a body-powered hook, the force triceps function. generated along the control cable forced the elbow into full flexion. It was necessary to utilize an outside locking joint normally intended for elbow disarticulation to stabilize the arm;
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difficulty in operating the lock was noted due to the triceps absence ( Fig 12A-12. ). Van Laere et al. reported a case complicated by complete absence of elbow and shoulder function. Following surgical arthrodesis of the shoulder, 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. ). 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, since the usefulness and degree of acceptance of the prosthesis will be much enhanced by it. Even if the elbow is flail and the skin over the proposed stump is insensate, proprioception may be intact and a useful prosthetic fitting may be obtained without stump breakdown ( Fig 12A14. ).
REHABILITATION
Modern surgical advances have resulted in a much less predictable range of impairment following BPI, and the prosthetist-orthotist is now faced with a confusing array of residual functions. Muscle transfers sometimes result in powerful EMG signals suitable for myoelectric control in abberant anatomic locations. Nerve transfers further complicate the issue since anomalous neuroanatomy may preclude precise myoelectric control despite a grossly powerful signal. Finally, muscle fatigue is frequently overlooked and virtually impossible to predict. 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. (see Chapter 8B) is strongly As a result of all these factors, a diagnostic prosthesis A recommended ( Fig 12A-17. ) and an interdisciplinary team approach encouraged. thorough physical examination including manual and EMG muscle testing is required to assess rehabilitation potential. Since BPI often has a lengthy recovery period, the majority will have become accustomed to functioning unilaterally, which can significantly reduce enthusiasm to master an adaptive device. It is therefore imperative that the patient be actively involved in all prescription decisions from the outset; without a motivated and cooperative individual, even heroic prosthetic/orthotic interventions are doomed to failure. Wynn Parry recommends utilization of a full-arm orthosis during the recovery period, beginning as soon as the patient has come to terms with the serious and potentially permanent nature of his injuries. 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. for orthotic intervention, i.e., "when the patient is beginning to accept the implications of his injury and yet has not become too one-handed." Once surgical reconstruction and spontaneous recovery are complete, amputation and trial with a prosthesis can be considered. The decision to choose amputation is always difficult; the opportunity to meet another BPI amputee who has successfully mastered a prosthesis may be helpful. Psychological and social work consultation may be useful to help the patient discuss the altered body image and employment possibilities that will follow amputation. The presence of chronic pain complicates prosthetic-orthotic intervention. In those cases where humeral traction worsens the pain, special care must be taken to prevent the weight of
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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.
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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
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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
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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
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12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library
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Chapter 12B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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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.
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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.
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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
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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.
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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.
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
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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.
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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.
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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
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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.
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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
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Chapter 12C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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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
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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
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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.
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Voluntary-closing devices ( Fig 12C-11. ) and externally powered hands grip the handlebars securely for safe steering control. Typically, the prosthesis is used for steering control, balance, and stability. The sound hand activates gears and brake levers. A Dual Brake Bicycle Lever (T.R.S., Inc.) is available ( Fig 12C-11. ) and allows one hand to control the front and rear brake systems simultaneously. (Note: The rear brake must activate first to ensure stability in stopping.) Gears can be grouped for easy access. The local bicycle pro shop can be a source for information or for modifications to ensure that the adaptations are completed safely. Motorcycling usually requires operation of a clutch lever. Unilateral amputees can clutch and throttle with the same hand with a little practice. Brake systems can usually be combined in tandem to be activated from a single pedal, thus eliminating the front brake lever. This allows the prosthesis to be used entirely for steering control, balance, and stability. Modifications should be performed by competent mechanics, so consultation with a local motorcycle dealer is suggested to ensure safe and proper adaptations.
BOWLING
Bowling remains as one of the more popular indoor recreations available. Bowling environments stimulate social interaction through team and league participation. It develops hand and eye coordination as well as overall coordination and balance. Bowling is primarily a unilateral activity, so people missing one hand may not be impaired or may wish to switch hands to bowl. Bilateral amputees and unilateral ones who do not wish to switch dominance need to use a prosthesis. If one is used, then omnidirectional wrist action is desirable. The HosmerDorrance Bowling Ball Prosthetic Adapter ( Fig 12C-12. ) is a time-proven prosthetic aid for bowling. It incorporates a flexible coupling and a cable-activated release system so that the ball can be cast smoothly and with control.
CANOEING/KAYAKING
Canoeing and kayaking are exciting and demanding recreations. These activities condition the arms, shoulders, and torso while developing balance and coordination. Gross motor bilateral upper-limb motions are emphasized, and adequate gripping power and prehension configurations are required. If a split hook is to be used, the Dorrance no. 7 Farm Hook (Hosmer-Dorrance Corp.) with at least 30 lb. of elastic band resistance is suggested. Voluntary-closing prehensors such as the Grip (T.R.S., Inc) ( Fig 12C-13. ) can be adapted to these activities with minimal modification. The natural gross motor patterns of paddling or rowing harmonize with the action of voluntary-closing devices and thereby create the required prehension. A simple hole bored through the end of a canoe paddle and padding the handle shaft with rubber inner tubing will improve prosthetic control. Similarly, rubber rings can be added to kayak paddles or boat oars to reduce prehensor slippage and improve control while paddling or rowing. Locking-type prehensors should never be employed in water sports activities for safety reasons.
DANCE/FLOOR EXERCISES/TUMBLING
These activities provide overall balance and coordination development while stimulating social interaction and mainstreaming. Requirements vary depending upon the specific activity, but considerations include strength, stability, flexibility, and cosmesis. Unilateral participation without a prosthesis is certainly possible, but a prosthesis may enhance performance. Passive cosmetic hands have been used as well as padded hooks. Externally powered hands are a possibility for dance, but the rigors of gymnastics and tumbling could prohibit their application. The Super Sport mitt in Fig 12C-14. is a flexible, energy-storing alternative for these activities and can satisfy some specialized recreation niches safely.
FISHING
Persons missing a hand(s) or who have a limb paralysis or dysfunction have a number of fishing options. The prosthesis must be utilized to either grasp a reel handle for line retrieving or to hold and control the fishing pole. Voluntary-closing prehensors ( Fig 12C-15. ) and
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externally powered prostheses function well with reels by providing a controlled grasp on the reel handles or rod; most split-hook systems have a tendency to pull or slip off under load. Many reels are available in either rightor left-handed retrieve models so that the amputees may select their preference. A small pair of locking needle-nose Vise Grip pliers provides an excellent accessory for handling small hooks, lures, and weights, which can prove difficult for many terminal devices or prosthetic hands. Fig 12C-16. illustrates an adaptation that utilizes a chest support and harness system for mounting the fishing rod. These are most applicable to people with high or severe levels of dysfunction. A novel modified reel design (Ampo-Fisher I, Bass-matic Corp., Canton, Ohio) is depicted in Fig 12C-17. . Electric reel systems (Royal Bee Corp., Pawhuska, Okla) are also available for one-handed control. Figure 12C-18 shows a prototype fly-fishing reel system that removes the reel from the rod entirely. Manually winding the line around the spool is required with this design. 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.
GOLF
Golf is one of the most popular outdoor sports. Accordingly, many persons missing a hand(s) may have an interest in playing the game. The United States Golfing Association (USGA) has established rules (USGA 14-3/15) regarding the use of artificial limbs while playing golf. Golf provides coordination, develops trunk and upper-body flexibility, and improves judgment. It is a social game into which many disabled groups have been able to mainstream easily. Upper-limb prostheses need to attach to the club handle or grip in some fashion. A flexible or multiaxis joint is required to enable a complete bilateral swing. Persons missing one hand have played golf single-handedly, but most amputees use prostheses for bilateral assist. A standard split hook, various body-powered pre-hensors, or an externally powered hand can be used to guide a club, but without a functional wrist, the game is primarily being played unilaterally. Many custom designs have evolved. Fig 12C-19. illustrates a Canadian modification whereby the club attaches directly to the prosthesis. Another design, the Robin-Aids golfing device (Robin-Aids Prosthetics, Inc., Vallejo, Calif), uses a flexible coupling for duplicating wrist and forearm movements. Fig 12C-20. illustrates the Amputee Golf Grip (AGG) (Recreation Prosthetics, Inc, Grand Forks, ND). This device is commercially available and meets the requirements of the USGA. Somewhat similar to the Robin-Aids device, the AGG also employs a flexible coupling linking the prosthesis to the club and utilizes a slide-on handle, adjustable for club grip diameter, that secures the club in place. Both offer improved performance because they enable the player to have an unrestricted swing allowing for a smooth follow-through. Using an unmodified club is an additional benefit. Note, however, that most of these devices function more easily depending upon handedness, and this leads to the necessity in some instances for a "cross-handed" grip to use the device successfully.
GUNS/HUNTING
Handling firearms for self-defense, recreation, or hunting is a pastime ingrained in American life and indirectly facilitated by participation in our military services. Shooting develops hand and eye coordination, balance, timing, and judgment. A prosthesis may be used either to support, hold and control or to trigger a firearm ( Fig 12C-21. ). In many cases simple modifications suffice. A military sling can add stability, with the strap grasped by or wrapped around a prosthesis. Whether the prosthesis is used for control or triggering is dependent upon dominant handedness or dominant eye. Rifles are easily modified by adding a ring or custom adapter to the forearm of the stock ( Fig 12C-22. ). Custom handles added to the forearm of the stock can also provide excellent control and stability. Pistols are more difficult to hold and modify due to their compactness. Voluntary-closing prehensors such as in Fig 12C-23. and externally powered hands ( Fig 12C-24. ) both provide significant gripping force, often controlling pistols and rifles with minimal or no modifications. Fig 12C-25. shows the SR-77 (SR-77 Enterprises, Inc., Chadron, Neb), a complex shooting system commercially available to people with high-level bilateral arm dysfunction or absence. Fig 12C-26. shows a shotgun heavily modified to be controlled and fired entirely with one
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arm. A local gunsmith is an excellent source of information and can usually customize firearms.
HOCKEY
Hockey continues to be popular, especially in the northern latitudes of the United States and throughout Canada. Youngsters in these areas play in regulated hockey leagues much like Little League for baseball. Hockey develops strength, endurance, coordination, and balance. Prosthetic requirements include a means of holding and manipulating the hockey stick. 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. Since safety is an issue, metal terminal devices should be used with caution. Padded or covered body-powered devices are preferable, and externally powered hands could provide the necessary functions.
HORSEBACK RIDING
Although a more select recreation, horseback riding is enjoyed by many individuals. Riding emphasizes balance and coordination combined with leg and torso strength and control. Riders must be capable of grasping either a saddle horn or the reins for control of the mount. Additionally, a rider should be able to adjust gear, bridles, saddles, and straps. The Rein bar ( Fig 12C-27. ) is one simple adaptation for riding. Such a bar can be controlled by many different types of prehensors. Externally powered hands and voluntary-closing prehensors, due to their superior grip forces, can be especially useful. Either kind can also be employed to grasp the reins or horn without an adapter and provide sufficient prehension for saddle adjustments. Safety is always a consideration. 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.
MOUNTAINEERING
Mountaineering including rock or technical climbing is becoming more popular throughout the country, especially in the West, but remains an elite pastime. Mountaineering demands stamina and strength. It develops agility, flexibility, balance, and coordination. It can be dangerous for the novice as well as the expert, so proper instruction and safety procedures are mandatory. Demands include a reliable prosthesis with secure hardware, gripping strength to handle and manipulate >ropes and gear, and a terminal device that can stand abuse as a tool for prying, jamming, or clinging to rock surfaces. Figure 12C-28 illustrates a transradial amputee using a stainless steel Grip (T.R.S., Inc.) prehensor during a mountaineering training session. The amputee is belayed with a top rope for protection from falls.
MUSIC
Instrument playing is a recreation many aspire to achieve. Playing an instrument develops hand and eye skills, rhythm, coordination, and self-confidence. Music fosters socialization and provides individual and group pleasure. Prosthetic requirements vary widely since playing is instrument specific. An adapter to play a guitar will differ dramatically from one for a violin ( Fig 12C-29. ) or another to play the piano ( Fig 12C-30. ). Virtually all adaptations for playing musical instruments are custom-made. Externally powered hands as well as body-powered prehensors have all been adapted from time to time for instrument play. Imagination is the key to developing an adaptation that works successfully for the amputee. Communicating with a music teacher for a particular instrument is an invaluable source of inspiration. Prototyping is usually required with trial and error to develop a useful adapter.
PHOTOGRAPHY
Photography is an enjoyable hobby for many people and poses few problems for someone missing a hand. Most cameras, regardless of format, can be manipulated with externally powered or body-powered prostheses.
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Custom adapters have also been developed. One specialized adapter, the AMP-U-POD (T.R.S., Inc.) ( Fig 12C-31. ), is designed to replace a standard terminal device and attaches directly to the prosthesis. It accepts all still and video cameras equipped with a tripod mount receptacle. Custom adapters are useful in securely balancing or stabilizing the camera to allow for easier focusing and metering adjustments prior to releasing the shutter.
SAILING
Sailing can range from a quiet meditative experience to one in which the sailor is on the cutting edge of excitement. Sailing is usually a social event and easily accomplished by a person missing a hand. Most body-powered prostheses can be designed for saltwater or freshwater activities if desired. Handling ropes, controls, and gear is the primary function required.
SNOWBOARDING
Snowboarding is one of the fastest-growing recreations in the country, with equipment innovations occurring continually. Snowboarding, or "shredding," combines aspects of skiing, surfing, and skateboarding. It develops coordination and balance and is available to a handless person with little or no adaptation. Leg and torso control is the primary requirement. Arms can be used to initiate turns but are not absolutely necessary for turning. A prosthesis can provide shock absorption and protection from a fall while enabling the participant to make easier binding engagements and adjustments. A prosthesis can also aid in getting up following a fall. It should be chosen with safety and durability in mind. Hard, jarring falls are common for the novice. A cosmetic passive hand or Super Sport would be suitable options. An externally powered prosthesis could be used, but the force of the falls might damage the arm and hand.
SNOW SKIING
As mentioned in the beginning of this chapter, skiing is a recreation that provides the physically challenged individual with the opportunity to mainstream as well as to compete. Skiing is a sport that builds self-esteem and confidence as well as the physical attributes of balance, strength, and coordination. Snow skiing does not necessarily require the use of ski poles, and many hand-less people downhill ski without these accessories. Cross-country or Nordic skiing, in contrast, is enhanced by upper-body propulsion, so poles are really more of a necessity than a convenience. Amputees have employed one pole successfully as well. Wrist extension is required to plant a pole accurately and quickly. Split hooks have been used for skiing, with the pole strap wound or tied into the hook. This allows limited control, with the pole being manually swung forward for a pole plant. Fig 12C-32. is the Hosmer-Dorrance Ski Hand, which force-fits down over the top of a modified ski pole. The flexible polymer body allows the ski pole to be snapped forward manually like a pendulum for pole planting. The Ski Hand is manufactured in several sizes to accommodate different ages of skiers. The All-Terrain Ski Terminal Device (AT-Ski-TD) ( Fig 12C-33. ) is another alternative. It is adjustable and allows for either manual or cable-activated pole plants. 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.
SWIMMING
Swimming is considered to be one of the best overall, low-stress, body-conditioning exercises. Swimming stimulates the cardiovascular system, increases flexibility, and strengthens muscle groups of the arms, torso, and legs. Many amputees swim successfully without an arm prosthesis. Competitive swimming or training may require a prosthesis to improve stroke resistance on the affected side(s). All present externally powered systems are subject to water damage. Conventional terminal devices are of little use for swimming. Fig 12C-34. illustrates one approach that uses a commercially available swimmer's training paddle fixed to the forearm with surgical tubing. The amputee swimmer using this system is a physician who regularly swims 1,800 m with normal lap times. Fig 12C-35. shows the POSOS/Tablada design (Professional Orthopedic Systems of
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Sacramento, Calif). This system uses a flat paddle and rigid prosthesis with a preflexed elbow. The flat paddle eliminated the tendency of the prosthesis to "submarine," and cause a loss of stroke volume during strokes such as the Australian crawl. Another model illustrated in Fig 12C-36. and Fig 12C-37. is the Freestyle TSD (therapeutic swim device, T.R.S., Inc.), which is commercially available. Unlike the previous custom models, the Freestyle TSD's patented design (Robert Gabourie, Niagara Prosthetics, St. Catharines, Ontario, Canada) allows it to collapse when retrieved. This action conserves energy because water resistance is reduced after the power stroke. The device flares open for resistance and propulsion during the power stroke. Competitive swimming generally requires a custom prosthesis. 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. Additionally, a prosthesis design is required that minimizes socket pistoning. 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.
WATERSKIING
This water sport can be very dangerous but is also exhilarating and develops overall balance and strength in the back, arms, and legs. Precautions are necessary to ensure safety. 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 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. A -in.-thick neoprene sleeve will float most arm prostheses in the water and add to the skier's stability prior to takeoff. The prototype hook illustrated was customfabricated from nylon. 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. Falls occur without warning, so release in all cases must be immediate, or serious injury can result. An approved life vest is strongly recommended.
WINDSURFING
A unique and demanding water sport, windsurfing combines the talents of sailing, surfing, and hang gliding. It stimulates balance, coordination, dexterity, and strength. 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. Additional needs include handling rope, uphauling, and maneuvering the mast with the sail in the water. Fig 12C-39. and Fig 12C-40. illustrate one successful body-powered system. Harnesses for body-powered systems should be worn outside wet or dry suits to allow unrestricted function. Saltwater windsurfing requires corrosionand rot-resistant prosthetic components. Externally powered systems are prohibited due to constant water exposure as in waterskiing. Caution is advised, and proper training is recommended to ensure a safe experience.
SUMMARY
The function-specific nature and varied demands of sports and recreation activities create continuous challenges for the prosthetics profession. Consumers are becoming better informed and frequently desire a prosthesis suitable for a variety of activities. Morphology and physiology are integrally linked with prosthetic design and construction. A thorough assessment of the patient's needs, including those for sports and recreation, will establish accurate design criteria. Specific static and dynamic stress evaluations conducted during construction of the prosthesis can help ensure a high-performance result. Patient education and communication continue to be very important. 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.
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Today no single technology is either versatile or cost-effective enough to serve alone. New designs, materials, components, and devices applicable to sports and recreation are evolving. Customized designs continue to arise, and more commercially available components are allowing easier access to specific activities. The physically challenged person has more opportunities to mainstream and compete in activities of sports and recreation than ever before. Foresight, creativity, patience, communication, and a willingness to teach as well as to learn will inevitably lead to even greater possibilities in prosthetic rehabilitation.
Acknowledgments
The author thanks the following individuals and organizations: Ron Baird of Longmont, Colo; Bassmatic Corp. of Pawhuska, Okla; Felice Celikyol of the Kessler Institute in West Orange, NJ; The Free Handerson Co. of Helena, Mont; Shellye B. Godfrey of Greenville, SC; Hosmer-Dorrance Corp. of Campbell, Calif; Elliot Marcus, M.D., of Huntsville, Ala; Professional Orthopedic Systems of Sacramento, Calif; Recreational Prosthetics, Inc., of Grand Forks, ND; Robin-Aids Prosthetics, Inc., of Vallejo, Calif; Royal Bee Corp. of Pawhuska, Okla; SR-77 Enterprises, Inc., of Chadron, Neb; Chuck Tieman of Blackwell, Okla; The War Amputations of Canada of Ottawa, Ontario, Canada; Bill White of Waterford, Penn; Ken Whittens of Duncan, Okla; and Biff Williams of Spokane, Wash. References: 1. Berger N, et al: The application of ISNY principles to the below-elbow prosthesis. Orthot Prosthet 1985; 39:16-20. 2. Billock JN: Northwestern University supracondylar suspension technique for belowelbow amputations. Orthot Prosthet 1972; 26:16-23. 3. Billock JN: Upper limb prosthetic management hybrid design approaches. Clin Prosthet Orthot 1989; 9:23-35. 4. Fillauer CE, et al: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92:103. 5. Fishman S, et al: ISNY flexible sockets for upper-limb amputees. J Assoc Child Prosth Orthot Clin 1989; 24:8-11. 6. Fornuff DL: Flex-frame sockets in upper extremity prosthetics. Clin Prosthet Orthot 1985; 9:31-34. 7. Radocy B: Technical note: The rapid adjust prosthetic harness. Orthot Prosthet 1983; 37:55-56. 8. Radocy R: Technical note: An alternative design for a high performance below elbow prosthesis. Orthot Prosthet 1986; 40:43-47.
Chapter 12C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 12D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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practical way via miniaturized electronics. Modern injection-molded composite plastics offered a strong but very light shell, while a modular design allowed rapid serviceability and upgrades as the design evolved. Other electronic elbows include the Boston Elbow, the first proportionally EMG-controlled elbow, and a much less complex elbow developed at New York University (NYU). Providing a much simpler, lower-cost alternative, the NYU elbow has been used primarily as a switch control device. The one-speed drive simplifies both control and mechanism, although sacrificing a number of features.
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Hook" by Hosmer, Inc. A myoelectric hook drive developed at Northwestern University in the early 1970s utilizes classic "lyre-shaped" hook shapes powered by a two-motor, two-speed drive that allows quick operation as well as a slower, high-force mode. This has been dubbed "synergetic" drive.
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terminal devices. There is promise that modern plastic materials may provide enough strength to replace the heavier metal terminal devices of the past, with more cosmetic colors and potentially greater durability of gripping surfaces utilizing newer polymer coatings rather than rubber. Present voluntary-closing, i.e., pulling the cable closes the hook, terminal devices may be improved and new versions available in the future. The Utah Terminal Device has been developed with the capability for a voluntary-closing mechanism as well as a voluntaryopening one. 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. Structures for body-powered arms may also be improved by the application of new materials. The experience with some myoelectric devices, e.g., the Utah Artificial Arm, has shown the potential for exoskeletal structures of modern composite plastics (reinforced with fiberglass and graphite). 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. Research at the University of Utah as well as other centers seeks to apply exoskeletal structures in bodypowered prostheses. Other components that may be improved by the application of new materials and design include the shoulder joint, which could potentially have a controllable lock to allow better positionability of the prosthesis at the shoulder joint. Micacorp, Inc. (Longview, Wash), is currently manufacturing a lockable shoulder joint, and Northwestern University has announced the development of a shoulder joint also. Prototype shoulder joints developed at the University of Utah that lock in 2 degrees of freedom are shown in Fig 12D-7.. Wrist components, positionable in multiple degrees of freedom, also are under development at the University of Utah. Studies of terminal device function have shown that since man-made devices have limited prehension capabilities, it is imperative that the amputee position them precisely for each particular prehension task. Lack of positionability at the wrist significantly limits the function available from any terminal device.
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External Power
The application of external power to artificial hands and elbows, thus eliminating the control cables (the most unpopular feature of body-powered arms), has had a great impact on upperlimb prosthetics in the last two decades. However, most commercially available devices must be considered firstor second-generation technology, and the next decade should see many continuing improvements on what has been an encouraging start.
Power Sources
Since batteries are a multibillion dollar consumer industry, 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. Also, disposable alkaline batteries have become a viable alternative for many amputees. Recharging is not necessary, and the price per battery is usually low enough to compete with an expensive rechargeable battery pack. Whether rechargeable or disposable, the use of readily available consumer batteries is expected to become more and more commonplace. Although pneumatic and hydraulic power sources are still considered in some centers, their application to arm prosthetics is not expected to expand due to the convenience of batteries and electric motors.
Control Methods
Nearly all of the currently used myoelectric prostheses utilize the classic two-site agonistantagonist control method. This is the most physiologically natural control and is usually easy for an amputee to master. Research should improve some of the remaining difficulties. Improved resistance to electrical interference from outside sources is possible and would improve the performance of most myoelectric systems. 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. 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. Brunswick. However, the issues of biocompatibility and additional surgeries are drawbacks for most patients. Present externally powered arms offer powered degrees of freedom at the elbow, wrist, and hand. However, simultaneous control of more than 1 degree of freedom is not easily accomplished. As mentioned previously, despite extensive research in the past on several methods for control of multiple degrees of freedom, 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- to 5-muscle clinical system. Postulate control could conceivably provide simultaneous control of 2 or 3 degrees of freedom in a single prosthesis. 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. 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. For instance, the remnant motions of the shoulder or humerus could be used for patients without good control over residual EMG signals. Sensors for the tension in a control cable have been developed that use either load-cell-type force transducers or force-sensitive resistive material. Practical experiments have controlled an electric elbow by converting the force information to a command for the elbow. A mechanical link to the elbow-forearm motion is provided by connecting the control cable directly to the forearm around a pulley, as shown in Fig 12D-5. and Fig 12D-6.. This provides the "physiologic proprioception" of Simpson's theory, like power steering on a car, so that the position sensation is provided, although little actual force is required. Fortunately, existing electric elbows will be adapted easily to a position controller input. The previously mentioned EPP controllers have been demonstrated with the Boston Elbow and the Hosmer Elbow. Fig 12D-7. shows position-controlled versions of the Utah Arm also. The joystick-type sensors actually control 2 degrees of freedom simultaneously by a bilateral forequarter amputee. Locking shoulder joints designed, with the other components, at the
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University of Utah, demonstrate the practicality of the concept and the large work envelope possible with them. Position control and EPP are not without their drawbacks, however. Dedicating a remnant body motion to one or more motions of the prosthesis may involve a sacrifice of natural function for some patients. Also, if the shoulder motion (protraction) in longer transhum-eral amputations is dedicated to elbow control, then a second independent direction of shoulder motion must be harnessed for control of prehension. Alternatively, myoelectic control could be used from biceps and triceps, if available. Although EPP is certainly a feasible approach for control of multiple degrees of freedom, it is difficult to envision any significant simplification or reduction of the challenge. Any approach will require sophisticated control logic and electronics as well as multiple motors and an external power source. By using time series analysis methods similar to Graupe's work described earlier, the group at the University of New Brunswick has claimed good success at distinguishing separate functions from a single EMG signal. When a computational technique known as a Hopfield network is used, 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). By using another mathematical device known as a "perceptron" the parameters can be analyzed to distinguish among the functions performed by the muscle, e.g., elbow flexion, elbow extension, and forearm pronation and supination. This method awaits a practical field trial, where muscle intent may be more difficult to decipher.
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Sensory Feedback in Artificial Hands Although previously mentioned work showed promise for the feasibility of a practical sensory feedback system, the technology promises to be relatively expensive and thus less attractive for commercial application in an era of cost containment by third-party payers. Pressure-sensing technologies are under development in the robotics industry, and "spin-off' from that area into prosthetics may make its application in prosthetics possible. Technologies utilizing reflection of light across a thin layer of polymer (polytetrafluoroeth-ylene [PTFE] or Teflon) have been experimented with, as has the application of strain gauges directly to the metallic fingers of an artificial hand. Presentation of the pinch force information to the amputee is another side of the problem. As mentioned previously, 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, perhaps within the socket. However, this approach will require the development of a very small actuator that can be installed within a socket. Nerve stimulation has appeared promising in the past, 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. necessary to transmit across the skin barrier. Other techniques such as electrotactile and vibro-tactile feedback may be possible as well. New electric drive modules for upper limbs are being developed at the Princess Margaret Rose Hospital in Edinburgh. A few modules of different sizes are planned that will be used to drive different joints in various sizes of prostheses, e.g., an adult-sized elbow may be also used as a child's shoulder. As shown in Fig 12D-11. , 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.
Partial-Hand Prostheses
One area that has been neglected in prosthetics research and development is the transcarpal, or partial-hand, prosthesis. Development is difficult because of the wide variety of loss suffered by these patients, from single digits to transcarpal. However, the feasibility of miniature motor and drive systems for individual fingers and a thumb has been demonstrated ( Fig 12D-12. ). Although the weight and size constraints remain daunting, Weir reports that by using a "syner-getic" drive, a pinch force of over 8 lb for each finger and a speed of 2 radii per second have been achieved. Future possibilities of small battery supplies, strong and lightweight plastics, and miniature electronics may allow a practical prosthesis in the future.
Elbow Prostheses
The trends toward smaller motors and improved plastics should also benefit transhumeral amputees. "Hybrid"-type fittings using one or more externally powered joints combined with body-powered components should continue to grow in popularity. 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. Experimental work on EMG control theory is not presently being pursued widely. 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. uses a prosthesis control emulator to compare control Some more recent work at MIT methods for a myoelectric elbow (a Boston Elbow). A simulation of "natural" control was made, i.e., in this case a position controller commanded by the difference of two muscle EMG signals, combined with variable elbow joint impedance (resistance) controlled by the coactivation of the two muscles. 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. They found that their "natural" controller had performance closer to the intact natural elbow. The group hopes to compare other control schemes in the future such as the Utah Arm controller, etc.
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Other Components
Improved shoulder joints should eventually be developed. 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. Externally powered solutions are being pursued by the Edinburgh group, 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. ). Smaller, higher-torque wrist rotation modules seem feasible and attractive to many amputees. Ideally, a wrist rotation unit can be used with wrist flexion either proximal or distal to the rotation joint itself. Current externally powered wrist units require significant length (approximately 2 in.), which makes installation difficult and makes it awkward to combine with a flexion joint. External power of humeral rotation should be expected as well since a modular wrist rotation device could conceivably also be used for humeral rotation. However, control of humeral rotation simultaneous with other motions will require a more sophisticated control scheme than those available commercially. Perhaps a simplification of one of the experimental methods for control of multiple degrees of freedom will prove successful. Direct attachment to remnant skeletal elements may yet see progress in the decade of the 1990s. Experiments conducted by using pyrolytic carbon materials and hydroxyapatite materials show promise for allowing attachment of man-made materials directly to bone. However, 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.
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enhancing effects on an amputee. Advanced prosthetics research has the potential to improve productivity, independence, psychological outlook, and general health as a direct result of improvements in technology. References: 1. Abul-Haj CJ, Hogan N: Functional assessment of control systems for cybernetic elbow prostheses Part II: Application of the technique. IEEE Trans Biomed Eng 1990; 37:1037-1047. 2. Alstrom C, Herberts P, Korner L: Experience with Swedish multifunctional prosthetic hands controlled by pattern recognition of multiple myoelectric signals. Int Orthop 1981; 5:15-21. 3. Andrew JT: Written communication, 1990. 4. Carlson L: Oral communication, 1991. 5. Carlson L, Radocy R, Marshall PD: Spectron 12 cable for upper-limb prostheses. J Prosthet Orthot 1991; 3:130-141. 6. Carlson L, Scott G: Extended physiological proprioception for the control of arm prostheses. Presented at the International Conference of the Association for the Advancement of Rehabilitation Technology, Montreal, June 1988, pp 90-91. 7. Clippinger F: A sensory feedback system for an upper-limb amputation prosthesis. Bull Prosthet Res 1974; 10:274-358. 8. DeLuca CJ: Control of upper-limb prostheses: A case for neuroelectric control. J Med Eng Technol 1978; 2:57-61. 9. Doubler JA, Childress DS: Design and evaluation of a prosthesis control system based on the concept of extended physiological proprioception. J Rehabil Res Dev 1984;21:19-31. 10. Erb RA: Cosmetic covers for upper and lower extremity prostheses. Progress reports, 1990. J Rehabil Res Dev 1991; 28:4. 11. Glass JM: Characterization and Testing of Synthetic Hy-droxyapatite and Hydroxyapatite Composite (dissertation). Department of Bioengineering, University of Utah, Salt Lake City, 1982. 12. Goulding PP: Extended Physiological Taction, Design and Evaluation of a Sensory Feedback System for Myoelectric Control of a Terminal Device (thesis). Department of Bioengineering, University of Utah, Salt Lake City, 1984. 13. Gow D: Written communication, 1991. 14. Graupe D, Cline W: Functional separation of EMG signals via ARMA identification methods for prosthesis control purposes. IEEE Trans Syst Man Cybernet 1975; SMC 5:252-259. 15. Heckathorne CW, Strysik JS, Grahn EC: Design of a modular extended physiological proprioception controller for clinical applications in prosthesis control. Presented at the 12th Annual Rehabilitation Engineering Society of North America (RESNA) Conference, New Orleans, 1989, pp 226-227. 16. Jacobsen SC, Knutti D, Johnson RT, et al: Development of the Utah Artificial Arm. IEEE Trans Biomed Eng 1982; 29:249-269. 17. Jerard RB, Jacobsen SC: Laboratory evaluation of a unified theory for simultaneous multiple axis artificial arm control. American Society of Mechanical Engineers (ASME) Trans 1980; 102:199-207. 18. Kato I, Sadamoto K: Mechanical Hands Illustrated, rev ed. Washington, DC, Hemisphere Publishing Corp, 1987. 19. Kelly MF, Parker PA, Scott RN: The application of neural networks to myoelectric signal analysis: A preliminary study. IEEE Trans Biomed Eng 1990; 37:221-230. 20. Kruit J, Cool JC: Below-elbow prosthetic system. J Rehabil Res Dev 1991; 28:21. 21. Lamb DW, Dick TD, Douglas WB: A new prosthesis for the upper-limb. J Bone Joint Surg [Br] 1988; 70:140-144. 22. LeBlanc M, Parker D, Nelson C: New Designs for Prosthetic Prehensors. Proceedings of the Ninth International Symposium on Advances in External Control of Human Extremities. Dubrovnik, Yugoslavia, 1987. 23. LeBlanc MA: Clinical evaluation of externally powered prosthetic elbows. Artif Limbs 1971; 15:70-77. 24. Lyman J, Freedy A, Solomonow M: Studies toward a practical computer-aided arm prosthesis system. Bull Prosthet Res 1974; 10:213-225. 25. Meek SG, Jacobsen SC, Straight R: Development of advanced body-powered prosthetic arms. Progress reports, 1989. J Rehabil Res Dev 1990; 26:14. 26. Meeks D, LeBlanc M: Evaluation of a new design: Body powered upper-limb prosthesis without shoulder harness. J Prosthet Orthot 1988; 1:45-49.
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27. Mooney VL, Predeki PK, Renning J, et al: Skeletal extension of limb prosthetic attachments-Problems in tissue reaction in Hall CW, Hulbert SF, Levine SN, et al (eds): Biomedical Materials Symposium Number 2: Bioce-ramics Engineering in Medicine (Part I). New York, In-terscience Publishers, 1972. 28. Motis GM: Final Report on Artificial Arm and Leg Research and Development. Contractors Final Report, Northrup Aircraft, 1951. 29. Nader N: The artificial substitution of missing hands with myoelectrical prostheses. Clin Orthop 1990; 258:9-17. 30. Peizer E, Wright DW, Mason C, et al: Guidelines for standards for externally powered hands. Bull Prosthet Res 1969; 10:215. 31. Plettenberg DH: A myoelectrically-controlled, pneumatically-powered hand prosthesis for children. J Rehabil Res Dev Winter 1991; 28:21. 32. Radocy R: Oral communication, 1990. 33. Rehabilitation Engineering Center, Children's Hospital at Stanford: Improvement of Body-Powered Upper-Limb Prostheses. Final Report, October 1989. 34. Scott RN, Brittain RH, Caldwell RR, et al: Myoelectric control systems-Progress report No. 17. UNB Bio-Eng Inst Res Rep 1980; 80:2. 35. Sears HH: Evaluation and Development of a New Hook-Type Terminal Device (dissertation). Department of Bio-engineering, University of Utah, Salt Lake City, 1983. 36. Shannon GF: A myoelectrically controlled prosthesis with sensory feedback. Med Biol Eng Comput 1979; 17:73-80. 37. Shaperman J, Setaguchi Y: The CAPP terminal device, size 2: A new alternative for adolescents and adults. Prosthet Orthot Int 1989; 13:25-28. 38. Simpson DC: The choice of control system for the multi-movement prosthesis: Extended physiological proprioception (e.p.p.), in The Control of Upper-Extremity Prostheses and Orthoses. Springfield, Ill, Charles C. Thomas, 1974, pp 146-150. 39. Stein RB, Charles D, Hoffer JA, et al: New approaches for the control of powered prostheses: Particularly by high-level arm amputees. Bull Prosthet Res 1980; 17:5162. 40. Weir RFF: The design and development of a synergetic partial hand prosthesis with powered fingers. Presented at the 12th Annual Rehabilitation Engineering Society of North America (RESNA) Conference, New Orleans, 1989, pp 473-474. 41. Wirta RW, Taylor DR, Finley FR: Pattern recognition arm prosthesis: A historical perspective-final report. Bull Prosthet Res 1978; 10:8-35.
Chapter 12D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Normal Gait
Jacquelin Perry, M.D. 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. Effectiveness depends on free joint mobility and muscle action that is selective in both timing and intensity. Normal function is also optimally conservative of physiologic energy. Pathologic conditions alter the mode and efficiency of walking. The loss of some actions necessitates substitution of others if forward progression and stance stability are to be preserved. Through a detailed knowledge of normal function and the types of gait errors that the various pathologic conditions can introduce, the clinician becomes able to define the significant deficits and plan appropriate corrective measures.
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.
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.). During the normal gait cycle approximately 60% of the time is spent in stance and 40% in swing. The exact duration of these intervals varies with the walking speed. There also are minor differences among individuals. The reciprocal action of the two limbs is timed to trade their weight-bearing responsibility during a period of double stance (i.e., when both feet are in contact with the ground) and usually involves the initial and terminal 10% intervals of stance. The middle 40% is a period of single stance (single-limb support). During this time the opposite limb is in swing.
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, standing stability, and energy conservationinvolve distinct functional patterns. These need to be understood for an appropriate interpretation of some of the limitations displayed by patients. Although for this description they will be separated, during walking all three action patterns are intertwined throughout each stride.
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Progression
There are two main progressional forces: 1. 1.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. 2. The second, which is generated by the contralateral swinging limb ( Fig 13-3.), starts with the onset of single-limb support. This action is particularly important before the body is aligned for an effective forward fall. The momentum generated by these two actions is optimally preserved at the onset of the next stance phase by floor contact with the heel. As the foot drops toward the floor, the pretibial muscles draw the tibia forward ( Fig 13-4.). At the same time the quadriceps ties the femur to the leg so that the thigh also advances (although at a slightly slower rate). Thus,
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throughout the stance period the heel, ankle, and forefoot serially serve as a rocker that allows the body to advance over the supporting foot ( Fig 13-5.). For this to occur the foot must be appropriately positioned by the end of swing and controlled as weight is applied. Then, during the support phases there must be adequate passive mobility at the ankle. This necessitates both a free joint range and ability of the calf muscles to yield as they provide tibial stability.
Standing Stability
Balance is challenged by two factors. The body is top-heavy, and walking continually alters segment alignment. During walking the body divides itself into two functional units-passenger and locomotor. The head, arms, and trunk are the passenger unit because they are carried rather than directly contributing to the act of walking. Muscle action within the neck and trunk serves only to maintain neutral vertebral alignment. There is minimal postural change occurring during normal gait. Arm swing is primarily a passive reaction to the momentum generated. The small amount of active control has not proved essential, as evidenced by the ease with which one carries packages. Also, experimental restraint of arm swing registers no change in the energy cost of walking. The composite mass center of these segments is just anterior to the tenth thoracic vertebra and thus lies well above the hip joints. This long lever (33 cm in an average adult ) makes balance of the passenger unit very sensitive to alignment changes of the supporting limbs. The locomotor unit consists of two limbs joined by the intervening pelvis. This makes the pelvis an element of both the passenger and the locomotor units, with two highly mobile junction sites, the lumbar spine and hip joints. Theoretically, weight-bearing stability of the limb is maximal when its three components (thigh, leg, and foot) are vertically aligned so that one is directly over the center of the other. If these segments were square blocks, there would be a broad shoulder to allow considerable tilting before balance was lost. Instead, the femur and tibia are tall narrow bones. Additionally, the articular surfaces are segments of a circle, so there are no restraining rims available in the sagittal plane and, consequently, no intrinsic stability. The skeletal architecture is designed for mobility. This means that other stabilizing mechanisms are needed. At the hip anteriorly and the knee posteriorly a strong ligament stabilizes one side of the joint. By using hyperextension to align body weight on the opposite side, the person is able to attain passive stability. No similar mechanism exists at the ankle or subtalar joints, however. Instead, here a free range of dorsiflexion-plantar flexion and in-version-eversion exists. Thus, only through direct muscular control is the tibia stabilized over the foot. 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. Posteriorly the weight-bearing segment of the heel is little more than 1 cm, for the significant factor is the rounded contour of the tuberosities and not the full length of the os calcis. By contrast, the anterior (forefoot) lever that extends to the weightbearing surface of the metatarsal heads averages 10 cm in an adult. Thus, for optimum foot support (equal anterior and posterior leverages), the body weight line (vector) must be anterior to the ankle joint. This increases the demand for active control of the ankle and subtalar joints. During walking the trunk and limb segments are continually moving from behind to ahead of the supporting foot. Thus passive stability is a fleeting experience. At the onset of stance, flexion torques are created at the hip and knee that must be restrained by active muscular effort. As body weight moves forward, this demand is gradually replaced by passive support from tense fasciae. Conversely, the demand for active ankle restraint (a plantar flexion force) does not begin until body weight moves forward of that joint axis. Once the forefoot becomes the major area of support, muscular response must increase rapidly. Thus the ever-changing alignment of body weight is stabilized by selective muscular control. 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 is the torque created, a product of force times leverage. The length of the lever (moment arm) is the perpendicular distance between the body weight line and each joint center. Body weight is the basic force, but its effect is modified by the direction in which it is moving. The composite effect is determined by measuring the instantaneous ground reaction forces. At the beginning and end of stance, body weight drops rapidly toward the floor. The resulting accelerations increase the ground reaction force to a value greater than the body weight. During the midstance period the body
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rises slightly as the limb becomes more vertical. This somewhat reduces the weight directed toward the ground. Consequently, the force demands presented to the muscles vary by both the loading experience and the alignment of body weight over the joints. Selective neural control and proprioception as well as adequate strength are needed for appropriate muscle response.
Energy Conservation
The basic measure of efficiency is energy expenditure per task performed. For walking, this is oxygen used per meter traveled. Oxygen is consumed as the muscles contract. Thus efficiency is improved by reducing the amount of muscular effort required to walk. This normally is accomplished by two mechanisms: momentum is substituted for muscle action wherever possible, and displacement of the body from the line of progression is minimized. 1. Optimum use of momentum occurs during the person's natural gait velocity. That motion pattern requires the least energy expenditure per meter traveled. Both a slower and a faster pace increase the energy cost. 2. Minimization of body displacement from the line of progression is accomplished by coordinating pelvic, knee, and ankle motion to keep the relative limb length fairly constant throughout stance. At the onset of a double stance, body height is lowest because the two limbs are diagonal. Conversely, the highest position occurs in the middle of single stance, when the supporting limb is vertical. For a normal adult step length of 70 cm the height loss would be abrupt, and ankle dorsiflexion of 22 degrees would be needed by the trailing limb. To reduce these extremes, normal gait involves three pelvic motions: lateral drop, transverse rotation, and anterior tilt. All three approximate 4 degrees and follow the swing limb. The stance limb contributes by two actions. 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. Also, heel rise in the latter half of stance adds relative length to the trailing limb. Through these actions the potential 7-cm displacement is reduced to 5 cm, a 30% saving.
Joint Motion
The interplay of progression, standing stability, 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. Each joint performs a representative pattern of motion. During stance the postural changes are induced passively by the influence of body weight. Swing-phase motion depends on muscle action. Ankle.-Two periods of plantar flexion and dorsiflexion are experienced in each gait cycle ( Fig 13-6.). At the onset of stance the ankle has a 90-degree position. As the heel is loaded, the foot drops into 10 degrees of plantar flexion. Then the action reverses and gradually reaches 10 degrees of dorsiflexion. At this time plantar flexion is resumed and reaches 20 degrees by the end of stance, although the latter arc of motion occurs in the double-stance period when the limb is being rapidly unloaded. With toe-off the foot is quickly raised to neutral dorsiflexion and maintained in this position throughout swing. Knee.-The knee also experiences two phases of flexion and extension in each gait cycle ( Fig 13-7.). Beginning in full extension (or flexed 5 degrees), it rapidly flexes to 15 degrees. Then it progressively extends to neutral. With the onset of double stance, it again begins to flex. This action continues in swing to reach 60 degrees before extension is resumed. Hip.-Only a single arc of hip extension and flexion occurs in each gait cycle ( Fig 13-8.). As the foot strikes the ground, the hip is in 30 degrees of flexion. Throughout stance there is progressive extension into 10 degrees of hyperextension. Then flexion begins in terminal double stance and continues through most of swing. When the 30-degree posture is reached, it is maintained until stance resumes.
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. This is identified by subdividing the continuum of limb action according to the tasks that must be accomplished. The result is eight functional units. Each constitutes one phase of gait.
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Normal events have customarily been used to designate the different gait phases. Although this was adequate for amputees, many other types of disability prevented the patients from accomplishing some of the key actions. The terms thus became meaningless. To avoid such confusion, a generic terminology was developed. Because it has proved universally applicable to normal, amputee, arthritic, and paralytic patients, it is the system that will be used in the ensuing discussion. Because one gait cycle blends into the next in an endless fashion, any event can be selected as the starting point. Initial floor contact is the most consistent event in both normal and pathologic gait and, thus, will serve as the first gait phase. Normal function is the model for judging a patient's gait. Disability reduces the limbs' effectiveness by altering their pattern of motion. The significance of the observed deviations relates to the changes in total limb posture that occur during the individual gait phases. Thus the basis of gait analysis is to have a firm concept of limb function during each gait phase, to know the purpose of the normal motion patterns, and to appreciate the penalties that disabled performance imposes.
Stance
To allow progression while also maintaining weight-bearing stability, the limb performs five distinct tasks that define the phases of stance.
Initial Contact
Of primary concern is the way the foot strikes the floor. Although this is a momentary posture, it is significant because of its influence on subsequent knee action. Heel strike with the foot at a 25-degree angle to the floor is the normal occurrence. The ankle is in an approximately neutral position (perhaps plantar-flexed 3 degrees). The knee is extended between 0 and 5 degrees of flexion, and the hip is flexed 30 degrees. 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. Three torques are generated: ankle plantar flexion, knee extension, and hip flexion ( Fig 13-9.). Control of both knee and ankle is critical to having normal heel strike. Dorsiflexion of the ankle to neutral is dependent on free joint mobility and active control by the pretibial muscles (tibialis anterior, long extensors of the great and common toes, and peroneus ter-tius). Knee extension is accomplished by quadriceps action. Hip position does not influence the mode of floor contact but does determine the angle between foot and floor.
Loading Response
Acceptance of body weight in a manner that ensures limb stability and still permits progression is the goal at this time. As weight is dropped onto the limb, a heel rocker action is initiated that leads to two significant motion patterns. The action at the ankle precedes and contributes to that occurring at the knee. Ankle. -After floor contact by the heel, the foot quickly drops into 10 degrees of plantar flexion in a controlled manner. 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. An unstable lever results from differences in bone length between these points. Strong action by the pretibial muscles retards the terminal arc of ankle plantar flexion, so forefoot contact is gradual. Thus, heel strike is heard but no foot slap. This action dominates the first 6% to 8% of the gait cycle. While these sagittal motions are occurring, 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. ). This joint. creates a valgus thrust on the subtalar joint. As the foot responds, support for the talus is reduced. The talus falls into internal rotation. The strong ankle ligaments carry the tibia and fibula with the talus so that the entire ankle joint turns inward.
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Knee. -Flexion of the knee to 15 degrees is initiated by the heel rocker action. As the pretibial muscles contract to restrain ankle plantar flexion, they also draw the tibia forward. This is a rapid action, and it advances the leg faster than the thigh and trunk can follow. As a result the body weight line shifts posterior to the knee, and a flexion torque (moment) is induced ( Fig 13-11. ). Two types of muscle action result. There is increased quadriceps activity to restrain the rate of knee flexion. Conversely, no longer are the hamstring muscles needed to prevent knee hyperextension. Marked reduction of semimembranosus and semitendinosus activity is the Persistence of the biceps femoris (long head) probably relates to its external response. rotation action at the knee. Hip. -Little change in thigh position occurs during the loading response. The large hip flexion moment present with the impact of initial floor contact is reduced by two passive actions. Rapid realignment of the vector to the body center brings the weight line close to the hip joint axis (see Fig 13-11. ). An extensor thrust created by propulsion of the limb through the heel rocker advances the femur as well as the tibia. Active muscular restraint of the hip flexion moments is provided primarily by the gluteus maximus and adductor magnus. Both these muscles markedly increase their activity after initial contact. Participation by the hamstrings is reduced because of their actions at the knee.
Midstance
Advancement of the body and limb over a stationary foot is the functional objective of this gait phase. As the other foot is lifted for swing, a period of single-limb support begins. Maximum stability is gained by having the foot stationary and in total contact with the floor (heel and first and fifth metatarsal heads). Ankle rocker action allows progression to continue, and this occurs through residual momentum and that generated by the contralateral swinging limb. As body weight advances across the arch, the base of the vector moves from the heel to the forefoot. This alters vector alignment at the ankle, knee, and hip, with resulting changes in joint posture and muscle control ( Fig 13-12. ). Ankle. -At the onset of single stance the ankle is still slightly plantar-flexed (5 degrees). From this position there is gradual dorsiflexion. The basic arc is from -5 to +5, with 10 degrees of dorsiflexion being attained just as the heel rises to initiate terminal stance. Thus an ankle rocker is created for body progression. Allowing the tibia to advance beyond the neutral position so that body weight moves over the forefoot is the critical action. As the body vector moves anterior to the ankle, a dorsiflexion moment is created that would accelerate the rate of limb advancement if it were not controlled. Judicious restraint is an essential component of knee stability. The soleus responds by restraining the tibia's progression. Assistance by the gastrocnemius reduces the effort that the soleus must exert, but it also induces a flexion torque at the knee. While these two muscles are acting to avoid excessive tibial advancement, they are doing so in a yielding manner; thus the desired degree of ankle dorsiflexion is attained. An available range and timely tibial restraint are the critical events during midstance. Knee. -Knee flexion induced during the loading response increases slightly and reaches its maximum of 18 degrees just as single-limb support is initiated. Motion of the knee then reverses to progressive extension, which depends on the tibia's being actively restrained by the soleus so that the femur can advance at a relatively faster rate. At approximately the middle of the midstance phase the body vector moves anterior to the joint center, and an extensor moment is begun. The need for active muscular control is terminated. Quadriceps action is maximal at the onset of midstance. It then progressively declines as the knee extends over the vertical tibia, and advancement of the body vector lessens the flexor torque. Once the vector becomes anterior to the knee axis, extension stability is provided passively, and the quadriceps relaxes.
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Hip. -Progressive decline in hip flexion and entry into extension allow the trunk to remain erect while the limb becomes more vertical. These motions are accomplished passively. The onset of single stance, however, creates new demands in the coronal plane. Lifting the opposite limb removes support for that side of the body ( Fig 13-13. ). The unsupported pelvis falls and creates quick hip adduction in the stance limb. This is rapidly limited to 4 degrees and then reversed by active abduction to the extent of slight over correction. Hip abductor muscle activity is intense throughout midstance while the extensors are quiet.
Terminal Stance
Forward fall to generate a propulsive force is the primary objective. Heel rise signifies the onset of this second phase of single stance. Now the forefoot serves as the progressional rocker, with the body falling forward of its area of support. This creates the primary propulsive force for walking. With the limb acting like a spoke in a wheel, the body's center of gravity drops slightly during advancement. Throughout terminal stance the ankle and foot are the critical sites of action. Ankle. -At the onset of heel rise the ankle drops into the maximum dorsiflexion (10 degrees) occurring in stance. Motion then reverses to reach 5 degrees of plantar flexion by the end of single-limb support. Hence stabilization in a relatively neutral position is the objective so that the forefoot can act as the propulsive rocker. Stability is accomplished by the triceps surae. With heel rise the body vector is concentrated at the forefoot ( Fig 13-14. ). The distance between the vector and ankle joint axis generates a maximal dorsiflexion torque. This must be restrained if the ankle is to maintain its neutral position. 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. Foot.-With body weight being applied at the ankle (talus) and supported by the forefoot, a strong dorsiflexion torque is generated through the midfoot. Stability is gained by inversion. This posture is initiated by the obliquity of metatarsal support. The line between the second Inversion of the and fifth metatarsal heads is 28 degrees anterior to the coronal plane. subtalar joint so changes the axes of the talonavicular and calcaneocuboid joints that they cease to be parallel. This locks all the midfoot joints (transverse tarsal, intercuneiform, cuneiform-cuboid, and metatarsal bases). Heel rise also initiates dorsiflexion at the metatarsophalangeal (MP) joint. While most of body weight is concentrated on the metatarsal heads, the bases of the proximal phalanges contribute by enlarging the support area. At the end of terminal stance the body is well forward, and the MP joint dorsiflexes approximately 20 degrees. All the foot and toe muscles are active. Inversion is preserved by the tibialis posterior and soleus. At the same time it is restrained by the peroneals (longus and brevis). The longand short-toe flexors also support the arch by the compressive force that their longitudinal alignment provides. Passive arch support is gained from the plantar fascia, which is tensed as the MP joint dorsiflexes. 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. Knee. -With the tibia stabilized on the foot, forward alignment of body weight passively extends the knee. Maximum extension varies between 0 and -5 degrees. At the end of terminal stance when the vector is at the margin of MP support, the knee begins to flex. Body weight is rapidly falling toward the other limb. There is no quadriceps action at this time, for knee extension stability is gained from the body vector's continually being anterior to the knee joint axis. Hip. -Passive extension of the hip joint continues as body weight advances beyond the supporting foot and the trunk remains erect. By the end of stance there are 10 degrees of hyperextension. The anterior joint structures are maximally stretched by falling body weight. This commonly stimulates the iliacus to provide a restraining force. There is no hip extensor activity during terminal stance. As body weight begins to fall toward the other limb, the hip abductors terminate their action, and passive abduction is induced.
Preswing
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Preparation of the limb for swing is the purpose of the actions that occur during the preswing phase. Floor contact by the other foot initiates this interval of terminal double support. Rapid transfer of body weight to that limb allows the desired actions to follow. The critical area of response is the knee. Knee. -There is rapid passive flexion to 40 degrees, which occurs because the body weight has rolled so far forward on the forefoot rocker that the tibia no longer is stable. As the tibia advances, the knee joint axis is moved anterior to the body vector. A flexion torque is created ( Fig 13-15. ). There is no flexor muscle action. The quadriceps (mainly the rectus femoris) may react briefly to restrain the rate of passive knee flexion if needed. Hip. -Flexion of the hip joint is initiated with the recovery from hyperextension to neutral that occurs during this phase. The iliacus, often accompanied by the rectus femoris, is active. Ankle and Foot.-There is rapid ankle plantar flexion to a 20-degree position, a passive event since all the significant musculature is relaxed at the time of contralateral foot contact. Only the flexor hallucis longus remains active. It sustains MP joint compression and restrains dorsiflexion while floor contact is maintained. This is not a major weight-bearing obligation, for the load is primarily on the other foot.
Swing
Lifting the foot from the ground and limb advancement followed by preparation for stance are the objectives of the three phases of swing.
Initial Swing
Recovery from a trailing posture is the task that is accomplished. This involves two critical actions: flexion of both the hip and the knee ( Fig 13-16. ). Hip. -From the neutral position attained at toe-off the hip rapidly flexes to 20 degrees. Although the iliacus is the major force advancing the thigh, the need for speed generates assistance from the sartorius, gracilis, and adductor longus. Knee. -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. Despite the fact that this is a critical event, there is not a dominant flexion force. Momentum from the advancing thigh is supplemented by action of the short head of the biceps femoris and the sartorius and gracilis. Ankle. -Dorsiflexion of the ankle is initiated, but only half the 20-degree plantar flexion present at toe-off is recovered in this brief time. Thus toe clearance of the floor is not dependent on ankle dorsiflexion during the initial phase of swing. The muscles contracting quickly to lift the foot are the tibialis anterior, long-toe extensors, and peroneus tertius.
Midswing
As limb advancement continues, the changes in the tibial alignment make foot control critical for floor clearance ( Fig 13-17. ). Hip. -Maximum flexion to 30 degrees is reached by continued iliacus action. Knee. -Relaxation of the flexor muscles allows the knee to extend passively. This accelerates advancement of the leg and foot. By the end of midswing, knee flexion (30 degrees) equals that of the hip, and the tibia is vertical. Ankle. -Dorsiflexion to neutral is accomplished and then maintained. Verticality of the tibia continues the need for active control of the foot. The tibialis anterior and other pretibial muscles respond accordingly.
Terminal Swing
Advancement is terminated, and the limb is prepared for stance. The critical event is complete knee extension ( Fig 13-18. ).
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Hip. -The 30 degrees of flexion attained in midswing is maintained. For this purpose momentum supports limb weight while the hamstrings prevent further motion. All three muscles-semimembranosus, semi-tendinosus, and biceps femoris long head-exhibit peak activity at this time. Knee. -Because gravity must be opposed and only a brief time is available for this, extension of the knee to neutral (0 or -5 degrees) continues under active control. The quadriceps provides the needed extensor force. All heads remain active. Simultaneous contraction of the hamstrings to decelerate hip flexion also prevents hyperextension of the knee. Ankle. -Continued neutral dorsiflexion is the basic posture, but the foot may drop into slight plantar flexion (3 to 5 degrees) at the end of the phase. The pretibial muscles tend to diminish their intensity of action as the semivertical position of the foot presents a lessdemanding torque.
SUMMARY
Five joints in each limb (hip, knee, ankle, subtalar, and metatarsophalangeal), under the selective control of 28 major muscles, coordinate their actions to provide continual progression and weight-bearing stability with minimal displacement of the body's center of gravity. To meet these demands each limb performs eight motion patterns that have been identified as the phases of gait. The sequence of muscle action relates to three major tasks being accomplished during each gait cycle: weight acceptance, single-limb support, and limb advancement. Preparation of the limb for weight acceptance begins in terminal swing when the hip extensors and quadriceps are activated. Following initial floor contact, 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. To ensure knee stability, the hamstrings and single joint hip extensors exchange their intensities. Continuation of the swing-phase ankle dorsiflexor control provides a heel rocker for progression and shock-absorbing knee flexion. Ankle plantar flexion modulates the heel rocker to protect the quadriceps from overde-mand. 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. These muscles increase their intensity as progression increases the demand torque at the junction of foot and leg (the ankle). Knee and hip extensor stability is provided passively by body alignment. Activation of the hip abductors (which actually began in the loading response) ensures lateral stability of the pelvis and trunk on the supporting limb. Subtalar and midfoot stability is gained from the perimalleolar muscles. Progression of the limb and body over the stationary foot depends on graduated ankle dorsiflexion to advance the tibia. Further progression of the tibia is gained by heel rise and forward roll over the forefoot in terminal stance. 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. The knee and hip are unlocked from their extended positions, and flexion is initiated. Active continuation of these events in initial swing and midswing lifts the toe to clear the floor and advances the limb. Dynamic dorsiflexion provides the necessary foot control. At the end of midswing, limb advancement ceases, and the preparations for stance begin. References: 1. Dempster WT: Space Requirements of the Seated Operator: Geometrical, Kinematic, and Mechanical Aspects of the Body With Special Reference to the Limbs. Dayton, Ohio, Wright-Patterson Air Force Base U.S. Wright Air Development Center Technical Report 55-159. 2. Inman VT: The Joints of the Ankle. Baltimore, Williams & Wilkins, 1976. 3. Inman VT, Ralston HJ, Todd F: Human Walking. Baltimore, Williams & Wilkins, 1981. 4. Lyons K, Perry J, Gronley JK, et al: Timing and relative intensity of hip extensor and abductor muscle action during level and stair ambulation: an EMG study. Phys Ther 1983; 63:1597. 5. Murray MP, Drought AB, Kory RC: Walking patterns of normal men. J Rone Joint Surg [Am] 1964; 46:335. 6. Perry J: Anatomy and biomechanics of the hindfoot. Clin Orthop 1983; 177:9. 7. Ralston HJ: Effects of immobilization of various body segments on the energy cost of
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human locomotion. Proceedings of the 2nd IEA Conference, Dortmund, W Germany, 1964. Ergonomics 1965; (suppl):53. Ralston HJ: Energy-speed relation and optimal speed during level walking. Int Z Angew Physiol 1958; 17:277. Saunders JBCM, Inman VT, Eberhart HD: The major determinants in normal and pathological gait. J Bone Joint Surg [Am] 1953; 35:543. Sutherland DH: An electromyographic study of the plantar flexors of the ankle in normal walking on the level. J Rone Joint Surg [Am] 1966; 48:66. Wright DG, Desai SM, Henderson WH: Action of the subtalar and ankle joint complex during the stance phase of walking. J Rone Joint Surg [Am] 1964; 46:361. Perry J: Gait Analysis of Normal and Pathological Function. Slack Inc, 1992.
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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
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During normal gait the knee is approximately in complete extension at heel strike. Immediately thereafter, the knee begins to flex and continues to do so until just after the sole of the shoe is flat on the ground. 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. The transtibial amputee may exceed this range of knee flexion on the amputated side for any of the following reasons: 1. Excessive dorsiflexion of the foot or excessive anterior tilt of the socket Normally, foot contact with the floor after heel strike is the result of ankle plantar flexion and 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, additional knee flexion is required to allow the foot to reach the floor after heel strike. 2. 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, 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. Also, 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. 3. Excessive anterior displacement of the socket over the foot As illustrated in Fig 14-1., 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). The force couple tending to cause rotation of the prosthesis in a flexion direction thus increases as the socket is moved farther anteriorly. 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. 4. 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. This location causes the suspension tabs to tighten as the knee joint extends and to loosen as the knee flexes. If the attachment points are unduly posterior, the suspension tabs will tighten to such an extent as to prevent the knee joint from reaching full extension. The supracondylar/suprapatellar-suspended prosthesis relies on a carefully molded convexity above the patella to ensure adequate suspension. If this anterior convexity is excessive, the knee joint will be restricted in extension. These situations are comparable to a flexion contracture in which tight posterior tissues do not permit full knee extension. B. 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. Excessive plantar flexion of the foot In normal walking, contact of the sole of the foot with the floor coincides approximately with the end of knee flexion and the beginning of knee extension. If the prosthetic foot is in an attitude of plantar flexion, foot flat will occur prematurely and prevent normal knee flexion after heel strike. 2. Excessively soft heel cushion or plantar-flexion bumper In the case of a solid-ankle, cushion-heel (SACH) foot with an excessively soft heel cushion, there will be a momentary delay between heel strike and the initiation of knee flexion. The knee will begin to flex only after the heel cushion has been fully compressed. With a single-axis ankle, an excessively soft heel bumper will allow the prosthetic foot to plantar-flex too rapidly and thus slap the floor. This abrupt contact of the foot with the floor will tend to decrease the range of knee flexion. 3. Posterior displacement of the socket over the foot As illustrated in Fig 14-2., 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), thus decreasing the tendency of the force couple to rotate the prosthesis in a flexion direction. If the socket is placed so far posteriorly that the line of force transmission through the socket falls posterior to the floor reaction, the prosthesis will
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tend to rotate backward, that is, the knee will be forced toward hyperextension rather than flexion. 4. 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. When the quadriceps muscle contracts, pressure between the anterodistal surface of the tibia and the socket is increased considerably. Consequently, stump discomfort may occur at heel strike. 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. This can be accomplished by (1) shortening the prosthetic step, (2) digging the heel into the ground by means of increased hip extensor activity, (3) adopting a forward lurch of the head and the shoulder, or (4) some combination of these. 5. Weakness of the quadriceps muscle If the quadriceps is not strong enough to control the knee at heel strike, the amputee may compensate in much the same way as he would if there were anterodistal tibial discomfort. These gait maneuvers tend to force the knee into extension and thereby lessen or eliminate the need for quadriceps activity. 6. 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. A brief period of instruction with adequate follow-up may establish a less deviant walking pattern. II. At midstance A. Excessive lateral thrust of the prosthesis Lateral thrust derives from the tendency of the prosthesis to rotate around the amputated limb. When this occurs, the medial socket brim presses against the femoral condyle while the lateral part of the brim tends to gap. A slight amount of this lateral thrust is fairly common, but if it is excessive, the amputee may complain of uncomfortable pressure on the medioproximal aspect of his knee, and damage to the skin and to the knee ligaments may result. Excessive lateral thrust may be caused by such factors as the following: 1. Excessive medial placement of the prosthetic foot At midstance, the sound limb is swinging, so all of the body weight is supported by the prosthetic foot on the floor. If this supporting foot is too far medial to the line of action of forces transmitted through the socket, as illustrated in Fig 14-3., a force couple is created that tends to rotate the socket around the stump. In almost all instances, this lateral thrust can be minimized or eliminated by "out-setting" the prosthetic foot slightly. 2. Abducted socket If a socket that has been set in excessive abduction (brim tilted medially, simulating genu valgum) is placed on the vertically positioned residual limb, the distal end of the prosthesis shifts medially, and the patient's weight tends to be borne on the lateral border of the foot. This, in turn, increases the lateral thrust of the socket brim. III. Between midstance and toe-off A. Early knee flexion (drop-off) Just prior to heel-off during normal gait, the knee is extending. At heel-off or immediately thereafter, knee motion reverses, and flexion begins. This knee flexion coincides with the passing of the center of gravity over the metatarsophalangeal joints. If the body weight is carried over these joints too soon, the resulting lack of anterior support would allow premature knee flexion or drop-off. Possible causes for this lack of anterior support are as follows: 1. Excessive anterior displacement of the socket over the foot The farther forward the socket is placed, 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. 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. 2. Posterior displacement of the toe-break or the keel
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3. Excessive dorsiflexion of the foot or excessive anterior tilt of the socket 4. Soft dorsiflexion bumper These conditions also minimize the distance that the body weight must move forward before anterior support is lost. The shorter this distance, the earlier and more abrupt will be the knee flexion. B. 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. Under such circumstances, the knee joint would remain in extension during the latter part of the stance phase, and the amputee might complain of a "walking-uphill" sensation since his center of gravity would be carried up and over the extended knee. This excessive anterior support can be brought about by the following: 1. Excessive posterior displacement of the socket over the foot 2. Anterior displacement of the toe-break or the keel 3. Excessive plantar flexion of the foot or excessive posterior tilt of the socket 4. Hard dorsiflexion bumper Some of the gait deviations discussed below in relation to the transfemoral amputee may also be noted in the transtibial patient. However, the incidence is small, and no separate discussion is warranted.
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How to observe: From behind the patient. Causes: 1. Pain or discomfort in the crotch area. The discomfort may be due to such factors as skin infection, adductor roll, or pressure from the medial socket brim. The amputee tries to gain relief by abducting his prosthesis, thus moving the medial part of the brim away from the painful area. 2. Contracted hip abductors. 3. Prosthesis too long. Excessive length makes it difficult to place the limb directly under the hip during stance and to clear the floor during swing. Widening the base helps to solve these problems. 4. Shank aligned in the valgus position with respect to the thigh section. 5. Mechanical hip joint set so that the socket is abducted. 6. Feeling of insecurity. The amputee compensates by widening his walking base.
CIRCUMDUCTION
Description: The prosthesis follows a laterally curved line as it swings ( Fig 14-6.). When to observe: Throughout swing phase. How to observe: From behind the patient. Causes: The basic cause of this deviation is a prosthesis that is too long, thus forcing the amputee to swing it to the side to clear the ground. The following are among the factors tending to produce excessive length: 1. Insufficient flexion of the knee because of insecurity or fear. 2. Manual knee lock, excessive friction, or a tight extension aid preventing the knee from flexing. 3. Inadequate suspension allowing the prosthesis to drop (piston action). 4. Too small a socket. The ischial tuberosity is above its proper location. 5. Foot set in excessive plantar flexion.
VAULTING
Description: The amputee raises his entire body by early and excessive plantar flexion of the sound foot ( Fig 14-7.). When to observe: During swing phase of the prosthesis. How to observe: From behind or from the side of patient. Causes: 1. Insufficient friction in the prosthetic knee. In the normal pattern, maximum elevation of the body occurs when the supporting limb is in the middle of stance phase and the other limb swings alongside it. When there is insufficient friction, heel rise is excessive, and the shank takes a longer time to swing forward. Because of this time lag, the body is no longer at maximum elevation as the prosthetic foot is at its lowest point in swinging through, and the prosthetic foot would fail to clear the ground unless the amputee gained additional time and clearance by vaulting. 2. Excessive length of the prosthesis. The amputee vaults to gain additional clearance so that the prosthetic foot will clear the ground as it swings through. The following are among the factors that may produce excessive length: A. Insufficient flexion of the knee because of insecurity or fear. B. Manual knee lock, excessive friction, or too tight an extension aid. C. Inadequate suspension allowing the prosthesis to slip off the stump (piston action). D. Too small a socket. The ischial tuberosity is above its proper location. E. Foot set in excessive plantar flexion.
SWING-PHASE WHIPS
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Description: Medial whip-At toe-off the heel moves medially ( Fig 14-8.). Lateral whip-At toeoff the heel moves laterally ( Fig 14-8.). When to observe: At and just after toe-off. How to observe: From behind the patient. Causes: 1. Improper alignment of the knee bolt in the transverse plane. 2. With a suction socket and no auxiliary suspension, whips may be seen because of the following: A. Weak and flabby musculature that rotates freely around the femur. B. A socket that is too tight or improperly contoured to accommodate muscles. Pressure from contracting muscle bellies causes the prosthesis to rotate around its long axis.
FOOT SLAP
Description: The foot plantar-flexes too rapidly and strikes the floor with a slap ( Fig 14-10. ). When to observe: Just after heel strike. How to observe: From the side. Listen for slap. Cause: The plantar-flexion bumper is too soft and does not offer enough resistance to foot motion as weight is transferred to the prosthesis.
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. ). When to observe: At the end of swing phase. How to observe: From the side. Listen for the impact.
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Causes: 1. Insufficient friction at the prosthetic knee. 2. Too tight an extension aid. 3. The amputee's fear of buckling causing him to extend the hip abruptly as the knee approaches full extension. This maneuver snaps the shank forward into full extension. 4. Absent or worn resilient extension bumper in the knee unit.
EXAGGERATED LORDOSIS
Description: The lumbar lordosis is exaggerated when the prosthesis is in stance phase, and the trunk may lean posteriorly ( Fig 14-13. ). When to observe: Throughout stance phase. How to observe: From the side. Causes: 1. Hip flexion contracture. 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). 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. 2. Insufficient socket flexion. 3. Insufficient support from the anterior socket brim. 4. Weak hip extensors. The extensors help to restrain the tendency of the pelvis to tilt forward. When this restraining force is lost, the resulting forward pelvic tilt and compensatory backward trunk bending cause increased lordosis. In addition, the amputee may roll his pelvis forward to assist the weak extensors to control knee stability. 5. Weak abdominal muscles. The abdominal muscles restrain the tendency of the pelvis to tilt forward. If the abdominal muscles are weak, some of this restraint is lost, and the amputee will show increased lordosis.
Chapter 14 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
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, and a "steady-state" condition is achieved that reflects the energy expended during the activity.
Aerobic Oxidation
The functional unit of energy for muscle contraction is adenosine triphosphate (ATP). In aerobic oxidation (citric acid cycle), carbohydrates and fats are oxidized through a series of enzymatic reactions leading to the production of ATP. The net equation for the aerobic metabolism of glucose is as follows: Glucose + 36ADP + 36P i + 36H+ + 60 2 > 6C02 + 36ATP + 42H2 0, where ADP is adenosine diphosphate.
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. The net equation for the glycolytic metabolism of glucose is as follows: Glucose + 2Pi + 2ADP > 2 Lactate + 2ATP. The lactate is buffered in the blood by bicarbonate, and this leads to the formation of C02 , which is exhaled in the expired air; this can be summarized by the following reactions: Lactate + NaHC03 > Na lactate + H 2 0 + C02 (gas).
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and aerobic oxidation processes occur. The serum lactate and expired C02 levels rise, thus reflecting the additional anaerobic activity. The respiratory exchange ratio (RER) is defined as the ratio of expired carbon dioxide (C02 ) to inspired oxygen (0 2 ). When exercise is performed at more strenuous work rates above the anaerobic threshold, the RER rises and reflects the contribution of anaerobic energy production required to meet the additional ATP demands. The amount of energy that can be produced by anaerobic means is limited. As reflected in the above equations, approximately 19 times more energy is produced by the aerobic oxidation of carbohydrates than by anaerobic oxidation. Anaerobic oxidation is also limited by the individual's tolerance to acidosis resulting from the accumulation of lactate. From a practical standpoint, the anaerobic pathway provides muscle with an immediate supply of energy for sudden and short-term strenuous activity. If exercise is performed at a constant rate at which the aerobic processes can supply the necessary ATP production, an individual can sustain exercise for a prolonged time without an easily definable point of exhaustion.
Oxygen Pulse
In the absence of cardiac disease, there is a linear relation between the rate of 0 2 uptake and heart rate.
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When performing exercise at the same rate of 0 2 uptake, higher heart rates are associated with leg exercise than with arm exercise. The ratio of the rate of 0 2 uptake to heart rate is the oxygen pulse. The oxygen pulse is higher during arm exercise than during leg exercise. Deconditioning due to sedentary activity or any disease process that impairs the delivery of oxygen to the cells also decreases the oxygen pulse.
Training
A physical-conditioning program can increase the aerobic capacity by several processes: improving cardiac output, increasing the capacity of the cells to extract oxygen from the blood, increasing the level of hemoglobin, and increasing the muscular mass (hypertrophy). As a result, endurance is increased. Not only A sedentary life-style has the opposite effect on maximum oxygen consumption. does atrophy of peripheral musculoskeletal structures occur, but there is also a central decline in stroke volume and cardiac output as a result of inactivity. Any disease process of the respiratory, cardiovascular, muscular, or metabolic systems that restricts the supply of oxygen to the cell will also decrease the V02 max. Bed rest for 3 weeks can result in a 27% decrease in the V02 max by decreasing cardiac output, stroke volume, and other factors. A special problem confronting most older vascular amputees is their limited exercise ability. 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. Diabetes decreases capillary permeability and therefore oxygen supply to the muscle due to basement membrane thickening. The status of physical fitness can be assessed by examining the oxygen pulse, which is the ratio of the mean rate of 0 2 uptake and heart rate. In different amputee groups walking without crutches, the 0 2 pulse is lower than normal, which suggests that despite successful prosthetic use, the average amputee leads a less active life-style resulting in a lower level of physical conditioning. This conclusion is supported by the result of V02 max measurements during one-legged and two-legged exercise in normal subjects and transfemoral amputees.
Loading
Loading the body with weights increases the rate of energy expenditure depending on the location of the loads. Loads placed peripherally on the foot have a much greater effect than do loads placed over the trunk. 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. On the other hand, a 2-kg load placed on each foot increased the rate of oxygen uptake 30%. This finding is predictible since forward foot acceleration is much greater than trunk acceleration and, therefore, greater effort is required. These findings are of clinical significance for patients requiring lower-limb prostheses and indicate the importance of minimizing weight.
UNILATERAL AMPUTATION
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Human locomotion involves smooth advancement of the body through space. While the goal of walking is progression in the forward direction, limb motion is based on the need to maintain a symmetrical, low-amplitude displacement of the center of gravity of the head, arms, and trunk (HAT) in the vertical and lateral directions. This conserves both kinetic and potential energy and is the principle of biological "conservation of energy." Saunders et al. described six determinants of normal gait that minimize energy expenditure. 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. Therefore, as long as ankle stability is provided, the loss of ankle and foot motion has a small effect on mechanical and physiologic energy expenditure. 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, 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. Since hip motion also plays an important role in minimizing vertical rise and fall of the HAT, the hip disarticulation or transpelvic-level amputation further increases energy cost and reduces speed.
Dysvascular Amputees
Dysvascular amputees walking with a prosthesis also selectively adjust their CWS to keep the 0 2 rate from rising above normal limits. As with traumatic amputees, 0 2 cost progressively increases, and the CWS progressively slows at higher amputation levels. 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. (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.) 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. Most older patients who have transfemoral amputations for vascular disease are not successful long-term prosthetic ambulators. Only a small percentage of these patients are functional ambulators. If able to walk, most have a very slow gait velocity and an elevated In contrast, traumatic transfemoral amputees heart rate if crutch assistance is required. have an adequate gait. It may be concluded that every effort must be made to protect dysvascular limbs early so that transfemoral amputation does not become necessary. If amputation is required, every effort should be made to amputate below the knee.
Bilateral Amputees
Few energy expenditure studies have been performed on bilateral amputees. Interpretation of the data on bilateral traumatic amputees must be made with caution since relatively few subjects have been studied. Table 15-2 summarizes data on both traumatic and vascular patients with bilateral amputation. This limited information indicates that the bilateral amputee expends greater effort than the unilateral amputee does. Of interest, 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
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energy cost than did their vascular transtibial/transtibial counterparts ( Table 15-2.). Gonzales et al. pointed out that in view of the fact that approximately 24% to 35% of diabetic amputees lose the remaining leg within 3 years, it is important to preserve the knee joint even if the stump is short since, should a unilateral transtibial amputee undergo another transtibial amputation, he would still expend 24% less energy than would a patient with a unilateral transfemoral amputation. Bilateral vascular amputees rarely achieve a functional ambulation status if one amputation is at the transfemoral level. Finally, of special interest, Wainapel et al. 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. than with conventional prostheses and crutches. While walking on stubbies is cosmetically unacceptable for most patients (except for gait training or limited walking in the home), the data from this single patient illustrates that it can result in a functional gait. References: 1. Astrand A, Astrand I, Hallback I, et al: Reduction in maximal oxygen uptake with age. J Appl Physiol 1973; 35:649-654. 2. Astrand PO, Rodahl K: Textbook of Work Physiology, ed 2. New York, McGraw-Hill International Book Co, 1977. 3. Astrand PO, Saltin B: Maximal oxygen uptake and heart rate in various types of muscular activity. J Appl Physiol 1961; 16:977-981. 4. Eberhart HD, Elftman H, Inman VT: Locomotor mechanism of amputee, in Klopsteg PE, Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill International Book Co, 1954, pp 472-482. 5. Gonzalez EG, Corcoran PJ, Reyes RL: Energy expenditure in below-knee amputees: Correlation with stump length. Arch Phys Med Rehabil 1974; 55:111-119. 6. James U, Nordgren B: Physical work capacity measured by bike ergometry (one leg) and prosthetic treadmill walking in healthy active unilateral above knee amputees. Scand J Rehabil Med 1973; 5:81-87. 7. Nowrozzi F, Salvanelli ML: Energy expenditure in hip disarticulation and hemipelvectomy amputees. Arch Phys Med Rehabil 1983; 64:300-303. 8. Saunders JB, Inman VT, Eberhart HD: Major determinants in normal and pathological gait. J Bone Joint Surg [Am] 1953; 35:543-558. 9. Steinberg FU, Garcia WJ, Roettger RF, et al: Rehabilitation of the geriatric amputee. J Am Geriatr Soc 1974; 22:62-66. 10. Wainapel SF, March H, Steve L: Stubby prostheses: An alternative to conventional prosthetic devices. Arch Phys Med Rehabil 1985; 66:264-266. 11. Waters RL, Hislop HJ, Perry J, et al: Energetics: Application to the study and management of locomotor disabilities. Orthop Clin North Am 1978; 9:351-377. 12. Waters RL, Lunsford BR, Perry J, et al: Energy-speed relation of walking: Standard tables. J Orthop Res 1988; 6:215-222. 13. Waters RL, Perry J, Antonelli D, et al: The energy cost of walking of amputeesInfluence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46. 14. Waters RL, Perry J, Chambers R: Energy expenditure of amputee gait, in Moore WS, et al (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 250-260.
Chapter 15 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 16A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
LEVEL SELECTION
Prediction of healing is the most important part of level selection. 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. The history, clinical course, and physical examination provide a wealth of information. Hair growth, nail growth, skin turgor and appearance, skin temperature with differences from level to level and from side to side, palpation of pulses, rapidity of onset of the problem, temperature curves, white blood cell response, and response to antibiotic treatment all aid in evaluation of the patient's problem. As a general rule, all length possible should be saved. However, function of midfoot amputations is such that it is wise to shorten long uncovered metatarsals in order to obtain sufficient plantar skin coverage. Split-thickness skin grafts do not do well when applied to weight-bearing surfaces of the foot. With newer techniques of microvascular transfer of innervated flaps, it is possible to salvage a ( Fig 16A-1.). A severe foot that would have required a higher amputation fracture/dislocation with skin, bone, and muscle loss would have required a transtibial amputation ( Fig 16A-2.). Debriding of the wound, external skeletal fixation, latissimus dorsi muscle transfers, and split-thickness skin grafts allowed full salvage and function ( Fig 16A-3. and Fig 16A-4.). Thus, a vascularized and innervated flap has saved a weight-bearing foot in an area where an amputation would have been performed. In grade MB open fractures of the tibia and fibula, there may be a marked loss of soft tissues with a deficiency of tissue A transtibial envelope, necrotic or absent bone, soft-tissue infection, but still a viable foot. amputation is indicated, but will be quite short.
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Length can be preserved through the use of a neurovascular island fillet from the foot, which will then be transferred to the end of the tibia and fibula to provide a transtibial amputation of Thus, saving all tissue possible from the injured foot can result in a more sufficient length. functional amputation. With few exceptions, the most functional residual foot is at the transmetatarsal level or lower. Loss of the toes, either partial or complete, will lead to relatively little disability that usually can be compensated for with simple shoe corrections. Sole stiffeners, rocker bottoms, and toe fillers aid in the restoration of function of short transmetatarsal, Lisfranc, and Chopart levels. Occasionally, a heel cord lengthening is needed to reduce distal pressures. Transfer of the everters and dorsiflexors may aid in balancing the residual foot.
VASCULAR ANALYSIS
Level selection in dysvascular patients has frequently been difficult. Oscillometry, plethysmography, ergo-metry, fluorescein tests, histamine wheal, radionuclide washout, laser Doppler, Doppler ultrasound, angiography, and similar tests have all been described as aids in evaluating the arterial blood flow. However, with all of these tests, clinical judgment still remains the most important part of level selection. In addition to the tests mentioned, an intraoperative test appears to have value in predicting healing. Appearance of bleeding at the skin level after release of the thigh tourniquet has been timed. When the most distal skin bleeds within 3 minutes after release of the tourniquet, there is an 80% to 85% chance for successful healing of the amputation incision. If bleeding is prolonged beyond 3 minutes, the next higher level should be tested. The tourniquet is not used if there has been previous vascular surgical procedures in the limb. Amputation is performed where healing is indicated by vascular analysis, adequate function is predicted, and the experience and skills of the operating surgeon are adequate for the procedure proposed.
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can allow local surgical procedures to be performed, 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. The index is to be measured at the proposed level of surgery. There can be a drop of pressure from the ankle to the midfoot that would be sufficient to preclude healing at the midfoot level. Nutritional status has also been noted to be an important predictor of healing. It must be again emphasized that all factors should be taken into consideration when determining amputation level.
ANESTHESIA
All types of anesthesia may be used. Individual selection is made from preference of the patient, coexisting medical problems, and preferences of the anesthesiologist and surgeon. Intravenous regional anesthesia with a two-level tourniquet is excellent and appears to interfere least with the patient's general condition. A contraindication to the use of the tourniquet would be recent vascular surgery. Regional anesthesia with perineural infiltration of the posterior tibial, superficial peroneal, and sural nerves can be reinforced with small amounts about the peri-incisional areas. 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. Hospital mortality has been less than 1% in the ankle disarticulation and foot amputation levels.
INFECTION
Many traumatic foot wounds and most diabetic ulcers are infected. Cultures and sensi-tivity studies are virtually mandatory in selection of the proper antibiotics. Inclusion of the infectious disease consultant as a member of the team has aided greatly in the care of these difficult patients.
Partial-Toe Amputation
The toes can be excised from the tip to the base through any type of incision, provided that the flaps have an adequate base to support the length. The flaps must close without tension.
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They may be side to side, long dorsal flaps, long plantar flaps, fish mouth flaps, or any combination. With the great toe, it is desirable to keep enough of the base of the proximal phalanx to preserve the attachment of the short flexor and extensor tendons. This has been well borne out in a recent article on great toes amputated for replacement of thumb loss. The mobile pad appears to offer marked protection to the skin under the first metatarsal head ( Fig 16A-7.). In the lesser toes, this does not seem to be as important, except in the fifth toe.
Toe Disarticulation
If sufficient viable skin is not present to allow a partial-toe amputation, a disarticulation at the metatarsophalangeal joint is quite satisfactory. Metatarsal head pressure can become more prominent, and fixation of the long extensor tendon to the dorsal joint capsule aids in elevation of the metatarsal head. A long plantar flap provides more durable skin coverage. Articular cartilage is resistant to infection and need not be arbitrarily removed. Stiffening, thickening and rockering of the shoe aids in restoring function of the great toe.
Transmetatarsal Amputation
This amputation may be performed for deformities resulting from trauma to the toes, loss of tissue, and infection or gangrene due to frostbite, diabetes, arteriosclerosis, scleroderma, McKittrick et al. outlined the indications for rheumatoid arthritis, and similar conditions. transmetatarsal amputation in a diabetic in 1949. Their indications are as true today as they were then. Gangrene must be limited to the toes and should not involve the web space. Infection should be controlled. The incision should not extend through hypoes-thetic areas or through infected areas. The patient should be free of pain. Palpable foot pulses are not necessary, but there should be no dependent rubor. Venous filling should be less than 25 seconds. To these criteria, we have added the transcutaneous Doppler ultrasound ischemic index. Healing has occurred in over 93% of our diabetics when the ratio was over 0.45 and in the nondiabetics when it was over 0.35.
Technique
A slightly curved incision traverses the dorsum of the foot obliquely at the level of the metatarsal necks ( Fig 16A-9.,A). It slants posteriorly to the lateral side approximately 15 degrees so that the residual foot will correspond to the break of the shoe. It continues on either side to half the thickness of the foot. It goes across the plantar surface of the foot just proximal to the base of the toes ( Fig 16A-9.,B). The incision is carried sharply to bone, and the metatarsals are divided at the proximal level of the incision ( Fig 16A-10. ). The periosteum is dissected distally, which then allows easier division of the metatarsal shafts. After division of the bone, the distal part of the foot is raised dorsally and divided from the plantar flap by an oblique incision. To remove pressure points from the plantar surface of the metatarsal shafts, they are beveled or rounded on their inferior edge. Wound irrigation is carried out to remove minor bits of debris from bone division. A Kritter irrigation tube is then introduced into the wound through a separate stab incision ( Fig 16A-11. ). The flap is enclosed with a single layer of nonabsorbable sutures. A light compression dressing is applied.
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The Kritter drain is removed in several days, and a walking cast is applied at 2 weeks. The residual foot heals rapidly, and most patients are able to use an ordinary shoe. On occasion, the lever arm of the distal part of the shoe can raise the pressure at the end of the amputation. In these cases, the sole is thickened, stiffened, and rockered. This will then imitate the action of the roll-off at the metatarsophalangeal joint ( Fig 16A-12. ).
Technique-Lisfranc Amputation
The procedure is demonstrated on a patient with diabetes mellitus who has a deformed infected forefoot. Bed rest and intravenous antibiotics have allowed regression of the surrounding cellulitis ( Fig 16A-15. ). There is still marked drainage from a plantar ulcer. Roentgenograms have shown osteomyelitis of the first, second, and third metatarsal heads. The proximal incision passes over the dorsum of the foot at the base of the metatarsals ( Fig 16A-16. ). 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. ). The tarsometatarsal joints are disarticulated at the first, second, and third metatarsal bases. The fourth and fifth metatarsal bases are cut through with a motorized saw and left in the residual foot. On occasion, 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. and Fig 16A-19. ). The residual foot is then dissected from the plantar surface, starting at the level of the short flexor muscles. The flap is then beveled to the distal edge. The wound is then checked for any residual infectious tissues. It is tailored to close without tension ( Fig 16A20. ). A Kritter tube is used to irrigate the wound postoperatively for 24 to 72 hours, depending upon the degree of preoperative infection ( Fig 16A-21. ). A light compression dressing is applied. Cultures have been taken during the procedure and aid in the postoperative antibiotic treatment. After removal of the Kritter tube, the patient is placed into a nonwalking cast. If healing is sufficient at 2 weeks, the patient is then allowed to ambulate in a cast. This is continued until healing is secure and the patient begins shoe trials.
Postoperative Function
The residual foot is shorter than that of a transmeta-tarsal amputation ( Fig 16A-22. ). Occasionally, an ankle-foot orthosis is required (see Fig 16A-14. ).
Chopart Amputation-Technique
Ablation of the forefoot at the talonavicular and calcaneocuboid joints closely parallels that of amputation at the tarsometatarsal joints. The plantar flap is long enough to fold up to the dorsum of the foot. In infected cases, no bone trimming is performed. In noninfected cases, the distal surfaces of the calcaneus are rounded to relieve potential pressure points. A
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percutaneous lengthening of the Achilles tendon is performed through three stab incisions: two medially and one laterally. The anterior tendons are sewn into the wound to aid in dorsiflexion.
Postoperative Function
A prosthetic device is necessary to allow standard shoe wear. If distal pressure ulcers arise despite rocker-ing of the shoe, it may be necessary to revise the residual stump by transferring the anterior tibial tendon into the center of the neck of the talus. Additional rounding of the calcaneus may be necessary, as well as further lengthening of the Achilles tendon.
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Med J 1989; 82: 1138-1142. 21. Holloway GA, Watkins DW: Laser Doppler measurements of cutaneous blood flow. J Invest Dermatol 1977; 69:306. 22. Holstein P: The distal blood pressure predicts healing of amputations on the feet. Acta Orthop Scand 1984; 55:227-233. 23. Hulnik A, Highsmith C, Boutin FJ: Amputations for failure in reconstructive surgery. J Bone Joint Surg [Am] 1949; 31:639. 24. Kahn O, Wagner FW Jr, Bessman AN: Mortality of diabetic patients treated surgically for lower limb infections and/or gangrene. Diabetes 1974; 23:287. 25. Karanfilian RG, Lynch TG, Zirul VT, 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. J Vase Surg 1986; 4:511516. 26. Katsanoris A, Brewster DC, Megerman J, et al: Transcutaneous oxygen tension and selection of amputation level. Am J Surg 1984; 147:510. 27. Kazamas TN, Gandor MP, Franklin DL: Blood pressure measurements with Doppler ultrasound flow meter. J Appl Physiol 1971; 30:585. 28. Kirkendahl WM, Burton AC, Epstein PH, et al: Recommendations for human blood pressure determination by sphygmomanometers. Circulation 1967; 36:908. 29. Kostuik JP, Wood D, Hornby R, et al: The measurement of skin blood flow and peripheral vascular disease by epi-cutaneous application of xenon-133. J Bone Joint Surg [Am] 1976; 58:833. 30. Kritter AE: A technique for salvage of the infected diabetic gangrenous foot. Orthop Clin North Am 1973; 4:21. 31. Kutz JE, Jupiter JE, Tsai T-M: Lower limb replantation: A report of nine cases. Foot Ankle 1983; 3:197-202. 32. Liny RS, Burkus JK: Long-term follow-up of Syme amputations for peripheral vascular disease. Foot Ankle 1988; 9:107-110. 33. Larsson U, Andersson GR: Partial amputation of the foot for diabetic arteriosclerotic gangrene-Results and factors of prognostic value. J Bone Joint Surg [Br] 1978; 60:126. 34. Letts M, Pyper A: The modified Chopart's amputation. Clin Orthop 1990; 256:44-49. 35. Levin ME: Medical evaluation and treatment, in Levin ME, O'Neil LW (eds): Diabetic Foot, ed 3. St Louis, Mosby-Year Book, 1983, pp 1-60. 36. LoGerfo FW, Carson JD, Mannick JA: Improved results with femoral-popliteal vein grafts for limb salvage. Arch Surg 1977; 112:567. 37. Malone JM, Anderson GG, Laoka SG, et al: Prospective comparison of non-invasive techniques for amputation level selection. Am J Surg 1987; 154:179-184. 38. Mann RA, Poppen NK, O'Kouskim M: Amputation of the great toe: A clinical and biomechanical study. Clin Orthop 226:192-204. 39. McIntyre KE, Bailey SA, Malone JM, et al: Guillotine amputation, the treatment of nonsalvagable lower extremity infections. Arch Surg 1984; 119:450-453. 40. McKittrick LS, McKittrick JB, Risley TS: Transmetatarsal amputation for infection and gangrene in patients with diabetes mellitus. Ann Surg 1949; 130:826. 41. Mehta K, Hobson RW, Jamil Z, et al: Fallability of Dop-pler ankle pressure in predicting healing of transmetatarsal amputation. J Surg Res 1980; 28:466-470. 42. Millstein SG, McCowen SA, Hunter GA: Traumatic partial foot amputation in adults. J Bone Joint Surg [Br] 1988; 70:251. 43. Mooney V, Wagner FW Jr: Neurocirculatory disorders of the foot. Clin Orthop 1977; 122:53. 44. Moore WS: Determination of amputation level measurement of skin blood flow with xenon-133. Arch Surg 1973; 107:798. 45. Most RS, Sinnock T: Epidemiology of lower extremity amputations of diabetic individuals. Diabetes Care 1983; 6:87-91. 46. Nakhgevany KB, Rhodes GE Jr: Ankle level amputation. Surgery 1984; 95:549-552. 47. Pinzur MS: Ray resection in the dysvascular foot. Clin Orthop 1984; 191:232. 48. Roach JJ, Deutsch A, McFarland DS: Resurrection of the amputations of Lisfranc and Chopart for diabetic gangrene. Arch Surg 1987; 122:931-934. 49. Romano RL, Burgess EM: Level selection in lower extremity amputations. Clin Orthop 1971; 74:177. 50. Ruben RR, Pitluk SC, Graham LM: Do operative results justify tibial artery reconstruction in the presence of pedal sepsis. Am J Surg 1988; 156:144-147. 51. Sanders WE: Amputation after tibial fracture: Preservation of length by use of a neurovascular island (fillet) flap of the foot. J Bone Joint Surg [Am] 1989; 71:435. 52. Scher KS, Steele FJ: Aseptic foot in patients with diabetes. Surgery 1988; 104:661. 53. Shah DM, Corson JD, Karmody AM, et al: Optimal management of tibial arterial
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trauma. J Trauma 1988; 28:228-234. 54. Volpicelli LJ, Chambers RB, Wagner FW: Ambulation levels of bilateral lower extremity amputees. J Bone Joint Surg [Am] 1983; 65:599-604. 55. Wagner FW Jr: A classification and treatment program for diabetic neuropathic and dysvascular foot problems. Instr Course Lect 1979; 28:143. 56. Wagner FW Jr: Amputations of the foot and ankle. Clin Orthop 1977; 122:62. 57. Wagner FW Jr: Orthopedic rehabilitation of dysvascular lower limbs. Orthop Clin North Am 1978; 9:325. 58. Wagner FW Jr: The dysvascular foot-A system for diagnosis and treatment. Foot Ankle 1981; 2:64. 59. Wagner FW Jr: The use of transcutaneous Doppler ultrasound in prediction of healing potential and selection of surgical level in dysvascular lower limbs. West J Med 1979; 130:59. 60. Welch GH, Lebermen DP, Polluck JG, et al: Failure of Doppler ankle pressure to predict healing of conservative forefoot amputations. Br J Surg 1985; 72:888. 61. Wheat LJ, Allen SD, Henry M, et al: Diabetic foot infections, bacteriologic analysis. Arch Intern Med 1986; 146:1935. 62. Wyss CR, Harrington RM, Burgess EM, et al: Transcutaneous oxygen tension as a predictor of success after an amputation. J Bone Joint Surg [Am] 1988; 70:203.
Chapter 16A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 16B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
Load-Bearing Structure
The foot is the means whereby the ground reaction forces generated during physical activities are transmitted to the body structure. During normal level walking these loads are directed initially onto the heel. 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. Once the foot is flat and until the heel leaves the ground as push-off is initiated, the supporting forces are shared between the heel and the ball of the foot, with only a small contribution from the lateral aspect of the midfoot. This method of load transmission is commonly attributed to the "arch structure" of the foot, even though it is now clearly understood that its effectiveness is a function of a number of both structural and neuromuscular mechanisms. Once the heel leaves the ground, 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. As body weight is transferred to the contralateral limb, this load falls and localizes on the plantar surface of the hallux.
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Joint Function
The functions of the joints of the foot have been the subject of endless investigation. 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. 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, which is initiated during the swing phase, continues after heel contact until the foot is flat. During this phase the foot pronates about the subtalar joint axis, thereby maintaining the normal toe-out position of the foot. Elevation of the lateral margin of the foot, which is a consequence of this movement, is counteracted by supination of the forefoot through a combined motion of the rays, thus ensuring that ground contact is achieved across the entire forefoot. After the foot is flat as the lower limb commences external rotation, the foot supi-nates about the subtalar joint axis to absorb this motion, thus avoiding slippage occurring between foot and ground. The associated depression of the
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lateral margin of the foot is in this instance counteracted by pronation of the forefoot, once again enabling the maintenance of full forefoot loading. After the heel leaves the ground, external rotation of the limb continues; however, the subtalar joint now reverses its direction of motion to pronate in conjunction with the forefoot, hence transferring the area of support medially onto the first metatarsal head and finally the hallux as the foot loses contact with the ground. A final word should be reserved for the role of the midtarsal joint. During the initial loading phase this joint acts in concert with the subtalar joint. Once subtalar supination commences, however, this joint locks and, 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.
RAY AMPUTATIONS
The biomechanical consequences of ray amputations will be largely dependent on the position and extent of the forefoot segments removed. In the case of diabetic patients, the resulting reduction in the area of the plantar surface available to transfer the forces encountered during physical activity may be significant. In those instances where the first or the fifth rays have been removed (with or without the intermediate rays), this effect will be aggravated by mediolateral instability and may result in more serious pressure problems, particularly during push-off ( Fig 16B-8.). 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. Custom insoles fabricated from pressure-
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sensitive materials may be used to distribute pressure evenly over the remainder of the foot. These insoles have a limited life expectancy since they are designed to gradually deform, thereby protecting the foot from excess pressures. Laminated foam insoles may be used to increase longevity. Generally a softer, more conforming foam is used against the skin, while a more durable, stiffer foam that will retain its shape longer is used for the base. One of the principal problems encountered by the patient with a ray amputation is shoe fit. 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., Fig 16B-10. , Fig 16B-11. to 16B-11).
TRANSMETATARSAL AMPUTATION
All those considerations referred to in connection with amputation of the toes also apply to the treatment of trans metatarsal amputations; however, the more significant loss of the loadbearing surface under the metatarsal heads that is experienced by these patients must also be addressed, most commonly by utilizing a shoe insert molded accurately under the remaining area of the longitudinal arch (see Fig 16B-5.). Since the subtalar joint remains free to function normally, this group of patients will experience some functional impairment due to the loss of normal forefoot mobility. Some flexibility in the construction of the forefoot filler to permit supination or pronation would be an advantage; however, this may be incompatible with the stiffening required to prevent shoe hyperex-tension during normal push-off (Life-Like Laboratory) ( Fig 16B-12. ).
Above-Ankle Designs
Early prosthetic designs took a form similar to an ankle disarticulation (Syme) prosthesis; however, as has previously been mentioned, these have been found to be bulky and heavy (see Fig 16B-2.). Alternative ankle-foot orthotic designs manufactured from thermoplastic materials are both lighter and more cosmetic; however, 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.). All above-ankle systems will inevitable restrict subtalar joint motion, thereby eliminating the normal mechanism for absorbing the longitudinal rotations of the limb. If slippage between the foot and the ground is to be avoided, the patient must adopt a modified pattern of hip motion.
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Patients wearing above-ankle devices will have the further disadvantage of a reduced range of ankle motion. Since the extent of the residuum precludes the use of a normal prosthetic ankle mechanism, these patients will be required to adopt compensatory hip and knee joint movements to cope with this restriction. This problem may be best addressed by the use of a rocker sole and cushion heel adaptation to the amputee's shoe.
Below-Ankle Designs
There appear to be four basic types of construction currently in use: 1. 2. 3. 4. Rigid Semirigid Semiflexible Flexible
All of these systems are laminated or thermoformed about a positive model of the remaining foot. These models are carefully modified to decrease pressure where required and increase pressure where tolerated. 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. These liners may be of varying thickness and stiffness, depending on skin tolerance. They are also prone to deterioration and will require replacement in time due to decreasing thickness and softness of the material. The profile of the foot is restored by a soft or rigid buildup added to the socket. Rigid and semirigid partial-foot prostheses will generally require cushion heel and rocker sole modifications to the patient's shoes. The use of rigid and semirigid prostheses is today less common due to the availability of improved semiflexible and flexible designs. Semiflexible designs utilize a combination of materials generally having urethane elastomer or a silicone base. These systems are fabricated over an exact model of the patients remaining foot. Care is taken to ensure a tolerable distribution of pressure. Reliefs are made for bone prominences, callosities, or sensitive areas. Material may be removed proximal to the calcaneus to improve the suspension of the prosthesis. A toe filler is attached to the socket either during the foaming processing or by gluing in place later. These fillers may simply fill the shoe shape or be carved to simulate the contours of an actual foot and toes. Color is added during the foaming process or may be painted on to match skin tones at the time of fitting. Modification of the socket to relieve excessive pressure is generally achieved by modification to the outside surface of the shell, thereby maintaining the smooth integrity of the socket inner surface. By reducing the socket thickness over the high-pressure area increased flexibility is achieved. The proximal edge of the socket opening is also thinned to avoid edge pressures. Some examples of semiflexible prostheses include the following:
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copolymer socket is inserted into a ure-thane elastomer (Lynadure, Medical Center Prostheses, Houston) cosmetic boot and is removable for adjustments. The finished prosthesis extends just above the ankle and is retained by lace-up closures anteriorly.
SUMMARY
A comfortable socket and a balanced foot are the twin objectives of all partial-foot prostheses. The choice of design to be employed will depend on the level of amputation, the condition of the remaining soft tissues, and the status of the ankle. The use of above-ankle designs should be limited to patients who require assisted ankle function, who experience difficulties with suspension, or who cannot tolerate full plantar weight bearing. 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. References: 1. Childs C, Staats T: The slipper type partial foot prosthesis, in Advanced Below Knee Prosthetic Seminar. Los Angeles, UCLA Prosthetic and Orthotic Education Program, Fabrication Manual, 1983. 2. Collins SN: A partial foot prosthesis for the transmetatar-sal level. Clin Prosthet Orthot 1977; 12:19-23. 3. Condie D, Stills M: Biomechanics and prosthetic/orthotic solutions-Partial foot amputations, in Amputation Surgery & Lower Limb Prosthetics. Boston, Blackwell Scientific Publications Inc, 1988. 4. Fillauer K: A prosthesis for foot amputation near the tarsal-metatarsal junction. Orthot Prosthet 1976; 30:9-11. 5. Hayhurst DJ: Prosthetic management of partial foot amputee. Inter-Clin Info Bull 1978;
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17:11-15. 6. Imler CD: Imler partial foot prosthesis I.P.F.P.-"Chicago Boot." Clin Prosthet Orthot 1987; 12:24-28. 7. Lunsford T: Partial foot amputations-Prosthetic and orthotic management, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981, pp 322-325. 8. RECAL Literature Search, University of Strathclyde, National Centre for Training and Eduation in Prosthetics and Orthotics, Curran Bldg, 131 St. James Rd, Glasgow, 640LS Scotland. 9. Stills ML: Partial foot prostheses/orthoses. Clin Prosthet Orthot 1987; 12:14-18. 10. Wilson MT: Clinical application of RTV elastomers. Orthot Prosthet 1979; 33:23-29.
Chapter 16B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 17A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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INDICATIONS
The classic one-stage disarticulation is indicated in all circumstances when this level is the most distal effective amputation that will heal primarily. It is not indicated with local infection or with inadequate circulation, as indicated by skin perfusion tests, volume plethysmography, or the ischemic index as measured by Doppler ultrasound. For infection of the forefoot, the two-stage method is preferred. Trauma about the foot, congenital anomalies, tumors, and acquired deformities that are not suitable for procedures at the trans-metatarsal, Lisfranc, or Since the modern Syme prostheses are Chopart levels are best treated at the Syme level. relatively light, comfortable, durable, and cosmetically acceptable, 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, near-normal gait is possible. In recent years, the Syme level has gained popularity and is assuming a justifiably important place in amputation through the lower limb. Even in elderly diabetic patients, 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.
SURGICAL TECHNIQUE
The incision ( Fig 17A-1.) begins at the tips of the malleoli, goes up across the ankle joint, and then proceeds straight down across the sole. The anterior tendons are pulled down, divided, and allowed to retract. Arteries are transfixed and large veins ligated. Smaller vessels are electrocoagulated. Nerves are pulled down gently, divided, and allowed to retract. 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. Syme, himself, 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. Dissection of the os calcis is started subperiosteal on the dorsal and lateral surfaces ( Fig 17A-3.). This allows gradual exposure of the flexor hallucis longus tendon, which is just lateral to the artery and nerves and aids in their protection. Subperiosteal dissection is continued medially to push the vital structures away from the body of the os calcis. Division of the Achilles tendon must be done carefully so that the posterior skin is not buttonholed. Continued stripping of the os calcis distally completes the removal of the foot. The tourniquet is released and hemostasis secured. Medial and lateral tendons are pulled down, divided, and allowed to retract. Opinion is divided as to the need to remove the plantar muscles. In this series, they have not been removed and are left in place. The only further dissection is for tissues that appear nonviable. The malleoli and approximately 1 cm of the anteroposterior aspect of the tibia are exposed subperi-osteally. The tibia and fibula are transected at right angles to the long axis of the weight-bearing line ( Fig 17A-4.). This provides a weight-bearing surface that is parallel to the floor. To obtain the broadest surface, the osteotomy is made so that the dome of the plafond is left with approximately 1.5 cm of cartilage. The greatest portion of the subchondral bone provides excellent weight transmission. The heel flap is now folded up into place for measurements, and the bones are palpated through the soft tissue. Any possible pressure points are smoothed with rongeurs and rasp. If the flap is too large, a full-thickness segment is removed from the distal edge. On rare occasions, bone must be removed to allow closure without tension. No attempts should be made to trim the dog-ears since the vascular supply to the flaps might be endangered. The dog-ears gradually regress and smooth down with casting and then with use of the prosthesis. Migration of an imperfectly anchored flap has been reported in some series. Various methods have been devised for fixation such as skewering the flap with a Steinmann pin in the distal part of the tibia, adhesive taping, and immediate casting. We recommend suturing the flap to the tibia and fibula through drill holes ( Fig 17A-5. and Fig 17A-6.). Inclusion of the plantar aponeurosis and the deep fascia in the tissues sutured provides excellent fixation. Subcutaneous tissue is closed with a few absorbable sutures. The skin is closed with nylon, polyethylene, polypropylene, wire, or similar nonabsorbable sutures ( Fig 17A-7.). A moderate dead space is created and should usually be drained. Postsurgical hematoma is diluted and evacuated through a two-lumen tube (modified Shirley drain or modified Foley catheter) for 24 to 48 hours. Lactated Ringer's, Hart-man's or similar physiologic solution is used. Surgical dressings may be soft or rigid. We have found no advantage to immediate ambulation and have allowed 7 to 10 days' healing before applying a weight-bearing plaster.
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Present Indications
The Syme ankle disarticulation performed in two stages is indicated in patients who have gangrene or infection of the forefoot, are not suitable for a transmeta-tarsal amputation, and have not responded to medical treatment or distal surgical care. The ischemic index should be 0.45 or higher in the diabetic and 0.35 in others. The patient should be a prosthetic candidate. The heel pad should be intact, and there should be no gross pus at the amputation site.
First-Stage Technique
To allow slightly longer skin flaps to cover the malleoli, the incisions are started 1 to 1.5 cm distal and 1 to 1.5 cm anterior to the tips of the malleoli ( Fig 17A-8.,A. The inferior incision courses directly down and across the sole and cuts all layers to the bone. The superior incision goes obliquely across the ankle joint. No tissue planes are dissected. The tendons are pulled down, cut off, and allowed to retract. The dorsalis pedis artery is ligated with a transfixing suture. The joint is entered across the dorsum of the talar neck. The medial and lateral collateral ligaments are divided, ultimately allowing the talus to be dislocated ( Fig 17A8.,B). 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.). Subperiosteal dissection is started on the superolateral surfaces of the os calcis. 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. ). Direct vision of the neurovascular bundle allows transection distal to the division into the medial and lateral plantar branches. Continued dissection distally allows medial retraction of the bundle and medial dissection of the os calcis. Care must be taken with the division of the Achilles tendon at its attachment to the os calcis, where it is virtually subcutaneous ( Fig 17A-11. ). Penetration of the skin has led to failure of the amputation even though the laceration was repaired. Division of the plantar aponeurosis and subperiosteal dissection of the os calcis medially complete the excision of the forefoot. The tourniquet is released at this point, and timing is started. Larger arterial bleeders are transfixed. Larger veins are ligated. Smaller vessels are coagulated. Bleeding is then assessed. If the most distal skin has not bled within 3 minutes, serious consideration should be given to going to the next higher level. If there is no bleeding in the flap distally at 5 minutes, then the Syme procedure should be abandoned and the amputation carried out at the transtibial level. A Shirley drain or Foley catheter is modified for irrigation and gravity drainage. Either the Shirley air filter or the Foley balloon tip is removed, and an intravenous tubing set is attached. The tip of the drainage tube is cut on a bevel. 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. The tube is then drawn into the cavity ( Fig 17A-12. ). Irrigation is started with 1 L of Ringer's lactate solution with 80 mg of gentamicin or similar aminoglycoside. Care must be taken not to exceed safe limits for ototoxicity and
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nephrotoxicity in these compromised patients. Irrigation is continued at approximately 1 L every 24 hours and is continued until the effluent is clear.
Closure
The heel pad is tested by folding it against the malleoli and plafond. If it is excessive in length, the skin and tissue should be removed until it closes with little or no tension. On occasion, the pad may shift medially or laterally due to a fascial band pressing one or the other of the malleoli. Division of the band and incision of the fat pad to provide a "nest" for the malleoli will hold the pad centered. 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. A few subcutaneous sutures will level the skin edges. The skin is closed with nonabsorbable sutures or skin clips ( Fig 17A-13. ). A compression dressing of fluffs is contoured over the stump and wrapped in place with a bias-cut stockinette. Care must be taken not to fold the dog-ears upon themselves because circulation may be compromised. Drainage is through gravity to a collecting bag, similar to a urine bag. Every 2 to 3 hours, the exit tube is clamped for 5 minutes to distend the cavity with irrigating fluid. Irrigation is continued for 48 to 72 hours, depending upon the degree of preoperative infection. The postoperative clinical course is also watched, and if there is fever or sign of local infection, the irrigation is continued. On occasion, this system has been left in place for 7 to 14 days. On removal, the tip is cut off aseptically and sent for culture and sensitivity studies. Systemic antibiotics are continued according to preoperative cultures for 1 week, unless the clinical course or late culture shows the presence of bacteria. Upon removal of the tubing, the stump is wrapped in plaster. Care must be taken not to fold the dog-ears and create pressure areas. Two pieces of felt with holes protect the dog-ears. When the patient is clinically stable, crutch ambulation is allowed. Weight bearing is begun for those who have a firm heel pad, good skin turgor, and no sign of residual infection. Approximately 50% of the patients are weight bearing after the first stage while awaiting the second stage.
Second Stage
Healing is usually secure enough at 6 weeks to perform the definitive amputation. Occasionally, a week or more in a walking cast is needed. An occasional patient will be infected at the suture line and will require debridement along the suture line. Occasionally, there will be deeper involvement, and the malleoli must be removed to allow closure over a further irrigation system. In the very low percentage of patients who do not heal after the first stage, a transtibial amputation is performed.
Postoperative Care
On discharge from the hospital, the patients are usually independent in walking casts. They are observed in the outpatient clinic, and casts are changed at 2-week intervals. The warning
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is given to stop weight bearing and to return immediately if any pistoning should occur due to stump shrinkage. At about 8 weeks, the stump has matured, and the first prosthesis is fabricated. The plaster cast has been an invaluable aide inasmuch as it mobilizes the patient, aides in the muscular venous pump action of the leg, protects the healing wound, and controls and maintains apposition of the heel pad. The Gait Laboratory, under the direction of Dr. Jac-quelin Perry, has performed function tests that show the Syme amputee to have greater stride length, faster cadence ( Fig 17A-19. ), greater velocity, and less oxygen consumption per meter traveled ( Fig 17A-20. ) than patients with more proximal amputations.
CONCLUSIONS
The Syme ankle disarticulation provides a long-lasting, durable residual limb, even in diabetic patients. The classic procedure, as described by Harris, remains the preferred procedure in cases without infection or dysvascular problems. 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. The two-stage technique has proved successful in patients with forefoot infections that preclude distal partial-foot procedures. The Syme ankle disarticulation is actually a partial-foot ablation because of retention of the heel with its excellent weight-bearing characteristics. Function at the Syme level is superior to any other major amputation in the lower limb. References: 1. Alldredge RH, Thompson TC: The technique of the Syme amputation. J Bone Joint Surg 1946; 28:415. 2. Baker GCW, Stableforth PG: Syme's amputation. A review of sixty-seven cases. J Bone Joint Surg [Br] 1969; 51:482. 3. Catterall RCF: Syme's amputation by Joseph Lister after sixty-six years. J Bone Joint Surg [Br] 1967; 49:144. 4. Dale GM: Syme's amputation for gangrene from peripheral vascular disease. Artif Limbs 1961; 6:44. 5. Francis H III, Roberts JR, Clagett PL, et al: Syme amputation: Success in elderly diabetic patients with palpable ankle pulses. J Vase Surg 1990; 12:237. 6. Harris RI: Syme's amputation. J Bone Joint Surg [Br] 1956; 38:614. 7. Harris RI: The history and development of Syme's amputations. Artif Limbs 1961; 6:4. 8. Jamy RS, Berkus JK: Long-term follow-up of Syme amputations for peripheral vascular disease associated with diabetes mellitus. Foot Ankle 1988; 9:107. 9. Lindqvist C, Riska EB: Chopart, Pirogoff and Syme amputations. A survey of twentyone cases. Acta Orthop Scand 1966; 37:110. 10. Mazet RR: Syme's amputation. J Bone Joint Surg [Am] 1968; 50:1549. 11. McElwain JP, Hunter GA, English E: Syme's amputation in adults, a long term review. Can J Surg 1985; 28:203. 12. McKeever FM: A discussion of controversial points- Amputation surgery. Surg Gynecol Obstet 1946; 82:495. 13. Nakhgevany KB, Rhoads JE Jr: Ankle level amputation. Surgery 1984; 95:549. 14. Ratliff AHC: Syme's amputation: Results after forty-four years, report of a case. J Bone Joint Surg [Br] 1967; 49:142. 15. Rosenman LD: Syme amputation for ischemic disease in the foot. Am J Surg 1969; 118:194. 16. Sarmiento A, Warren WB: Reevaluation of lower extremity amputations. Surg Gynecol Obstet 1969; 129:799. 17. Shelswell JH: Syme's amputation. Lancet 1954; 2:1296. 18. Spittler AW, Brennan JJ, Payne JW: Syme amputation performed in two stages. J Bone Joint Surg [Am] 1954; 36:37. 19. Srinivasan J: Syme's amputation in insensitive feet. J Bone Joint Surg [Am] 1973; 55:568. 20. Stuyck J, Vandenberk P, Reynders P: Syme's amputation. Acta Orthop Belg 1990; 56:535. 21. Thomsen S, Jakobsen BW, Wethelund JO, et al: Antibiotic prophylaxis in lower
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extremity amputations due to ischemia. Arch Orthop Trauma Surg 1990; 109:72. 22. Syme J: Amputation at the ankle joint. Lond Edinburg Monthly J Med Sci 1843; 2:93. 23. Wagner FW Jr: A classification and treatment program for diabetic, neuropathic and dysvascular foot problems. Instr Course Lect 1979; 28:143. 24. Wagner FW Jr: Amputations of the foot and ankle. Clin Orthop 1977; 122:62. 25. Wagner FW Jr: The diabetic foot and amputations of the foot, in Mann RA (ed): Surgery of the Foot, ed 5. St Louis, Mosby-Year Book, 1986, p 421. 26. Wagner FW Jr: The dysvascular foot, a system for diagnosis and treatment. Foot Ankle 1981; 2:64. 27. Wagner FW Jr, Buggs H: Use of Doppler ultrasound in determining healing levels in diabetic dysvascular lower extremity problems, in Bergen JG, Yaojst (eds): Gangrene in Severe Ischemia of the Lower Extremities. New York, Grune & Stratton, 1978, p 131. 28. Warren R, Thayer TR, Achenbach H, et al: The Syme amputation in peripheral arterial disease. A report of six cases. Surgery 1955; 37:156. 29. Waters RL, Perry J, Antonelli D, et al: Energy costs of walking of amputees: The influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42.
Chapter 17A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 17B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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, multiple problems still exist in the design of the "ideal" prosthesis. Reports in the literature of "new prosthetic approaches" attest to the fact that the final perfect prosthesis has not yet been designed. In addition to producing the artificial limb, the pros-thetist may aid in postoperative management by applying walking casts. These protect the tissues during the healing phase and hasten contouring of the stump (see Fig l7A-18).
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and have been largely abandoned. As a result, almost all contemporary Syme prostheses utilize a nonarticu-lated foot. For many years, a modified solid-ankle, cushion-heel (SACH) foot was the only available Although clinically successful, the rigidity of the wooden keel added significant option. stresses to the prosthesis and was not suitable for some vigorous activities, 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. In an effort to overcome these shortcomings, several more flexible foot options are now available. 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. It has a flexible anterior keel that allows an easier rollover and reduces the ground reaction forces on both prosthesis and More recently, several dynamic-response feet have become available in a residual limb. low-profile style suitable for the Syme amputee. 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. Flex-Foot and the similar Springlite design are also available for the Syme level. Both designs utilize a carbon composite spring heel and keel to simulate ankle motion. The Quantum foot from England provides similar function by using fiberglass-reinforced spring keels/ heels and has also been adapted for Syme prostheses. Patient acceptance of these newer alternatives has been favorable thus far, but reliability and specific indications have yet to be determined.
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Cosmesis
Plastic laminates provide a thinner wall. Air-cushion types that require no window and doublewalled types with an inner elastic panel are less unsightly because they require no straps, buckles, or other outside paraphernalia for closure. However, they are thicker just above the ankle ( Fig 17B-3.,C and Fig 17B-4.,C).
PROSTHETIC CONSIDERATIONS
Indications for each of the described types of prostheses will depend primarily on the physical characteristics of the residual limb. Most patients can be fitted with a closed double-wall prosthesis with attached flexible inner walls fabricated with expandable material. The closed rigid shell with a flexible removable inner socket may allow even earlier donning of the limb without undue difficulty. The closed prosthesis presents a much neater appearance and is particularly desirable for women. When the amputation stump has a bulbous and irregular distal end, often seen in older amputees and after trauma, it may be necessary to fabricate one or more windows in the
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prosthetic shell to allow the terminal tissues to slide past the smaller and narrower proximal area. The prosthetist may need to innovate and deviate from standard designs in certain unusual circumstances. Almost without exception, all prostheses will be fitted with the SACH foot described earlier. Surgeons performing the Syme ankle disarticulation can often simplify prosthetic considerations by careful attention to bone contour and heel pad positioning. Improvements in design and materials have allowed amputees using old-style prostheses to convert successfully to using the modern limbs now available.
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. Virtually no training is required during the cast period except for occasional use of crutches or a pickup walker at the outset. After delivery of the prosthesis, instructions are given for donning and doffing. In addition, the patient is taught stump hygiene, use of prosthetic stockings, and daily maintenance of the prosthesis. Most patients state that it will take a day or two to get used to the limb.
SUMMARY
Modern plastic materials and construction techniques permit manufacture of Syme prostheses that are improved in appearance and durability, lighter in weight, free from malfunction of mechanical components, and simpler and less costly to manufacture. References: 1. Foort J: The Canadian type Syme prosthesis. Lower extremity amputee research project, series 11, issue 30. Berkeley, Calif, University of California, Institute of Engineering Research, 1956. 2. Gordon EJ, Ardizzone J: SACH foot prosthesis. JBone Joint Surg [Am] 1960; 42:226. 3. Marx HW: An innovation in Syme's prosthetics. Orthot Prosthet 1969; 23:131. 4. Mazet R Jr: Syme's amputation. JBone Joint Surg [Am] 1968; 50:1549. 5. Michael JW: Component selection criteria: Lower limb disarticulations. Clin Prosthet Orthot 1988; 12:99-108. 6. Murdoch G: Syme's amputation. J R Coll Surg Edinb 1975; 21:15. 7. Radcliffe CW: The biomechanics of the Syme prosthesis. Artif Limbs 1961; 6:76. 8. Romano RL, Zettl JH, Burgess EM: The Syme's amputation: A new prosthetic approach. Inter-Clin Info Bull 1972; 11:1. 9. Sarmiento A, Gilmer RE Jr, Finnieston A: A new surgical-prosthetic approach to the Syme's amputation. A preliminary report. Artif Limbs 1966; 10:52. 10. Warner R, Daniel R, Leswing AL: Another new prosthetic approach for the Syme's amputation. Inter-Clin Info Bull 1972; 12:7. 11. Wilson AB: Prostheses for Syme's amputation. Artif Limbs 1961; 6:52.
Chapter 17B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library
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Chapter 18A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library
loss is 10% per year. With sufficient longevity, therefore, transtibial amputees often face the prospect of opposite lower-limb loss. The chances of ambulation as a bilateral transtibial amputee therefore become a major concern. Pooled data on 137 patients showed that 77% of bilateral transtibial amputees were able to attain functional ambulation. In summary, the importance of preserving the knee joint cannot be overemphasized. It allows younger patients to continue a vigorous life-style and elderly patients the opportunity to walk as opposed to wheelchair confinement. In view of the high risk of later contralateral amputation, every effort should be made to preserve at least a transtibial level at the first amputation.
CAUSAL CONDITIONS
With aging of the general population, trauma has been replaced by peripheral vascular disease as a leading cause of lower-limb amputation. Smoking appears to be related to this increase. In a review of 51 male lower-limb amputees in the United Kingdom, Stewart found a significantly higher incidence of smokers as compared with the general population (82.4% vs. 55%). Another series reported that 58% of 110 transtibial amputees were smokers. The precipitating cause of amputation may be gangrene, infection, or intractable claudication. In diabetes mellitus, the vast majority of amputations are related to various types of foot injury secondary to peripheral sensory neuropathy, with often minor foot damage providing a portal for infection. Infection in diabetics may be difficult to combat at the tissue level due to decreased leukocyte activity in the hyperglycemic state. Patients often continue to walk on infected feet due to a loss of deep pain sense, thereby rapidly spreading the infection along tissue planes. Neuropathic arthropathy, which can be initiated by presumably minor trauma, may also lead to amputation if the foot and ankle skeletal structure becomes severely damaged ( Fig 18A-1.,A and B). Although diabetics often develop atheromatous disease at an earlier age than the general population does, it may be difficult to distinguish the relative importance, in causation of gangrenous changes, of atheromatous changes seen in larger vessels and more peripheral small-vessel disease. Although the population of diabetics appears to be growing, it is conjectural whether this is due to earlier detection, increased longevity related to better treatment, or other factors. It is certain, however, that an increasing percentage of lower-limb amputations is being done in diabetics. For example, a 1956 study showed diabetes as a factor in only 16% of cases. In contrast, combined data from 17 studies published between 1961 and 1988 showed that an average of 52% of patients (range, 30% to 75%) had diabetes mellitus as the primary or secondary causal factor in amputation. In Hansen's disease, infection of peripheral nerves with Mycobacterium leprae will cause foot insensitivity. Progressive loss of bone and soft tissues, aggravated by intractable deep infection following skin ulceration, may require transtibial amputation ( Fig 18A-2.). Severe tissue destruction from fungal infection may occur in the presence of normal sensation, as in mycetoma or "Madura foot" ( Fig 18A-3.).
INDICATIONS
In general, transtibial amputation is indicated when the process requiring ablation cannot be effectively eliminated by lesser procedures. In cases of severe foot infection, usually related to diabetes mellitus, 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). In peripheral vascular disease with distal gangrene, this level is suitable if there is sufficient vascularity present at the level selected. In cases of trauma to the foot and leg, 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). In addition, if there has been warm ischemia of the leg and foot for more than 6 hours following severe vascular injury to the lower limb, a primary amputation should be consid-ered. When reconstruction after trauma has resulted in an unsatisfactory limb due to deformity, pain, nonunion, or persistent infection, transtibial amputation will provide a good solution ( Fig 18A-4.). This should be done as soon as it becomes apparent that further attempts at salvage have little likelihood of success. Adherence to this approach will preserve the patients fiscal, physical, and psychological assets, thereby preventing chronic invalidism. Finally, transtibial amputation should be favored over the transfemoral level whenever there is a reasonable
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possibility of ambulation.
CONTRAINDICATIONS
Inadequate vascularity at amputation sites between the knee and ankle, for any reason, is an absolute contraindication to transtibial amputation. Dependent rubor or gangrenous changes about the upper portion of the tibia, whether gradual or sudden in onset, should lead to consideration of a primary transfemoral amputation. Severe rest pain in the proximal portion of the calf may indicate the need for a primary transfemoral amputation as well. A knee flexion contracture severe enough to prevent use of a transtibial prosthesis may be best served by a knee disarticulation, provided that the skin at that level is viable and will heal primarily. A relative contraindication to transtibial amputation is prolonged nonambulatory status. If the patient is bed bound, a knee flexion contracture will very likely develop. A knee disarticulation can be a good choice in this situation because it provides much better sitting balance than a transfemoral residual limb does. Persson, however, 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. There are several conditions mistakenly thought of as relative contraindications to transtibial amputation. A diabetic or a patient with Hansen's disease (leprosy) need not be denied a transtibial level on the basis of insensate skin. With good prosthetic fitting and regular observation of the skin for areas of pressure, the amputee should do extremely well. Hemiparetic patients can often manage household ambulation with a transtibial prosthesis. Even poor knee control can be managed easily with a hybrid "prosthosis" that combines a transtibial prosthesis with orthotic knee control componentry, provided that flexion or extension patterning is not extreme and that reasonable balance is present. If they are able to comprehend and follow instructions, they can do quite well ( Fig 18A-5.). Even if they are not prosthetic candidates, sitting and kneeling activities will be enhanced by leaving as much of the leg as possible. Children with congenital foot deformities requiring revision for use of a prosthesis are not well served by transtibial amputation. This will interfere with the growth of the residual limb and make its relative length less in adulthood. In these cases, disarticulation at the ankle joint will preserve end weight-bearing capability and allow a moderate increase in length over time (see Chapter 35).
PREOPERATIVE CARE
There are several very important aspects to the preoperative management of prospective amputees. These are largely related to the reason for amputation. Patients undergoing amputation for trauma, although usually young and healthy, often have concomitant injuries to other skeletal parts, soft tissues, or viscera. A careful evaluation must be done to rule out injury to areas other than the affected limb. When dysvascularity related to peripheral vascular disease with or without diabetes mellitus leads to amputation, the presence of associated disease must be assumed. One study found that 76% of 70 patients coming to transtibial amputation had various other degenerative diseases. Special attention must be directed to control of congestive heart failure, arrhythmias, electrolyte imbalance, dehydration, hypertension, bronchitis, and diabetes for optimum results, with the emphasis on rapid preoperative treatment. In cases of diabetes mellitus, the infection that has led to the need for amputation often totally disrupts diabetic control. Since the control of infection and of hyperglycemia are interdependent, they must be approached simultaneously for optimum effect. Following initial aerobic and anaerobic wound cultures, broad-spectrum antibiotic therapy should be started, pending bacterial sensitivity studies. Care should be taken to avoid nephrotoxic drugs where possible. If they are needed, renal function should be closely monitored. Icing of a necrotic/infected limb to control local and systemic effects of the infectious process remains controversial. While its use has been suggested in selected cases, Pedersen et al. condemned this practice and stated that following icing, a transfemoral amputation is unavoidable. Instead, they advocated prompt drainage of abscesses, followed by appropriate antibiotics and bed rest. A wide range of bacteria may be associated with foot infections in diabetics. They include gram-positive, gram-negative, aerobic, and anerobic organisms, occasionally singly but more
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often in various combinations. Hoar and Torres found Staphylococcus aureus, Streptococcus hemolyticus, and Proteus vulgaris to be most common. Fearon et al. cultured more than 15 different bacteria in a series of diabetic gangrene cases. Systemic infection secondary to wet gangrene or infections independent of the foot must also be controlled preoperatively. Specifically, evidence of genitourinary and pulmonary infections should be sought. Assessments of wound healing potential are also indicated. These include the serum albumin level as an indicator of nutritional status (normal, 3.5 g/dL or more) and the total lymphocyte count as a measure of immu-nocompetence (at least 1,500/mm ). If these values are abnormal, one may expect difficulties with primary wound healing. Reversal of the catabolic state associated with infection should be initiated preoperatively, preferably by oral intake. The addition of nutritional supplements such as ascorbic acid, zinc, and ferrous sulfate should present no additional clinical problem, but significant caloric enhancement will require matching increases in hypoglycemic agents. If time and the patients' condition allow, they should be introduced to the team members who will be caring for them postoperatively. The physical therapist can initiate a preoperative program to condition the entire body, prevent contracture of the hip and knee on the side of (see Chapter 23). the amputated limb, and teach safe ambulation with a walker or crutches Because the patient looks to the amputation surgeon for guidance, a unique opportunity exists to influence the surgical outcome insofar as patient compliance is concerned. A reasonably detailed account of the expected course through prosthetic fitting should be given. 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. increase in both wound infection and reamputation rates in lower-limb amputees who smoked cigarettes. A psychologist experienced in dealing with amputees can encourage them to express their anxieties regarding both the surgical and prosthetic phases of care. A preoperative visit by a trained amputee peer counselor matched with the patient by age, sex, and level of amputation can be very beneficial.
LEVEL SELECTION
There are several aspects to correct selection in the individual case. In trauma, 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.). Tumor surgery requires that adequate margins free of disease be the surgeon's first concern, with preservation of limb length secondary ( Fig 18A-7.). In dys-vascular cases, the surgeon should first determine that the limb is not salvageable by reconstructive vascular surgery, either entirely or with limited loss at the toe, ray, or transmetatarsal level. Second, it should be determined whether a transtibial level has a reasonable chance of healing. Third, a level that will heal and be durable and optimally functional should be chosen. In cases of foot infection, the proximal extent of infection along tissue planes may determine whether a ray or transmetatarsal amputation or a Syme ankle disarticulation is feasible. If purulence has extended proximal to the ankle, an open ankle disarticulation with fascioto-mies and compartmental debridement is indicated to preserve length. Although level selection is multifactorial, many studies have tried to oversimplify the problem by basing success or failure solely on one criterion. 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, there remains an intermediate gray zone of unpredictability. The inability to reach consensus on the best test or tests for level selection clearly shows that the best test, which does not yet exist, would be one that predicts failure with 100% accuracy and thus guides the surgeon away from that 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. If failure then occurred, operative factors other than tissue blood flow should be sought, such as poor nutritional status, tissue glycosylation secondary to chronic hyperglycemia, infection, suboptimal surgical technique, or poor postoperative wound management. The more traditional methods of level selection are considered in this chapter. For a detailed discussion of laboratory tests designed to give more objective measurements of limb and tissue blood flow, the reader is referred to Chapter 2C. In practice, level selection by either
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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. 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. Even with the development of more sophisticated tests, most surgeons continue to rely on factors that can be easily evaluated by touch and sight, including peripheral pulses, skin warmth and texture, color of the foot dependent and elevated, hair growth, and the presence of indolent ulcers, tissue necrosis, gross infection, or lymphangitis. Regarding the evaluation of peripheral pulses, if they can be easily felt, they are usually there. If they cannot be felt, however, they may still be present but obscured by edema, hypotension, or obesity. A significant number of transtibial amputations will heal despite the absence of palpable pulsation at any given level, including the superficial femoral level. In a series of 113 transtibial amputations, 57% healed with only an aortic pulse present; the addition of a femoral pulse increased the success rate to 81%. With palpable popliteal or pedal pulses, all transtibial amputations in this series healed. The data from six papers were combined and analyzed regarding the relationship of healing rate to the presence of a palpable popliteal pulse. Although 65% of these patients had no popliteal pulse felt, 82.5% These findings point out the difficulty in evaluation of healed at the transtibial level. collateral circulation by palpation. The profunda femoris artery, which may be the only major vessel providing collaterals to the calf, is inaccessible to the palpating finger. Arteriography has been found to bear little correlation to the healing potential of transtibial Arteriography is now used chiefly amputations, on a par with reliance on palpable pulses. to determine the feasibility of vascular reconstruction. Many surgeons have relied on the trial skin incision. The presumption is that if the skin bleeds within 3 minutes after incision at the proposed level, it should heal at that level; if the skin does not bleed, the surgeon should immediately move proximally. Ken-drick, however, noted no correlation between bleeding of a trial skin incision and healing potential. The basic question of how distally the initial trial skin incision should be made remains unaddressed. A distal trial incision that bleeds, however, should encourage the surgeon to proceed at that level. Once the decision has been made to amputate at the transtibial level, an equally important choice must be made as to the exact length to be retained ( Fig 18A-8.). The shortest useful amputation must include the tibial tubercle to preserve knee extension by the quadriceps. Flexion at this level is provided by the semimembranosus and biceps femoris. Beyond universal agreement as to this shortest possible functional level, the ideal length for optimal prosthetic function has not been determined. The amputation method advocated by Burgess, which results in a cylindrical stump, effectively limits length to approximately 15 cm since the leg begins to taper beyond that point. Marsden recommends limiting the length to 15 cm on the basis that the prosthetist will have less trouble fitting a prosthesis. There are a number of opinions, however, expressed over several decades that cast doubt on this certitude. Harris, although recommending a short transtibial amputation in his paper of 1944, noted that a long transtibial amputation is stronger than a shorter one. Despite this recognized functional advantage, 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. compatible with healing should be retained, while Epps stated that the basic rule was to save all length possible, correlating it to function and the prosthetic components to be used. McCollough et al., while not specifying what they considered optimal length, flatly stated that the longer the residual limb, the better the gait. This position is supported by work showing that transtibial amputees with longer limbs require less energy to ambulate. In summary, there is no longer an ideal length or site of amputation. In dysvascular cases with an absent popliteal pulse, amputation in the proximal half of the leg would seem reasonable, with a bony level as distal as the junction of the proximal and middle thirds. In cases with good blood flow to the ankle, 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.
ANESTHESIA
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The various types of anesthesia useful in transtibial amputation may be classified as follows: 1. Local anesthesia. -An extremely ill or even moribund patient can have a transtibial amputation done without pain under local anesthesia. The agent is injected along the proposed incision line and deeper tissues infiltrated as necessary. Nerves, especially the posterior tibial, are individually injected prior to any manipulation and section. Agents containing epinephrine are avoided. 2. Regional anesthesia. -For patients with severe cardiopulmonary compromise, a sciaticfemoral block can be very effective. It can be supplemented, if necessary, with a local anesthetic. 3. Low spinal anesthesia. -This technique has little effect on the pulmonary system. Control of blood pressure, however, can be problematic. If hypotension occurs, it is corrected with fluid administration and/or vasopressors. 4. General anesthesia. -In the healthy patient undergoing amputation for trauma, it can be quite safe and effective. If the patient has severely compromised cardiopulmonary function, however, it may not be the best choice. In summary, the choice of anesthesia depends on the patient's condition, the skills and experience of the individual anesthetist, and the patient's choice, if he is fit to receive any type of anesthetic.
SURGICAL TECHNIQUE
Amputation is no longer to be considered as purely the ablation of a useless or debilitating part, but rather as a reconstructive procedure to restore ambulatory function. As more functional goals for the transtibial amputee have been appreciated, new techniques have To achieve optimal been developed in an attempt to enhance function at that level. function, the surgeon must be willing at times to do staged procedures. The ultimate goal is a residual limb that will interface well with a prosthesis. To achieve this end, 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. Use of a thigh tourniquet is recommended in cases of amputation for trauma. In dysvascular cases, a tourniquet may be in place, but only inflated if bleeding is problematic during surgery. There are two criteria for the primary healing of transtibial residual limbs. First, as discussed above, is proper selection of level. A second and equally important criterion is the proper technical management of tissues during the procedure. The placement and measurement of flaps must be accurately related to the cross-sectional area of the leg at the bony level selected. Otherwise, either the bone will need to be shortened to avoid closure under tension, or redundant soft tissue will have to be excised. 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. Transtibial amputations may be classified as follows: 1. Closed amputations 2. End weight-bearing amputations 3. Open amputations
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The subcutaneous tissue and investing fascia are cut in line with the skin incision. At this point, 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. The anterior compartment muscles are carefully divided to expose the neurovascular structures. The artery should be doubly ligated, the veins ligated, and the nerve cut under slight tension. The tibia is stripped of periosteum only to the level of transection to reduce the chance of bone spur formation. It is then cut transversely with a saline-cooled power saw. The fibula is cleared with an elevator and cut obliquely to form a facet facing posterolateraly. 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. ). A long amputation knife is passed behind the tibia and fibula and drawn distally to create a tapered myofasciocutaneous flap ( Fig 18A-11. ). The peroneal and posterior tibial arteries are clamped, divided, and doubly ligated, and the veins are singly ligated. The posterior tibial nerve may be ligated to secure its intrinsic vessels, or it may be dissected out and lightly cauterized. The nerve is then cut and allowed to retract proximal to the bone end. The lesser saphenous vein is found in the posterior flap and ligated while the adjacent sural nerve is cut under tension. The deep calf musculature is excised to reduce the bulk of the posterior flap ( Fig 18A-12. ). A bulky soleus may also be tapered further to contour the distal tibia padding. If necessary, the flap edges can be trimmed further to obtain a good fit. The cooled power saw is now used to cut a bevel in the anterior end of the tibia. Both bone cuts are now carefully smoothed and contoured with a bone file ( Fig 18A-13. ). The wound may be closed by using either a myodesis or myoplasty technique. Myodesis provides firm fixation of the posterior muscle padding to the tibia, thus preventing later retraction. It is contraindicated, however, in cases of severe dysvascularity in which the blood supply to the muscle appears compromised. In these cases, myoplasty will be sufficient. To effect myodesis, drill holes are placed each side of the tibial crest bevel. Other holes may be placed medially and laterally as well. All bone detritus must be carefully washed from the wound after drilling. Following placement of a suction drain, the myodesis sutures are inserted. The tissues joined to the bone by these sutures include the anterior investing fascia, the gastrocnemius (or tapered Achilles tendon in the case of a long transtibial amputation), and the posterior investing fascia ( Fig 18A-14. ). A heavy absorbable suture works well for this. The medial and lateral portions of investing fascia and muscle flap are sutured with further interrupted absorbable suture. No subcutaneous sutures are necessary, and the skin is closed with interrupted nylon sutures widely spaced. The intervals are reinforced with adhesive paper strips ( Fig 18A-15. ). A posterior myofasciocutaneous flap can be formed down to the distal extent of the soleus muscle, with the technique becoming progressively easier in more distal amputations ( Fig 18A-16. ). There are several anatomic reasons for this. With distal tapering of the calf, the cross-sectional area of the leg decreases, and this results in a much shorter, widely based posterior flap. Distal muscle bulk is much less, thus resulting in minimal muscle excision to allow closure. Less tissue mass also results in less tendency for "dog ear" formation. Finally, control of venous bleeding is simplified because of fewer venous plexuses distally. A well-padded plaster or fiberglass cast is applied with the knee in full extension. 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. ). The cast is made as light as possible to allow the patient greater mobility in bed and on crutches.
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18A-19. ,A-C).
Skew Flaps
This approach is designed for the severely dysvascu-lar patient in whom all major vessels are occluded. 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. To take advantage of this fact, the creation of anteromedial and posterolateral flaps is suggested. If the posterolateral flap is seen to have very poor blood supply at the time of skin incision, it can be shortened. This approach combines features of the long posterior flap and sagittal flaps ( Fig 18A-23. ,A and B).
Singer Procedure
This is another approach to end weight bearing in transtibial amputation for trauma. The indications are limited, criteria are strict, and the surgery is precise. Tibial diaphyseal bone loss must be extensive enough to preclude skeletal reconstruction, but the posterior tibial nerve and foot should be intact. The heel pad and sole tissues are dissected from the skeleton of the foot, with the posterior tibial nerve left in continuity. The nerve is folded into the soft tissues of the residual limb, and a posterior tibial-popliteal arterial anastomosis is done. The heel pad is then sutured over the end of the residual limb to provide end weight bearing after healing.
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. 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. 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. The open circumferential technique, whereby each
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successive layer is cut and allowed to retract before cutting deeper layers, has the advantage of less exposure of the deeper soft tissues and bone and perhaps conserves some bone length. It will, however, have to be revised to allow a good soft-tissue envelope reconstruction over the end of the bones. A much better technique utilizes open flaps. In this case, all viable tissue is preserved by forming rough myofasciocutaneous flaps whose length and orientation are dictated by the trauma or infection. While such flaps may appear excessively long initially, considerable shrinkage will occur before closure is feasible. If the flaps are so long that some distal viability is lost, this portion will be removed at the time of closure. Of these three, this last technique preserves the maximum amount of bone length ( Fig 18A-25. ,A and B). In cases of irreparable loss of foot vascularity and sensation associated with segmental tibial fracture, 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. 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. ,A and B and Fig 18A-27. ,A-C). In trauma cases, there may be instances in which there is enough muscle to adequately cover the bones but insufficient skin to completely close the wound. It is not necessary in these cases to shorten the bones to the level where full coverage by skin is possible. Available skin can be rotated to cover the anterodistal part of the tibia, the site where the greatest stress occurs during prosthetic walking. The remainder of the muscle is covered with a split-thickness skin graft ( Fig 18A-28. ,A and B and Fig 18A-29. ,A-C). If tissue planes In cases of severe foot infection, an open ankle disarticulation is useful. proximal to the ankle are involved, they may be easily opened medially and/or laterally to thoroughly debride the infected compartments ( Fig 18A-30. ,A-D).
Treatment of Fascia
The crural or investing fascia should be cut at the same level as the skin and subcutaneous tissue. It should never be separated from the surrounding soft tissues in order to prevent damage to any small perforating vessels serving the skin. In closing a myofasciocutaneous flap, 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. This, in turn, allows the use of fewer skin sutures, which may contribute to less skin necrosis. Complete closure of the fascia also prevents scarring of skin directly to bone, which would prevent dissipation of shear forces generated at the socket-skin interface.
Treatment of Muscle
Muscle is considered to carry at least some blood from the deep arteries of the leg to the skin. It is therefore generally accepted that muscle should not be dissected from its overlying investing fascia. Muscle may be trimmed to provide sufficient padding for the end of the tibia without unnecessary bulk. Any ischemic or necrotic muscle should be excised. This condition appears most commonly in the anterior compartment. If muscle tissue is merely pale, it may be left because it will probably fibrose in time. Healing can occur following the complete
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Treatment of Nerves
The nerves to be specifically found and transected during transtibial amputation include the superficial peroneal, saphenous, deep peroneal, sural, and posterior tibial. The posterior tibial nerve may present sufficient intrinsic vascular supply to warrant ligation or cauterization of its vasa nervorum. A variety of methods have been advocated to inhibit neuroma formation by traumatizing the proximal cut end of the nerve. The best approach appears to be simple The cut proximal end retracts into the sharp division following mild traction on the nerve. soft tissues where the inevitable neuroma will be protected during prosthetic gait. Dellon et al. demonstrated that nerve ends surgically buried in muscle show no tendency toward neuroma formation. Malawer et al. 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, 0.25% to 0.5%) by a standard infusion pump at the rate of 2 to 3 mL/hr over the first 72 hours. The catheter is easily removed where it exits the postoperative cast.
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. Various authors have suggested a bevel of 45 to 60 degrees as being optimal. All bone If cutting with a power saw should be done with saline cooling to prevent thermal necrosis. the surgeon wishes to avoid fluid splattering, a Gigli saw may be used instead to cut the tibial shaft from posterior to anterior. As the saw enters the anterior cortex, it is directed proximally to cut the bevel. The fibula should be no more than 0.5 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. complaints of soft-tissue impingement during prosthesis use, the fibula may be cut with a bevel facing posterolaterally. Both bones should be carefully filed to remove all sharp edges and points. Prior to closure, the wound should be generously irrigated to wash away bone detritus. Total removal of the fibula may be required in cases of fibular osteomyelitis or bony necrosis due to circumferential muscle loss or abscess formation. Removal may also be beneficial in a very short transtibial amputation at the level of the tibial tubercle where, if left in place, the fibular head may produce pain by its ball-like presence in the socket ( Fig 18A-31. ). Bleeding from the tibia or fibula can be controlled by electrocautery and closure of the wound. 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.
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however, 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. 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. After this, therapy can be switched to oral narcotics or nonsteroidal anti-inflammatory drugs. In this way, habituation should not occur. Alternatively, 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. contribute to prevention of pain. Infection prevention is an important aspect of postoperative management that is met in most cases with perioperative intravenous antibiotics. If infection was an overriding factor in the amputation, however, one or more antibiotics chosen from organism sensitivities should be continued for 2 to 5 days postoperatively. 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. The patient should be made mobile as soon as possible to prevent the deconditioning that may occur within just a few days. On the first postoperative day, the patient should be sitting out of bed with the residual limb elevated to the level of the chair seat. By the next day, the patient should be in the physical therapy department beginning ambulation on the parallel bars. This is followed by the use of crutches or a walker as conditioning and balance improve (see Chapter 23). Early mobilization has been enhanced in recent years with the introduction of the immediate postoperative prosthesis and its more commonly used component, the rigid postoperative If an immediate postoperative prosthesis has been applied, limited weight bearing on cast. the residual limb can start almost immediately provided that the patient demonstrates sufficient strength, balance, proprioception, and cognition to accurately determine the weight applied. The cost of hospital stay has become a major issue in recent years. In the past, many patients remained in the hospital or rehabilitation center following surgery until they had healed, been fitted with a prosthesis, and thoroughly trained in its use. In the United States, this is no longer financially feasible. 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. In that case, they will stay until these goals have been achieved or abandoned as unrealistic. All further care, including prosthetic fitting and follow-up, is accomplished on an outpatient basis. Hospitalization for prosthetic gait training can be justified in cases of marked deconditioning, advanced age, bilateral concomitant lower-limb amputations, or great distance from the center. The psychological needs of the amputee must also be met. Counseling by various team members can be quite helpful in allaying anxiety regarding the prosthetic phase of care. Visits by a trained amputee peer counselor matched with the patient by age, sex, and amputation level can be of inestimable help. Amputee/ consumer peer support groups can be extremely helpful in smoothing the amputee's transition to the community, especially by providing a comfortable social, educational, and recreational outlet.
SUMMARY
Transtibial amputation, by saving the knee joint, provides the amputee with the possibility of near-normal function in regard to ambulation and overall life-style. With the availability of new information on the efficacy of transtibial amputation and improved methods of determining potential healing levels in a limb, the majority of major lower-limb amputations are now being done at the transtibial rather than the transfemoral level. Diabetes is now seen to be a primary or secondary cause of amputation in at least 50% of cases. 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. The aim of amputation surgery is a well-healed, sen-sate, functional end organ that will interface well with a prosthesis. Selection of length is based on etiologic factors and on clinical and laboratory evaluation. As much length as possible should be preserved, compatible with disease eradication and good prosthetic function. Meticulous management of
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tissues will lead to preservation of the length obtained at surgery. Myodesis is advocated in cases in which local dysvascularity is not a problem. Postoperative rigid dressings are strongly recommended because of local protection of the wound and the prevention of edema and knee flexion contractures. Early mobilization prevents deconditioning, thereby allowing early discharge to an outpatient status. Early prosthetic weight bearing has great value in selected cases if closely monitored. Optimal amputee management is best achieved through a team approach beginning even before surgery. References: 1. Alter AH, Moshein J, Elconin KB, et al: Below-knee amputation using the sagittal technique: A comparison with the coronal amputation. Clin Orthop 1978; 131:195-201. 2. Bagdade JD, Nielsen K, Root R, et al: Host defense in diabetes mellitus: The feckless phagocyte during poor control and ketoacidosis. Diabetes 1970; 19:364. 3. Baker WH, Barnes RW, Shurr DG: The healing of below-knee amputations: A comparison of soft and plaster dressings. Am J Surg 1977; 133:716-718. 4. Barber GG, McPhail NV, Scobie TK, et al: A prospective study of lower limb amputations. Can J Surg 1983; 26:339-341. 5. Bard G, Ralston HJ: Measurement of energy expenditure during ambulation, with special reference to evaluation of assistive devices. Arch Phys Med Rehabil 1959; 40:415-420. 6. Bickel WH: Amputations below the knee in occlusive arterial diseases. Surg Clin North Am 1943; 23:982-994. 7. Block MA, Whitehouse FW: Below-knee amputation in patients with diabetes mellitus. Arch Surg 1963; 87: 682-689. 8. Boontje AH: Major amputations of the lower extremity for vascular disease. Prosthet Orthot Int 1980; 4:87-89. 9. Bowker JH: Surgical techniques for conserving tissue and function in lower-limb amputation for trauma, infection, and vascular disease. AAOS Instr Course Lect 1990; 39:355-360. 10. Brodie IAO: Lower limb amputation. Br J Hosp Med 1970; 4:596-604. 11. Burgess EM: The below-knee amputation. Bull Prosthet Res 1968; 10:19-25. 12. Castronuovo JJ, Deane LJ, Deterling RA, et al: Below-knee amputation. Is the effort to preserve the knee joint justified? Arch Surg 1980; 115:1184-1187. 13. Cheng EY: Lower extremity amputation level: Selection using noninvasive hemodynamic methods of evaluation. Arch Phys Med Rehabil 1982; 63:475-479. 14. Chilvers AS, Briggs J, Browse NL, et al: Belowand through-knee amputations in ischaemic disease. Br J Surg 1971; 58:824-826. 15. Cranley JJ, Krause RJ, Strasser RS, et al: Below-the-knee amputation for arteriosclerosis obliterans. Arch Surg 1969; 98:77-80. 16. Cumming JGR, Jain AS, Walker WF, et al: Fate of the vascular patient after belowknee amputation. Lancet 1987; 2:613-615. 17. de Cossart L, Randall P, Turner P, et al: The fate of the below-knee amputee. Ann R Coll Surg Engl 1983; 65:230-232. 18. Deffer PA: More on the Ertl osteoplasty. Amputee Clin 1970; 2:7-8. 19. Dellon AL, MacKinnon SE, Pestronk A: Implantation of sensory nerve into muscle: Preliminary clinical and experimental observations on neuroma formation. Ann Plast Surg 1984; 12:30-40. 20. Dickhaut SC, DeLee JC, Page CP: Nutritional status: Importance in predicting woundhealing after amputation. J Bone Joint Surg [Am] 1984; 66:71-75. 21. Dwars BJ, Rauwerda JA, van den Brock TAA, et al: A modified scintigrafic technique for amputation level selection in diabetics. Eur J Nucl Med 1989; 15:38-41. 22. Epps CH Jr: Amputation of the lower limb, in Evarts CM (ed): Surgery of the Musculoskeletal System, ed 2. New York, Churchill Livingstone Inc, 1990. 23. Ecker ML, Jacobs BS: Lower extremity amputation in diabetic patients. Diabetes 1970; 19:189-195. 24. Eraklis A, Wheeler B: Below-knee amputations in patients with severe arterial insufficiency. N Engl J Med 1963; 269:933-943. 25. Ertl J: About amputation stumps. Chirurgie 1949; 20:2-12, 218. 26. Fearon J, Campbell DR, Hoar CS, et al: Improved results with diabetic below-knee amputees. Arch Surg 1985; 120:777-780. 27. Fleurant FW, Alexander J: Below knee amputation and rehabilitation of amputees. Surg Gynecol Obstet 1980; 151:41-44. 28. Gonzalez EG, Corcoran PJ, Reyes RL: Energy expenditure in below-knee amputees: Correlation with stump length. Arch Phys Med Rehabil 1974; 55:111-119.
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29. Harris JP, Page S, Englund R, et al: Is the outlook for the vascular amputee improved by striving to preserve the knee? J Cardiovasc Surg 1988; 29:741-745. 30. Harris PD, Schwartz SI, DeWeese JA: Midcalf amputation for peripheral vascular disease. Arch Surg 1961; 82:381-383. 31. Harris RI: Amputations. J Bone Joint Surg 1944; 26:626-634. 32. Harris WR: Below-knee amputation: A technical note. Can J Surg 1987; 30:392-393. 33. Heller RF, Hayward D, Hobbs MST: Decline in rate of death from ischaemic heart disease in The United Kingdom. Br Med J 1983; 286:260-262. 34. Hoar CS, Torres J: Evaluation of below-the-knee amputation in the treatment of diabetic gangrene. N Engl J Med 1962; 266:440-443. 35. Kacy SS, Wolma FJ, Flye MW: Factors affecting the resuits of below knee amputation in patients with and without diabetes. Surg Gynecol Obstet 1982; 155:513-518. 36. Keagy BA, Schwartz JA, Kotb M, et al: Lower extremity amputation: The control series. J Vasc Surg 1986; 4:321-326. 37. Kendrick RR: Below-knee amputation in arteriosclerotic gangrene. Br J Surg 1956; 44:13-17. 38. Lange R, Bach A, Hanse S, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985; 25:203-208. 39. Lepantalo M, Isoniemi H, Kyllonen L: Can the failure of a below-knee amputation be predicted? Ann Chir Gynaecol 1987; 76:119-123. 40. Lim RC, Blaisdell FW, Hall AD, et al: Below-knee amputation for ischemic gangrene. Surg Gynecol Obstet 1967; 125:493-501. 41. Lind J, Kramhoff M, Bodtker S: The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop 1991; 267:211-217. 42. Loon HE: Below-knee amputation surgery. Artif Limbs 1961; 6:86-99. 43. Louie TJ, Bartlett JG, Tally FP, et al: Aerobic and anaerobic bacteria in diabetic foot ulcers. Ann Intern Med 1976; 85:461-463. 44. McCollough NC, Jennings JJ, Sarmiento A: Bilateral be-low-the-knee amputation in patients over fifty years of age: Results in 31 patients. J Bone Joint Surg [Am] 1972; 54:1217-1223. 45. McCollough NC III, Harris AR, Hampton FL: Below-knee amputation, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981, pp 341-368. 46. McCollum PT, Spence VA, Walker WF, et al: A rationale for skew flaps in below-knee amputation surgery. Pros-thet Orthot Int 1985; 9:95-99. 47. Mclntyre KE Jr, Bailey SA, Malone JM, et al: Guillotine amputation in the treatment of nonsalvagable lower-extremity infections. Arch Surg 1984; 119:450-453. 48. Malawer MM, Buch R, Khurana JS, et al: Postoperative infusional continuous regional analgesia (PICRA): A technique for relief of postoperative pain following major extremity surgery. Clin Orthop 1991; 266:227-237. 49. Marsden FW: Amputation: Surgical technique and postoperative management. Aust N Z J Surg 1977; 47:384-392. 50. Moore TJ: Amputations of the lower extremity, in Chapman M (ed): Operative Orthopaedics. Philadelphia, JB Lippincott, 1988. 51. Moore WS, Hall AD, Lim RC: Below the knee amputation for ischemic gangrene. Comparative results of conventional operation and immediate postoperative fitting technique. Am J Surg 1972; 124:127-134. 52. Murdoch G: Amputation surgery in the lower extremity. Prosthet Orthot Int 1977; 1:7283. 53. Murray DG: Below-knee amputations in the aged: Evaluation and prognosis. Geriatrics 1965; 20:1033-1038. 54. Paloschi GB, Lynn RB: Major amputations for oblitera-tive peripheral vascular disease with particular reference to the role of below-knee amputation. Can J Surg 1967; 10:168-171. 55. Pedersen HE, LaMont RL, Ramsey RH: Below-knee amputation for gangrene. South Med J 1964; 57:820-825. 56. Perry T: Below-knee amputations. Arch Surg 1963; 86: 199-202. 57. Persson BM: Sagittal incision for below-knee amputation in ischaemic gangrene. J Bone Joint Surg [Br] 1974; 56:110-114. 58. Pohjolainen T, Alaranta H: Lower limb amputations in southern Finland. Prosthet Orthot Int 1988; 12:9-18. 59. Purry NA, Hannon MA: How successful is below-knee amputation for injury? Injury 1989; 20:32-36. 60. Rizzo RL, Matsumoto R: Above vs. below knee amputations: A retrospective analysis. Int Surg 1980; 65:265-267. 61. Robinson K: Long-posterior-flap myoplastic below-knee amputation in ischaemic
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disease: Review of experience in 1967-1971. Lancet 1972; 2:193-195. 62. Robinson K: Skew flap myoplastic below-knee amputation: A preliminary report. Br J Surg 1982; 69:554-557. 63. Robinson KP: Skew-flap below-knee amputation. Ann R Coll Surg Engl 1991; 73:155157. 64. Roon AJ, Moore WS, Goldstone J: Below-knee amputation: A modern approach. Am J Surg 1977; 134:153-158. 65. Rush DS, Huston CC, Bivins BA, et al: Operative and late mortality rates of above knee and below knee amputations. Am Surg 1981; 47:36-39. 66. Sarmiento A, Warren WD: A re-evaluation of lower extremity amputations. Surg Gynecol Obstet 1969; 129:799-802. 67. Singer DI, Morrison WA, McCann JJ, et al: The fillet foot for endweight-bearing cover of below knee amputations. Aust NZJ Surg 1988; 58:817-823. 68. Smith BC: A twenty year follow-up in fifty below-knee amputations for gangrene in diabetics. Surg Gynecol Obstet 1956; 103:625-630. 69. Stewart CPU: The influence of smoking on the level of lower limb amputation. Prosthet Orthot Int 1987; 11:113-116. 70. Termansen NB: Below-knee amputation for ischaemic gangrene. Acta Orthop Scand 1977; 48:311-316. 71. Thornhill HL, Jones GD, Brodzka W, et al: Bilateral below-knee amputations: Experience with 80 patients. Arch Phys Med Rehabil 1986; 67:159-163. 72. Wagner FW Jr: Resident Training Manual. Rancho Los Amigos Medical Center, Calif. 73. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking amputees: The influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46. 74. Yaramenko D, Andruhova RV: Below-knee amputation in patients with vascular disease and prosthetic fitting problems. Prosthet Orthot Int 1986; 10:125-128.
Chapter 18A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 18B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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health problems may use a walker and wear the prosthesis only 4 to 5 hours daily, but is nevertheless ready for definitive fitting because a degree of con-sistancy in activity level and residual-limb condition has been achieved. While preparatory systems are intended to accommodate the multiple changes experienced by a recent amputee, a definitive prosthesis differs primarily in that its design and components are geared toward the goals of the patient after activity levels, prosthetic wearing schedules, and residual-limb changes have all stabilized. A definitive prosthesis may closely resemble the intermediate prosthesis that preceded it, or it may differ dramatically depending upon the goals that have emerged during rehabilitation. When deciding upon an appropriate prosthesis, the patient and the clinic team is faced with a wide variety of choices due to numerous innovations in prosthetic components, materials, and techniques during the last several decades. Each technique, socket configuration, suspension system, alignment, and component has specific advantages and disadvantages that can be balanced to provide the optimum combination for the patient's unique needs.
SOCKET INTERFACES
The PTB Hard Socket
The hard socket ( Fig 18B-2.) is rigid plastic and therefore has specific advantages and disadvantages when compared with a socket with a soft liner or distal pad. This style of socket is primarily indicated for a residual limb with good soft-tissue coverage and no sharp bony prominences. It is not recommended for residual limbs with thin skin coverage, scarring, skin grafts, or a predisposition to breakdown. Advantages: 1. 2. 3. 4. 5. Perspiration does not corrode the socket. Less bulky at the knee than with an insert. Easy to keep clean. Contours within the socket do not compress or pack down with use. Reliefs or modifications can be located with exactness.
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Disadvantages: 1. Requires extra skill in casting and modification. 2. Difficult to fit bony or sensitive residual limbs. 3. Not as easily modified as a socket with a liner.
Soft Liners
Soft liners ( Fig 18B-3.) are fabricated over the modified cast to fit inside the socket. 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. They are often fabricated from a 5-mm polyethylene foam material. Occasionally silicone gel is used for the more sensitive residual limb. 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. Soft liners are recommended for patients with peripheral vascular disease; for thin, sensitive, or scarred skin and sharp bony prominences; and for patients with peripheral neuropathy. 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. The added protection of a soft liner may also benefit the highly active patient. Advantages: 1. Provides a soft, protective socket interface. 2. Is appropriate for the majority of residual limbs. 3. Rebound in the liner may aid circulation by providing a "pumping action" and by providing intermittent pressure over bony prominences. 4. Is easily modified. Disadvantages: 1. 2. 3. 4. 5. Materials may deteriorate over time. Not as sanitary as a hard socket because liners tend to absorb fluids. Increases bulk around the knee and proximal circumference of the prosthesis. The liner may compress over time with resultant loss of intimate fit. Increases the weight of the prosthesis.
Distal Pads
To improve overall comfort and to help prevent edema, the distal portion of PTB sockets generally incorporate a soft pad. A few special instances may not call for these protective pads, but most often they are standard. Advantages: 1. May aid in venous and lymphatic return. 2. Provides increased comfort. 3. Protects the distal portion of the residual limb when it settles into the socket as a result of volume loss. 4. Facilitates future modifications of the distal end of the socket. Disadvantages: 1. Added fabrication time. 2. Increased weight. 3. May be less hygienic due to absorption of fluids.
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requiring rigid support, are enclosed only in the flexible socket. This technique often results in a more comfortable socket and can be utilized in en-doskeletal or exoskeletal systems. Advantages: 1. 2. 3. 4. Decreased weight. Increased comfort. Improved heat dissipation. The inner socket may be replaced to accommodate anatomic changes.
Disadvantages: 1. More difficult and time-consuming to fabricate. 2. May not be as cosmetic as conventional prostheses.
SUSPENSION VARIANTS
Cuff Suspension
The cuff ( Fig 18B-5.) is generally fabricated from da-cron and lined with leather. It encircles the thigh and purchases over the femoral condyles and proximal part of the patella. 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. Cuff suspension is appropriate for average-length residual limbs with good knee stability. It is not recommended for short residual limbs since they generally require increased surface area contact and rotational control through more proximal trim lines. Excessive scarring or sensitive skin in the area in contact with the cuff may be another contraindication. Advantages: 1. 2. 3. 4. 5. Adjustability. Ease of donning and doffing by the patient. Adequate suspension for the majority of transtibial amputees. Provides moderate control of knee extension. Easily replaced.
Disadvantages: 1. Cannot completely eliminate socket pistoning. 2. During knee flexion, may pinch soft tissue between the posterior proximal end of the socket brim and the cuff. 3. May restrict circulation. 4. Provides no added mediolateral stability.
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with moderate to severe ligamentous laxity usually require the added stability of metal joints and a thigh corset rather than supracondylar suspension alone. Advantages: 1. 2. 3. 4. Suspension is an inherent part of the socket. Is less restrictive to circulation than a cuff or thigh corset. Aids in knee stability, rotational control, and pressure distribution. Reduces pistoning.
Disadvantages: 1. Modifications over the patella and femoral condyles must be precisely located. 2. Enclosure of the patella can inhibit comfortable kneeling. 3. May be less cosmetic and more destructive to clothing because higher trim lines protrude when the knee is flexed.
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Sleeve Suspension
The suspension sleeve ( Fig 18B-10. ) has been in use since 1968 when it was introduced at the University of Michigan, Ann Arbor. Sleeves are prefabricated from thin latex rubber or neoprene and come in a variety of sizes. They fit snugly over the proximal aspect of the prosthesis and are rolled up over the patient's thigh 2 or 3 in. proximal to the prosthetic socks. By making contact with the patient's skin, the sleeve converts the socket into a sealed chamber. Three suspensory forces attributed to the sleeve are described by Chino (1975): negative pressure created during the swing phase, friction between the residual limb and the socket, and longitudinal tension in the sleeve. Sleeves may serve as the sole means of suspending a prosthesis, but they also provide excellent auxiliary suspension during sports and recreational activities for those who normally use supracondylar suspension. Sleeves are contraindicated as the sole suspension for very short limbs or those that require more proximal trim lines for added knee stability. 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. Some patients living in hot, humid climates may find that the sleeve creates perspiration and hygiene problems. Advantages: 1. 2. 3. 4. Simple and effective means of suspension. Helps minimize socket pistoning. Good auxiliary suspension. Does not create proximal constriction.
Disadvantages 1. Provides no added knee stability. 2. Suspension is greatly decreased if the sleeve is punctured. 3. Perspiration may build up under the sleeve and create skin irritation or hygiene problems. 4. Must be replaced regularly. 5. Sleeves may restrict full knee flexion and require good hand function to don and doff.
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added between the corset and socket. The check strap can be adjusted to limit knee extension to varying degrees, depending upon the patient's needs. Prior to 1958, the thigh corset combined with a waist belt was probably the most common form of transtibial prosthetic suspension. Since sockets were open ended and did not fit as intimately as today's total-contact sockets, the main purpose of the thigh corset was to utilize the thigh to share weight bearing and reduce torque forces about the residual limb. The extended lever arm of the joints and corset provided maximum me-diolateral stability, and the use of a hyperextension check strap, if adjusted properly, could effectively prevent recurvatum. The trade-off, however, was that the lack of total contact combined with a tightly laced corset often resulted in chronic distal edema. Also, because the corset bound the thigh tightly and reduced muscular demands, it frequently contributed to marked atrophy of the thigh musculature. While modern total-contact socket designs (and suspension systems) have greatly reduced the need for joints and thigh lacers, they are still appropriate when maximum mediolateral or anteroposterior stability is required. Knee joint instability is a common indication. The corset also provides some degree of shared weight bearing and is useful when partial unloading of the residual limb is necessary. Patients who perform exceptionally heavy-duty work may benefit from the added stability of joints and corset suspension. Advantages: 1. 2. 3. 4. Provides maximum mediolateral stability. Can provide maximum prevention of recurvatum. Redistributes some weight bearing and torque forces to the thigh. Increases proprioceptive feedback.
Disadvantages: 1. 2. 3. 4. 5. 6. 7. 8. Can contribute to distal edema. Tends to atrophy thigh musculature. Leather is not very hygienic. Joint centers must be precisely located to minimize motion between the leg and the prosthesis. Adds weight and bulk to the prosthesis. Not very cosmetic. Requires more fabrication time. Usually requires additional suspension of a fork strap and waist belt.
Disadvantages:
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1. Discomfort of wearing a belt. 2. Does not provide even suspension through swing phase (the tension of the elastic is proportional to the degree of knee flexion). 3. The fork strap does not provide any resistance to knee extension. 4. No mediolateral stability is provided by waist belt suspension alone.
PROSTHETIC FEET
The prosthetic foot is an important, multifaceted component of the transtibial prosthesis. The primary purpose of the prosthetic foot is to serve in place of the anatomic foot and ankle. In doing this, the prosthetic foot should provide the following functions: 1. Joint simulation. -In the normal human foot and ankle, the talocrural joint allows plantar flexion and dorsiflexion, the subtalar joint allows inversion and eversion, and the other joints of the foot (in particular, the metatarsophalangeal joints) allow smooth rollover during heel-off and toe-off. These motions are vital to normal energy-efficient gait and are particularly important during ambulation on uneven ground. A successful, 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. 2. Shock absorption. -The foot must absorb the impact of heel strike and weight acceptance without transmitting excessive forces to the residual limb. Too much shock absorption, in contrast, might fail to generate the normal knee flexion moment when the foot is flat and result in an unacceptable gait pattern. 3. A stable weight-bearing base of support.-This is important during stance phase or when the amputee is standing. 4. Muscle simulation. -In normal human gait, the dorsiflexors eccentrically lengthen to prevent foot slap after heel strike. During midstance and heel-off, the plantar flexors stabilize the ankle joint and resist the powerful dorsiflexion moment that occurs during these phases of gait. During running or rapid walking, the plantar flexors may actually "push off" and assist in propelling the weight of the body forward. The primary way in which a prosthetic foot substitutes for muscle activity is through stance-phase stability (substitution for the plantar flexors). In addition, some prosthetic feet allow controlled plantar flexion and dorsiflexion, thus simulating both dorsiflexors and plantar flexors. Through dynamic response principles, a few specialized feet actually provide some degree of dynamic "push-off" during late stance. 5. Cosmesis.-While function of the prosthetic foot is of primary concern to the prosthetist, the importance of cosmesis cannot be overlooked. The design of a particular foot may enhance or diminish its cosmetic appeal. There are essentially four different designs of prosthetic feet available for use with transtibial prostheses. They are SACH (solid-ankle, cushion-heel) feet, single-axis feet, multiaxis feet, and flexible-keel-dynamic-response feet. Each will be discussed in detail.
SACH Foot
The light weight, durability, low cost, and cosmesis of the SACH foot make it the single most frequently recommended prosthetic foot. Although recent innovations in prosthetic foot design may change this, 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 available for multiple shoe styles and heel heights, postoperative uses, Syme's fittings, external-keel "waterproof' fittings, and pediatric sizes.
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Shock absorption at heel strike in the SACH foot is good. It is dependent upon the density of the heel cushion and the superincumbent weight of the patient. Heavier patients require firmer heel cushions. The SACH foot has excellent stability due to several determinants. During standing activities, the heel cushion provides resistance when the patient "rocks" backward on the heel. Softer heel cushions produce less resistance to this motion and may diminish the stability of the weight-bearing base in the sagittal plane. This factor is probably more significant for bilateral amputees who lack a sound foot for balance control and proprioception. The second determining factor is keel length. Resistance to dorsiflexion in the SACH foot is proportional to the length of the keel. A longer keel will increase the toe lever arm but may result in excessive hyperextension forces at the knee during late stance. 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 third determining factor is keel width. The wider the keel, the more stable the base of support. External-keel SACH feet are more stable in the coronal plane because of the widened keel. Plantar flexor muscle simulation in the SACH foot is accomplished by the presence of the solid keel and ankle, which prevents ankle dorsiflexion. The dorsiflexors are simulated by the cushion heel, which absorbs plantar flexion forces during heel strike and foot flat. The invertors and evertors are simulated to a small degree by compression of the rubber sole. Cosmesis of the SACH foot is good. Since there is no motion in the ankle, the junction between the foot and shank can be reduced to a barely perceptible line. However, a difference between the materials of the shank and foot is often still visible. The postoperative SACH foot ( Fig 18B-15. ) is designed so that the patient can walk without shoes or in slippers. As the name implies, its primary use is on postoperative or temporary prostheses. It has no heel rise, and since no shoes are worn, the postoperative foot has a wider sole than a standard SACH foot to provide more stability. The molded rubber foot and heel are softer, which makes the postoperative foot very shock absorbent. The SACH foot is indicated for virtually all patients, young and old, wearing temporary, intermediate, or definitive transtibial prostheses. The standard SACH foot is contraindicated for ankle disarticulation amputees. This level requires a special design. Advantages: 1. 2. 3. 4. 5. Moderate weight. Good durability. No moving components. Minimal maintenance. Good shock absorption for moderately active patients.
Disadvantages: 1. 2. 3. 4. Limited plantar flexion and dorsiflexion adjustability. The heel cushion deteriorates over time. The heel cushion may loose elasticity. The rigid forefoot provides poor shock absorption for high-output activities.
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external-keel SACH foot. The foot's wider keel makes it ideal for patients who require added stability, although an attempt should be made to gain stability through prosthetic alignment first. The external-keel SACH foot also permits the prosthesis to be made waterproof.
SINGLE-AXIS FOOT
The single-axis foot ( Fig 18B-18. ) is available for exoskeletal or endoskeletal prostheses. Its components include a solid wood internal keel, a molded foam rubber shell, a metal singleaxis joint, a rubber plantar flexion bumper, and a dorsiflexion stop. Ankle plantar flexion and dorsiflexion are provided in a limited way by rotation about the ankle joint. Minimal inversion and eversion occur through the flexibility of the rubber sole. Toe dorsiflexion is simulated by the flexibility of the rubber toe section. The single-axis foot offers shock absorption at heel strike through the plantar flexion bumper, which is available in multiple durometers. Because the foot plantar-flexes after heel strike, thus dampening knee flexion moments, and since it is in contact with the ground for a longer period of time, stance-phase stability is excellent. Single-axis feet have specific application in transfem-oral (above-knee) prosthetics and are rarely necessary for transtibial amputees, although some amputees prefer the sensation of ankle motion. Advantages: 1. The plantar flexion capability provides increased knee stability at heel strike and foot flat and may lessen the difficulty of descending inclines. 2. Plantar flexion resistance can be varied. Disadvantages: 1. 2. 3. 4. Relatively high maintenance due to moving components. Increased weight. Less cosmetic. Tendency to "squeak."
Multiaxis Foot
This foot ( Fig 18B-19. ) provides more ankle motion than any other prosthetic foot. Available for endoskeletal and exoskeletal prostheses, it provides motion in all three planes, which makes it particularly suitable for patients who walk on uneven terrain. Its components include a solid-wood internal keel, a molded rubber foot, a central rubber rocker block that allows sagittal-plane motion, and a transverse ankle joint that provides inversion, eversion, and transverse rotation. Joint simulation is achieved by the various bumpers. Although transverse rotation is not truly an anatomic ankle joint motion, it reduces shear forces transmitted to the residual limb and is an alternative to a rotation unit. Shock absorption is excellent in the multiaxis foot because of the many bumpers. The degree of compressibility and rebound of these individual components determines the degree of shock absorption during various gait phases. Because of the many motions it allows, the foot may be considered less stable statically. 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. Muscle simulation is the same as that of the single-axis foot, with added true simulation of the invertors and evertors through the corresponding rubber bumpers. Cosmesis is comparable to the single-axis type due to the space required between the ankle block and foot. It is a good option for patients who traverse frequently over uneven terrain, but its increased weight and maintenance may overshadow its advantages. It is not recommended for patients who are weak and debilitated, those for which cosmesis is a priority, or those with limited access to prosthetic follow-up.
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Advantages: 1. Allows motion in all planes. 2. Reduces torque on the residual limb. 3. Adjustability. Disadvantages: 1. 2. 3. 4. Increased weight. Increased maintenance. Decreased cosmesis. May provide less stability than other feet on smooth surfaces.
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anatomy and less pressure over soft tissue. Further, even if pressures are equalized over the surface area of the residual limb, some bony or sensitive areas may be unable to tolerate these forces. The problem is increased when patients have unusually thin skin, sharp bony prominences, scars, or neuromas. In contrast, 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. Most fitting problems can be accommodated through appropriate socket design. In order to apply greater pressure to pressure-tolerant areas and less to pressure sensitive areas, tissues are selectively loaded through inward contours over weight-bearing surfaces and reliefs over sensitive areas. Areas within the socket that require relief ( Fig 18B-23. ) are the tibial crest, tibial tubercle, lateral tibial flare, distal tibia fibular head, peroneal nerve, hamstring tendons, and the patella. Pressure-tolerant areas ( Fig 18B-24. ) are the patellar ligament, medial tibial flare, medial tibial shaft, lateral fibular shaft, and the anterior and posterior compartments.
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Alignment refers to the spatial relationship between the prosthetic socket and foot. Correct dynamic alignment may be determined by the prosthetist as the patient ambulates on an adjustable alignment unit. This unit allows for anteroposterior foot positioning, anteroposterior tilting of the socket, mediolateral foot positioning, mediolateral tilting of the socket, height adjustment, and rotation of the prosthetic foot. Proper anteroposterior foot positioning will result in even weight distribution between the heel and toe portion of the foot statically. Dynamically this will result in a smooth, energy-efficient gait pattern, including controlled knee flexion after heel strike, smooth rollover with a limited recurvatum tendency, and heel-off prior to initial heel contact on the contralateral foot. Proper anteroposterior socket tilt will result in an attitude of initial flexion statically, thus loading those areas that are pressure tolerant. Dynamically proper flexion not only improves the weight-bearing characteristics of the socket but also allows for a smooth gait pattern, places the quadriceps muscles "on stretch" to give them a mechanical advantage for control of the prosthesis, and limits recurvatum forces during midstance and terminal stance. Proper mediolateral foot positioning will result in loading of the proximomedial and distolateral aspects of the residual limb statically. Dynamically it will duplicate the normal genu varum moment at midstance and provide optimum loading of the medial tibial flare during stance phase. It is necessary to note that optimum foot inset is related to the length and condition of the residual limb. A short residual limb may require that foot inset be reduced. 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. Foot inset results in appropriate loading of the medial tibial flare, a narrow-based gait pattern, decreased energy expenditure, and increased torque on the residual limb due to the normal genu-varum moment at mid-stance. It also provides for a more cosmetic appearance to the prosthesis. Reduced foot inset results in a wide-based gait pattern, increased energy expenditure, but decreased torque on the residual limb because the genu varum moment is limited or eliminated. 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. This general rule may not apply if the patient exhibits pelvic obliquity, congenital leg length discrepancy, or unilateral femoral shortening. Such cases must be taken individually, and often the best indicator of correct length is through gait analysis and patient comfort. Proper height will result in a smooth and symmetrical gait with no excessive trunk lean to either side. 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. A transtibial prosthesis is initially aligned so that the medial border of the foot is parallel to the line of progression. This initial alignment results in a slight external rotation of the prosthetic foot, thereby approximating the 5 to 7 degrees of normal anatomic toe-out. However, this position may need to be altered during static and dynamic alignment so that foot position during ambulation matches that of the sound limb. Foot rotation can also affect prosthetic function. How this occurs may be understood if the keel of the foot is viewed as a lever arm. During stance phase the tendency of the body to fall over the foot is resisted by the counterforce of this lever arm. Rotation of the foot therefore directly affects the length and the direction of force exerted by the lever arm. The net effect of externally rotating the foot is to increase stability by widening the base of support. There is a cosmetic trade-off, of course, if the toe-out attitude of the prosthesis does not match that of the contralateral limb. Fig 18B-27.1 , 27.2 , 27.3 , 27.4 , 27.5 , 27.6 summarize prosthetic alignment deviations and their causes and gives corrective measures.
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anterior or posterior in relation to the socket, but the position of the toe break in relation to the foot remains constant. (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.) Dynamic alignment is of course still necessary to determine the optimum foot position. Keel widths are determined by the manufacturers. A wider keel provides greater medial lateral stability during stance phase by widening the base of support. For example, externalkeel feet and the Carbon Copy II have wider keels than other feet do. The difference, however, is rarely significant enough to be the sole rationale for prescribing these. The function of prosthetic feet varies so greatly today that it is important to mention the differences between rigid and flexible keels. Keel flexibility provides for a smoother gait pattern with a less pronounced transition at toe break. To optimize resistance of the forefoot during the late stance phase, the flexible-keel-dynamic-response foot can be moved anteriorly or slightly plantar-flexed during alignment of the prosthesis. The heel cushion absorbs shock and helps initiate knee flexion during loading response. Increased heel stiffness results in greater knee flexion forces at heel strike and decreased shock absorption. Conversely, lower heel stiffness results in lower knee flexion forces and increased shock absorption. 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. As in similar prosthetic decisions, the choice must be based upon the patient's needs. Heavier patients are more likely to require a firm heel cushion to provide sufficient heel leverarm force during loading response. In contrast, lighter patients will generally require mediumor soft-density heel cushions to avoid creating an excessive heel lever arm. Very active patients may prefer a firm heel cushion since more rapid cadences increase the net loading on the foot. Geriatric patients or household ambulators often require soft heel cushions to limit knee flexion forces and maximize shock absorption. The more susceptible the residual limb is to pain or skin breakdown, then the greater is the probability that the patient will benefit from a softer heel. The prosthetic foot is designed to function under the stress of ambulation. It compresses, rebounds, flexes, and extends as it operates throughout the gait cycle. With the exception of postoperative feet and those designed for barefoot ambulation, the prosthetic foot is designed to fit inside a shoe. It should not be surprising, then, that the function of a prosthetic foot can be enhanced or decreased by the shoe within which it is fitted. At times it may be necessary to modify the foot or the shoe configuration to ensure optimum function. Attention must be given to shoe heel height, shoe heel material and shape, and shoe fit as related to foot motion. Shoe heel height is probably the single most important factor of shoe fit as regards prosthetic foot function. It is essential that shoe heel height match the built-in heel rise of the foot. 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. Once a prosthesis has been aligned and fabricated, the patient should not significantly increase shoe heel heights unless an appropriate wedge is added inside the shoe. The material and contours of the heel of the shoe can make a significant difference in the way the prosthetic wearer ambulates. For example, a soft crepe heel enhances the shock absorption qualities of a SACH foot. In comparison, a hardwood or rubber heel will tend to increase the knee flexion moment during loading response. If such heels present a problem, it is appropriate to round or bevel the posterior corner of the heel, thereby decreasing the knee moment at heel strike. Women's high heels may compromise stance-phase stability and are not recommended for weak, debilitated patients. When a solid-ankle foot is forced into a tight-fitting shoe, the ability of the foot to compress and bend during ambulation is diminished. It is always better to fit the shoe slightly looser on the foot so that maximum flexibility is achieved.
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each. The prosthetic prescription should represent a consensus between all the members of the health care team, including the patient. The following factors influence the prescription recommendation.
Age
This can only serve to give a general idea about the patient's activity level. A younger patient tends to be active and therefore usually requires a durable prosthesis that will function for many activities. An elderly patient will often have a lower activity level, may have other concurrent health problems, and will generally require a lightweight prosthesis with a protective socket interface.
Sex
Again, this category can only provide a general guideline based on stereotype. A woman with an amputation may place cosmesis at the top of her list of concerns, whereas a male may prefer function even at the expense of cosmesis.
Geographic Location
The patient's geographic location may be very important. If the patient lives in an extremely hot, humid climate where perspiration is a chronic problem, leather liners or rubber suspension sleeves may be questionable options since both can create skin or hygiene problems. If the patient lives in a rural community and has difficulty returning for follow-up, components that require frequent maintenance are not practical.
Date of Amputation
When the amputation is recent, 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. If the amputation occurred years ago, the results of any previous prosthetic fittings should be discussed.
Medical Condition
The patient's general health and specific medical condition are major factors to consider in the recommendation for a prosthesis. Although prostheses are not prescribed according to disease categories, conditions or complications associated with certain pathologies may influence the choice of components.
Activity Level
The patient's activity level affects the components prescribed. A patient who is very athletic requires a sturdy, durable prosthesis, perhaps with specialized components. In comparison, a household ambulator will require a lightweight prosthesis designed for a less-strenuous activity level.
Type of Employment
If the patient works outdoors or on uneven terrain, an exoskeletal prosthesis with a multiaxis foot may be appropriate. A businesswoman, on the other hand, may prefer the cosmesis of an endoskeletal prosthesis with a high-heel SACH foot and sculpted toes.
Sports
As materials and techniques are improved, it is becoming more common for patients to request a prosthesis designed for sports. Transtibial prosthetic components and techniques are available for swimming, skiing, jogging, and other sports. 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.
Previous Prosthesis
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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, an awareness of problems with the old prosthesis can help avoid difficulties with the new prosthesis.
Patient Goals
The patient's personal goals should be taken into consideration and prosthetic design tailored to those goals whenever possible.
Distal Padding
If distal coverage is thin, the length of the socket and the fit of the distal pad are of critical importance. If distal soft tissue is very heavy, this will probably decrease as the patient uses the prosthesis, and the limb may actually lose contact with the distal pad in the socket. If this occurs, a new distal pad must be fabricated to restore total contact.
Subcutaneous Tissue
Residual limbs with prominent bones and thin subcutaneous tissue will probably require the added protection of a soft liner in the socket. Because of their inherent protective padding, residual limbs with heavy subcutaneous tissue can often be fitted with hard sockets and a distal end pad.
Skin Problems
Skin problems such as blisters, ulcerations, cysts, verrucose hyperplasia, 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. Allergic skin reactions caused by materials can be remedied by choosing an alternate material.
Range of Motion
The patient should ideally be able to achieve full knee extension and flexion. If an extension contracture is present, a minimum of 35 degrees of knee flexion is necessary for normal ambulation. If the patient has a flexion contracture of greater than 25 degrees, prosthetic
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fitting will be difficult. When contractures exist, the patient may be referred for physical therapy. Contractures that cannot be reduced will have to be accommodated in the prosthesis.
BIBLIOGRAPHY
Abrahamson MA, Skinner HB, Effney DJ, et al: Prescription options for below knee amputees. Orthopedics 1985; 8:210-225. Atlas of Limb Prosthetics: Surgical and Prosthetic Principles. St Louis, Mosby-Year Book, 1981. Burgess EM: Amputation surgery and postoperative care, in Bonjeree SN (ed): Rehabilitation Management of Amputees. Baltimore, Williams & Wilkins, 1982. Burgess EM, Hittenberger DA, Forsgren SM, et al: The Seattle prosthetic foot-A design for active sports: Preliminary studies. Orthot Prosthet 1983; 13:25-32. Burgess EM, Matsen FA, III: Current concepts: Vascular disease. / Bone Joint Surg [Am] 1981; 65:1493-1497. Burgess EM, Zettl JH: The Management of Lower Extremity Amputations. Washington, DC, U.S. Government Printing Office, 1969. Campbell JW, Childs CW: The S.A.F.E. foot. Orthot Prosthet 1980; 34:3-17. Committee on Prosthetic-Orthotic Education: The Geriatric Amputee Principles of Management. Washington, DC, National Academy of Sciences, 1971. Friedmann, LW: The Surgical Rehabilitation of the Amputee. Springfield, 111, Charles C
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Thomas Publishers, 1978. Gerhardt JJ, King PS, Zettl JH: Amputations: Immediate and Early Prosthetic Management. Bern, Switzerland, Hans Huber Publishers, 1982. Hittenberger DA: The Seattle Foot. Orthot Prosthet 1986; 40:17-23. Kostuik JP: Amputation Surgery and Rehabilitation: The Toronto Experience. New York, Churchill Livingston Inc, 1981, p 18. Levy WS: Skin Problems of the Amputee. St Louis, Warner H Green Inc, 1983. Lower Limb Prosthetics, 1982 revision. New York University Post-Graduate Medical School, 1982. Lower Limb Prosthetics Including Prosthetists Supplement, 1982 revision. New York University Medical Center, 1982. McCollough NC III, Harris AR, Hampton FL: Below knee amputation, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981. Mier RH III: Amputations and prosthetic fitting, in Fisher SV, Helm PA (eds): Comprehensive Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984. Mensch G, Ellis P: Physical therapeutic management of lower extremity amputees, in Bonjeree SN (ed): Rehabilitation Management of Amputees. Baltimore, Williams & Wilkins, 1982. Mooney V, Harvey JP Jr, McBride E, et al: Comparison of postoperative stump management: Plaster versus soft dressings. J Bone Joint Surg [Am] 1976; 58:365-368. Pritham C: Suspension of the below knee prosthesis: An overview. Orthot Prosthet 1979; 33:1-19. Selected articles from Artificial Limbs January 1954 to Spring 1966. New York, Robert K Krieger Publishing Co Inc, 1970. Staats TB: Advanced prosthetics techniques for below knee amputees. Orthopedics 1985; 8:210-225. Staros A, Goralink B: Lower limb prosthetic systems, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981, pp 227-314. Vitali M, Robinson K, Andrews BG, et al: Amputations and Prostheses. London, Balliere Tindall, 1978. Weiss J, Middleton L, Gonzalez E, et al: The thigh corset: Its effect on the quadriceps muscle and its role in prosthetic suspension. Orthot Prosthet 1983; 3:58-63. Wilson BA Jr, Pritham C, Stills M: Manual for Ultralight Below Knee Prosthetics. Temple University, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, 1977. Wu Y, Brncick MD, Krick HJ, et al: Scotchcast P.V.C. interim prosthesis for below knee amputees. Bull Prosthet Res 1981; 10:36, 40-45. Wu Y, Keagy RD, Krick HJ, et al: An innovative removable rigid dressing technique for belowthe knee amputation. J Bone Joint Surg [Am] 1979; 6:724-729.
Chapter 18B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 19A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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unphysiologic unloading of the terminal part of the residual limb and indirect load transfer of transfemoral and transtibial amputations. 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. 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. load transfer, the residual limb has a bulbous distal shape. The distal portion of the femur can be narrowed and/or shortened to cosmetically decrease the bulbous end, but at the expense of decreased surface area and increased pressure concentration for weight bearing. 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, 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. Residual-limb volume fluctuations (e.g., as in renal failure) are also better tolerated than in surgical levels, which require intimate prosthetic socket fit.
SURGICAL PROCEDURES
Soft-Tissue Envelope
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The soft-tissue envelope is the interface between the hard prosthetic socket and the hard bone of the residual limb. Most late breakdowns in residual limbs, however, are due to tissue shear, not direct pressure. To minimize late tissue breakdown, the soft-tissue envelope should be formed with a mobile, nonadherent muscle mass and full-thickness skin in the areas of load transfer ( Fig 19A-5.).
Sagittal Flaps
Knee disarticulation, as advocated by Wagner and others, allows the patient to be operated upon in the supine position under regional anesthesia. This technique is well suited to the dysvascular patient since the skin flaps, being equal, each have minimal length ( Fig 19A6.,A). On closure, the surgical scar lies posteriorly, between the femoral condyles ( Fig 19A6.,B). The gastrocnemius is retained to provide a cushioned soft-tissue envelope that will allow comfortable direct load transfer. 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. In this case, the posterior junction is placed more distally to achieve equal sagittal flaps. Each flap is mobilized proximal to the knee joint. The patellar ligament is isolated and skived off the tibial tubercle. The knee joint capsule is incised circumferentially at the level of the joint, and the cruciate ligaments are skived from their attachments on the tibia. The vascular bundle components are ligated at this level, and the tibial and peroneal nerves are transected proximally and allowed to retract. The gastrocnemius is divided distally to form a flap long enough to allow gastrocnemius myofascia to be sutured to the remaining knee joint capsule. The skived patellar ligament is sutured to the stumps of the cruciate ligaments, 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.,A). The menisci can be removed because their shock-absorbing function will be replaced by the gastrocnemius muscle flap. The posterior fascia of the gastrocnemius is then sutured to the remaining knee joint capsule, and the skin is reapproximated ( Fig 19A-7.,B). The suture line assumes a midline posterior position between the femoral condyles. A soft compression or rigid plaster or fiberglass dressing is applied.
Circumferential Incision
The main value of this technique is that no flaps are produced; however, the operation must be performed with the patient in the prone position. The knee is flexed to 90 degrees, and a circumferential skin incision is performed approximately 1.3 cm ( in.) distal to the tibial tuberosity. Anteriorly and medially, the incision is carried down to bone, with the patellar tendon and pes anserinus elevated before the knee joint is entered. The capsule and ligaments are incised circumferentially at the joint level. The cruciate ligaments are skived from the tibia, the origins of the gastrocnemius from the femur, and the biceps femoris from the fibular head. The patellar tendon and biceps femoris are sutured to the stumps of the cruciate ligaments. The an-teromedial portion of the retinaculum is sutured to the posterior part of the capsule and semimembranosus. The skin is closed longitudinally, and an appropriate dressing is applied ( Fig 19A-9.).
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Reduction Osteoplasty
Reduction osteoplasty decreases the bulk of the distal end of the residual limb to permit fabrication of a more cosmetic prosthetic socket. This is accomplished at the cost of decreased suspension from the expanded femoral condyles, so auxiliary suspension might be required. The distal articular surface can be retained, as advocated by Mazet and Hennessy, simply by trimming the medial, lateral, and posterior protruberances. Burgess advocates shortening the femur by removing the distal portion of the condyles in order to keep the knee centers level ( Fig 19A-10. ). By maintaining the expanded metaphyseal region of the distal end of the femur, direct load transfer can still be accomplished. Any of the described surgical approaches can be modified to incorporate these options. Reduction osteoplasty, however, should generally be reserved for traumatic and tumor patients with normal vasculature in whom the extra surgical dissection will not compromise wound healing.
SUMMARY
Knee disarticulation allows the direct transfer of body weight from the end of the residual femur to the prosthesis. This restores useful proprioception as well as the ability to take advantage of the intrinsically stable, poly-centric four-bar-linkage prosthetic knee joint. Weight bearing and shear stress dissipation are enhanced when the distal end of the femur is covered with a mobile, nonadherent cushion fashioned from the gastrocnemius muscle belly. In children, knee disarticulation has the added advantages of preservation of distal femoral growth potential and the elimination of appositional bony overgrowth. In adults, 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. Another relative indication for knee disarticulation is in patients with large residuallimb volume fluctuations as seen in severe renal failure or congestive heart failure. In addition, 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. In these cases, knee disarticulation rather than transfemoral amputation is recommended for the reasons mentioned above. References: 1. Burgess EM: Disarticulation of the knee. A modified technique. Arch Surg 1977; 112:1250-1255. 2. Epps CH Jr, Schneider PL: Treatment of hemimelias of the lower extremity. Long-term results. J Bone Joint Surg [Am] 1989; 71:273-277. 3. Greene MP: Four bar linkage knee analysis. Orthot Pros-thet 1983; 37:15-24. 4. Inman VT, Ralston HJ, Todd F: In Human Walking. Baltimore, Williams & Wilkins, 1981. 5. Loder RT, Herring JA: Disarticulation of the knee in children. A functional assessment. J Bone Joint Surg [Am] 1987; 69:1155-1160. 6. Mazet R, Hennessy CA: Knee disarticulation. A new technique and a new knee-joint mechanism. J Bone Joint Surg [Am] 1966; 48:126-139. 7. McCollough NC III: The dysvascular amputee: Surgery and rehabilitation. Curr Probl Surg 1971; 00:000. 8. Pinzur MS, Gold J, Schwartz D, et al: Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics 1992, in press. 9. Pinzur MS, Smith DG, Daluga DJ, et al: Selection of patients for through-the-knee amputation. J Bone Joint Surg [Am] 1988; 70:746-750. 10. Rogers SP: Amputation of the knee joint. J Bone Joint Surg 1940; 22:973-979. 11. Thomas B, Schopler S, Wood W, et al: The knee in arthrogryposis. Clin Orthop 1985; 194:87-92. 12. Wagner FW: A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. In-str Course Lect 1979; 28:143-165.
Chapter 19A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 19B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
POSTOPERATIVE MANAGEMENT
Although immediate postoperative fitting with a prosthesis is technically feasible, it is rarely provided today. This may have more to do with the unfa-miliarity of this level of amputation to both prosthetist and surgeon than any other factor. Soft gauze dressings followed by elastic bandaging once the wound has healed is probably the most common approach. However, knee disarticulation can be managed by the same range of techniques as more familiar amputations. These include the use of an inflated air splint (with or without a walking Unna's paste semirigid dressing, and a novel polyurethane foam apparatus over it), dressing that is formed directly over the residual limb between layers of stockinette. This latter technique (Neofract) incorporates a full-length zipper for easy dressing removal. While immediate ambulation on a plaster of paris socket is seldom advocated for the dys-vascular individual today, some opt to use the postoperative plaster cast alone, preferably applied by the surgeon in the operating theater. Those who advocate such a rigid dressing believe that it enhances wound healing and facilitates rehabilitation.
Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists
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BIOMECHANICS
Although the biomechanics of the transfemoral (above-knee) amputation are well known, the principles of knee disarticulation biomechanics are less commonly understood. The basic problem at midstance is similar: to stabilize the superincumbent body mass during single-limb support on the prosthesis ( Fig 19B-1.). The resultant socket stresses, however, are significantly different from those at the transfemoral level. Successful knee disarticulation surgery is predicated on the ability to comfortably tolerate full end weight bearing on the residual limb. Once this is accomplished, there is no need for any proximal weight bearing, and ischial contact is superfluous. As is the case in all end weight-bearing amputation stumps (e.g., the Syme level), the effective center of rotation in the socket is at the distal-most aspect. Thus, 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.,A). In contrast, the center of rotation for the transfemoral socket is located near the ischium, so
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ambulation causes rotary forces at the distal part of the socket ( Fig 19B-2.,B). Since the transfemoral socket is primarily pelvic bearing, the femur is relatively unconstrained and tends to displace within the soft tissue distally. In the knee disarticulation socket with end weight bearing, the femur is effectively stabilized by body weight. 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. Suspension in the knee disarticulation socket is ideally provided by intimate fitting just proximal to the condyles. 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.). It should be noted that particularly for obese or muscular individuals, it may be extremely difficult to secure adequate supracondylar suspension. This is especially true for the initial fitting when postoperative edema may be present. In such cases, ( Fig it may be necessary to augment suspension with suction or a Silesian belt variant 19B-4.). 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. Because the center of rotation is just above the knee mechanism and because the bony lever arm is full length with undisturbed musculature, it is easier for the knee disarticulate to control the prosthetic knee mechanism than if he were a transfemoral amputee.
SOCKET VARIATIONS
A number of socket variations are possible and differ primarily in their adjustability and cosmetic appearance. Since knee disarticulation in children preserves the distal femoral growth plate and eliminates the risk of bony overgrowth, the prosthetist will encounter a significant percentage of pediatric cases. Zettl has described a segmental socket design with independently adjustable proximal and distal portions to accommodate linear growth in ( Fig 19B-5.). Because children. Suspension is achieved by adjustable supracondylar straps immature condyles are not very bulky, it is sometimes possible to create a self-suspending ( Fig 19B-6.). This socket where flexible inner walls barely allow the condyles to pass approach may also be feasible when the condyles have been surgically trimmed. Because such sockets are extremely difficult to fit and allow no adjustments, they are only rarely encountered. 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. This would obviate the prosthetic problems of limited cosmesis and restricted choice of knee mechanisms that are inherent in knee disarticulation. However, such differential growth is not inevitable. 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. Another socket option for this level is the traditional anterior lacing design. Although originally ( Fig 19B-7.), it can be easily adapted to modern developed for molded leather sockets flexible plastics. Despite being somewhat cumbersome to don and doff, it has the advantage of accommodating moderate volume fluctuations in the residual limb. Botta of Switzerland is With two decades of one of the leading prosthetic advocates of knee disarticulation fittings. experience involving several hundred cases, he advocates a carefully molded distal liner to protect the condyles and provide suspension ( Fig 19B-8.). When combined with a socket that is rigid distally but gradually changes to flexible at the proximal edges, he reports good ( Fig 19B-9.). Because the polyethylene success even with geriatric and bilateral amputees foam inner liner can be readily adjusted to maintain snug pressure over the condyles, marked This ultimately improves cosmesis for fleshy individuals distal atrophy occurs over time. since the residual limb dimensions become smaller than the uninvolved thigh ( Fig 19B-10. ). Kristinsson of Iceland has reported success with a variation using a flexible rubber cup that terminates just above the condyles to provide suction suspension. Since the patient pushes his condyles into the suspension cup to don the prosthesis, this version is termed the The majority of the thigh is not covered by Icelandic Push-on Suction Socket (ICEPOSS). any socket materials; an adjustable circumferential band is attached to a medial strut to provide stability ( Fig 19B-11. ). There are two primary approaches to taking the plaster of paris cast impression for knee
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disarticulation sockets. Lyquist suggests a weight-bearing procedure by placing a foam pad beneath the cast while the plaster is wet to form the transcondylar contours. This technique is difficult for some geriatric or bilateral amputees to manage. Botta and Baumgartner advocate a non-weight-bearing method with the amputee supine and stress meticulous hand molding of the femoral condyles. Their technique is applicable to geriatric as well as other knee disarticulation amputees. 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. Relief is usually provided for the lateral posterior femoral condyle. Most knee disarticulation sockets are laminated of reinforced plastic resins, but thermoplastic materials are also being used successfully, particularly for geriatric individuals.
COMPONENTRY
Despite its functional advantages, 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. As a recent text notes, "Until about fifteen years ago none of the prosthetic knee mechanisms available could meet even reasonable cosmetic requirements, nor could they meet the functional demands of the young active amputee." Most available knee units are designed for transfemoral amputation; when used for knee disarticulation, they protrude as much as 2 in. beyond the anatomic knee center. Although this causes no significant gait deviations, it results in a decidedly bizarre appearance that most find objectionable. It also makes sitting in confined spaces such as automobile and theater seats difficult since the thigh segment juts out so far. From the time knee disarticulation was first reported by Fabricius Hildanus in 1581 until the early 1970s, the only available knee alternative was external hinges similar to those used on knee-ankle-foot orthoses. Because these hinges transmit weight-bearing forces in the knee disarticulation socket (in contrast to their orthotic application), lack of durability has been a chronic problem. In addition, external hinges offer no swing-phase control. Since disarticulation retains full femoral leverage and thigh musculature, this is a significant disadvantage. One manufacturer provides a yoke attachment permitting use of a fluid( Fig 19B-12. ). controlled cylinder with these hinges, but durability remains a concern Although external hinges result in the least possible protrusion of the thigh segment when sitting, a somewhat wider mediolateral dimension is the inevitable result ( Fig 19B-13. ). Many find the bulky appearance objectionable despite specialized finishing techniques to minimize the discrepancy. The only other available alternative for knee disarticulation is the polycentric knee. Greene has published an excellent paper discussing the four-bar class of poly-centric mechanisms, As he notes, it is possible to analyze the including those designed for knee disarticulation. function of four-bar polycentric knees through geometric analysis. The intersection of the anterior and posterior knee links define the instantaneous center of rotation: the effective ( Fig 19B-14. ). At heel strike, 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. Because the instantaneous center is both proximal and posterior to the anatomic knee center, such mechanisms are very stable ( Fig 19B-15. ). Like the human knee, the locus of rotation of the four-bar polycentric knee changes with the flexion angle ( Fig 19B-16. ). This has two major effects on amputee gait. One is that the effective length of the shin shortens with increasing knee flexion. 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. The first polycentric knee designed for knee disarticulation applications was developed at the Orthopedic Hospital Copenhagan (OHC) in 1969. Careful design of the linkage arms results in a mechanism that appears to fold back under the thigh when sitting, 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. ). Several European and Asian manufacturers have developed similar polycentric designs during the past decade. Some are available in lightweight versions of carbon fiber or titanium. Locking modules are also available for those who unable to manage a free knee ( Fig 19B19. ). Due to the inherent stability of polycentric knees, manual locking is only rarely necessary. With the widespread availability of polycentric mechanisms, the cosmetic liability of knee
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disarticulation has been reduced, although not completely eliminated ( Fig 19B-20. ). Durability has also improved over that of external hinges, but specialized knee disarticulation joints are not as rugged as conventional transfemoral mechanisms. 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, Chapter 20B, and Chapter 21B). 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.
SUMMARY
Although knee disarticulation remains uncommon in most of North America, it has strong proponents in many quarters. There is general consensus that it is functionally superior to higher-level amputation provided that full end weight bearing is achieved. It is undoubtedly the transfemoral level of choice for children since it preserves the distal epiphysis and avoids bony overgrowth. The cosmetic liabilities and knee mechanism shortcomings have been significantly reduced through the development of specialized four-bar polycentric designs, but prosthetic options, appearance, and durability are still somewhat compromised when compared with the transfemoral levels. References: 1. Agarwal AK, Goel MK, Srivastava RK, et al: A clinical study of amputations of the lower limb. Prosthet Orthot Int 1980; 4:162-164. 2. Bar A, Seliktar R, Susack A: Pneumatic supracondylar suspension for kneedisarticulation prostheses. Orthot Prosthet 1977; 31:3-7. 3. Batch JW, Spittler AW, McFaddin JG: Advantages of the knee disarticulation over amputation through the thigh. J Bone Joint Surg [Am] 1954; 36:921-930. 4. Baumgartner RF: Failures in through-knee-amputation. Prosthet Orthot Int 1983; 7:116-118. 5. Baumgartner RF: Knee disarticulation versus above-knee amputation. Prosthet Orthot Int 1979; 3:15-19. 6. Botta P, Baumgartner RF: Through-knee socket design and manufacture. Prosthet Orthot Int 1983; 7:100-103. 7. Botta P, Baumgartner RF: The knee disarticulation prosthesis, in Murdoch G, Donovan RG (eds): Amputation Surgery & Lower Limb Prosthetics. Oxford, England, Blackwell Scientific Publications, 1988. 8. Burgess EM, Romano RL, Zettl JH: Amputation management utilizing immediate postsurgical fitting. Prosthet Orthot Int 1969; 3:28-37. 9. Cummings GS, Girling J: A clinical assessment of immediate postoperative fitting of prosthesis for amputee rehabilitation. Phys Ther 1971; 51:1007-1011. 10. Donaldson WF: Knee disarticulation in childhood. Inter-Clin Info Bull 1962; 1:5-9. 11. Eaton WR: Knee disarticulation treated as above-knee amputation. Inter-Clin Info Bull 1962; 1:11-14. 12. Ebskov B: Choice of level in lower extremity amputation-nationwide survey. Prosthet Orthot Int 1983; 7:58-60. 13. Edwards JW (ed): Orthopedic Appliance Atlas, vol 2. Ann Arbor, Mich, American Academy of Orthopedic Surgeons, 1960. 14. Ghiulamila RI: Semi-rigid dressing for postoperative fitting of below-knee prosthesis. Arch Phys Med Rehabil 1972;53:186-190. 15. Gilley R: Technical note: Cosmesis and the knee disarticulation prosthesis. Clin Prosthet Orthot 1988; 12:123-127. 16. Glattly HW: A statistical study of 12,000 new amputees. South Med J 1964; 57:13731378. 17. Greene MP: Four bar linkage knee analysis. Orthot Prosthet 1983; 37:15-24. 18. Harding HE: Knee disarticulation and Syme's amputation. Ann R Coll Surg Engl 1967; 40:235-237. 19. Hughes J: Biomechanics of the through-knee prosthesis. Prosthet Orthot Int 1983; 7:96-99. 20. Kay HW, Newman JD: Relative incidences of new amputations. Orthot Prosthet 1975; 29:3-16. 21. Kempfer JJ: Technical note: Thermoplastic use in the geriatric knee-disarticulation prosthesis. J Prosthet Orthot 1990; 3:38-40. 22. LeBlanc MA: Patient population and other estimates of prosthetics and orthotics in the U.S.A. Orthot Prosthet 1973; 27:38-44.
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23. Lexier RR, Harrington IJ, Woods JM: Lower extremity amputation: A five-year review and comparative study. Can J Surg 1987; 30:374-376. 24. Little JM: The use of air splints as immediate prostheses after below-knee amputation for vascular insufficiency. Med J Aust 1970; 2:870-872. 25. Lyquist E: Casting the through-knee stump. Prosthet Orthot Int 1983; 7:104-106. 26. Lyquist E: The knee unit dilemma with respect to the knee disarticulation procedure, in Murdoch G, Donovan RG (eds): Amputation Surgery & Lower Limb Prosthetics. Oxford, England, Blackwell Scientific Publications, 1988. 27. Lyquist E: The OHC knee-disarticulation prosthesis. Orthot Prosthet 1976; 30:27-28. 28. Mandrup-Poulsen T, Jensen JS: Incidence of major amputations following gangrene of the lower limb. Prosthet Orthot Int 1982; 6:35-37. 29. Mazet R, Schmitter ED, Chupurdia R: Disarticulation of the knee: A follow-up report. J Bone Joint Surg [Am] 1978; 60:675-678. 30. Michael JW: Component selection criteria: Lower limb disarticulation. Clin Prosthet Orthot 1988; 12:99-108. 31. Murdoch G: The postoperative environment of the amputation stump. Prosthet Orthot Int 1983; 7:75-78. 32. Oberg K: Knee mechanisms for through-knee prostheses. Prosthet Orthot Int 1983; 7:107-112. 33. Pritham CH, Fillauer CE, Fillauer KD: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92-103. 34. Radcliffe CW: The Knud Jansen lecture: Above knee prosthetics. Prosthet Orthot Int 1977; 1:146-160. 35. Richards JF, Pierce JN: Knee disarticulation successfully fitted with a PTS socket. Inter-Clin Info Bull 1977; 16:7-10. 36. Shaw IB: Choice of prosthetic knee for bilateral knee disarticulation (abstract). J Assoc Child Prosthet Orthot Clin 1986; 21:55. 37. Steen Jensen J: Life expectancy and social consequences of through-knee amputations. Prosthet Orthot Int 1983; 7:113-115. 38. Steen Jensen J: Success rate of prosthetic fitting after major amputations of the lower limb. Prosthet Orthot Int 1983;7:119-121. 39. Sweitzer RR: A Silastic-lined knee-disarticulation prosthesis. Inter-Clin Info Bull 1973; 12:5-9. 40. Weiner DS: Prosthetic stimulation of femoral growth following knee disarticulation. Inter-Clin Info Bull 1976; 15:15-16. 41. Wells GG, Bigelow E, Messner DG: Knee disarticulation following snakebite in a young child. Inter-Clin Info Bull 1972; 11:1-5. 42. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. Phys Ther 1971; 51:144-151. 43. Zettl JH, Brunner H, Romano RL: Knee disarticulation socket design for juvenile amputees. Inter-Clin Info Bull 1977; 16:11-15.
Chapter 19B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 20A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
BIOMECHANICS
The normal anatomic and mechanical alignment of the lower limb has been well defined ( Fig 20A-1.). 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. The femoral shaft axis measures 9 degrees from the vertical. The normal anatomic alignment of the femur is thus in adduction, 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, thus producing a smoother and more energy-efficient gait. In most transfemoral amputees, mechanical and anatomic alignment is disrupted since the residual femur no longer has its natural anatomic alignment with the tibia, leaving the femoral shaft axis in abduction as compared with the sound limb. The abducted femur of the transfemoral amputee leads to an increase in side lurch and higher energy consumption. In addition, the major portion of the adductor insertion is lost in conventional transfemoral amputations. Only the adductor magnus has an insertion on the mediodistal third of the femur. Once this attachment is lost at the time of surgery, the femur swings into abduction because of the relatively unopposed action of the abductor system. 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. As the insertions of the adductor muscles are lost, their effective moment arm becomes shorter. Thus a smaller mass of adductor muscle would have to generate a larger force to
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hold the femur in its normal position. They are unable to generate this force to hold the femur, and an abducted position is then maintained. Prosthetists have recognized that residual femoral abduction compromised patient function and that prosthetic fitting of the transfemoral amputee was not satisfactory. 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. shape is also claimed to better control abduction of the residual femur. 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. The adductor magnus has a moment arm with the best mechanical advantage as compared with the adductor longus and brevis ( Fig 20A-2.). Transection of the adductor magnus at the time of amputation leads to a major loss of muscle cross-sectional area, a reduction in the effective moment arm, and a loss of up to 70% of the adductor pull. This combination results in overall weakness of the adductor force of the thigh and subsequent abduction of the residual femur. In addition, 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. It has been noted that a reduction in muscle mass at amputation, combined with inadequate mechanical fixation of muscles as well as atrophy of the remaining musculature, was the major factor for the decrease in muscle strength detected in transfemoral amputees. Most noticeable was a decrease in strength of the flexor, extensor, abductor, and adductor muscles of the hip, which correlated with inadequate muscle stabilization. The goal of surgery in a transfemoral amputation should be the creation of a dynamically balanced residual limb with good motor control and sensation. Preservation of the adductor magnus muscle is possible and helps maintain the muscle balance between the adductors and abductors. 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. 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. 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. Although muscle stabilization is advocated as a means of controlling the femur, in actuality this is infrequently achieved since the remaining muscle mass will have retracted at the time of transection ( Fig 20A-3.). 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. the muscles are resected from the bony attachment. Once the myodesis has been done, the remaining tissue can be excised.
Trauma
The majority of patients who require a transfemoral amputation for trauma are generally in the younger age group. Most times the indication for amputation will be severe soft-tissue, vascular, neurologic, and bone injury. Maximum length should be retained, but it is important to have a good soft-tissue envelope and avoid a split-thickness skin graft to bone (refer to Chapter 2B). 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. On occasion, split-skin grafts may be used with a view to secondary skin expansion.
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Fractures of the femur should be stabilized by appropriate means rather than amputating through a proximal fracture site. The orientation of skin flaps is not critical, but closure should be without tension.
Infection
Amputation for severe infection or osteomyelitis should be done as a two-stage procedure with antibiotic coverage. In some situations, the placement of antibiotic-impregnated methacrylate beads is useful for controlling local infection. All infected tissue must be excised (refer to Chapter 2D).
Tumors
Often the level of amputation is determined by the type and location of the tumors. The principles of tumor eradication need to be considered, while at the same time, as long a stump as possible is preserved. Preservation and restoration of function are important factors (refer to Chapter 2E).
TECHNIQUE
In general, a tourniquet is not used for the majority of transfemoral amputations. If necessary, a sterile tourniquet can be placed as high on the thigh as possible and released prior to setting muscle tension. Skin flaps should be marked out prior to the skin incision ( Fig 20A4.). Anterior flaps are fashioned longer than posterior flaps so that the suture line will be posterior. A long medial flap in the sagittal plane is also acceptable, and any flap configuration that will enhance feasible preservation of length is acceptable in trauma or tumor. One should make the skin flaps longer than may be initially thought necessary to avoid having to shorten the bone too much. Once the major vessels have been isolated, they should be ligated and cut at the proposed level of bone section. The major nerves should be dissected 2 to 4 cm proximal to the bone cut and sectioned with a new, sharp blade. The central vessel can be lightly cauterized or secured by a stitch tie around the nerve. 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. Muscles should not be sectioned until they have been identified. The quadriceps should be detached just proximal to the patella to retain some of its tendinous portion. The adductor magnus is detached from the adductor tubercle by sharp dissection and reflected medially to expose the femoral shaft. It may be necessary to detach 2 to 3 cm of the magnus from the linea aspera. The smaller muscles should be transected approximately 1 to 2 in. longer than the proposed bone cut to facilitate their inclusion and anchorage. 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 7.5 to 10 cm above the knee joint line. The blade should be cooled with saline. Two or three small drill holes are made on the lateral cortex of the distal end of the femur 1 to 1.5 cm from the cut end. Additional holes are made anteriorly and posteriorly. 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.). Prior to securing the stitches, the femur is held in maximum adduction, while the adductor magnus is brought across the cut end of the femur while maintaining its tension. Additional anterior and posterior sutures are placed to prevent the muscle from sliding forward or backward on the end of the bone. Once the adductor magnus has been anchored, the quadriceps is sutured to the posterior aspect of the fe>mur via the posterior drill holes ( Fig 20A-6.). The hip should be in extension when this is done to prevent creating a hip flexion contracture. The remaining hamstring muscles are then anchored to the posterior area of the adductor magnus. The investing fascia of the thigh is then sutured as dictated by the skin flaps. Subcutaneous stitches may be used to approximate the skin edges, and fine nylon sutures (3.0 or 4.0) are used to close the skin and are placed no closer than 1 cm apart, especially in dysvascular cases. Fig 20A-7. shows a postoperative roentgenogram with the femur held in adduction by the adductor myodesis.
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Although some authors advocate the use of myoplasty alone to anchor the muscles, this technique does not restore normal muscle tension, nor does it allow for adequate muscle control of the femur. At the time of myoplasty the agonist and antagonist groups of muscles are sutured to each other over the bone end. This does not provide a stable situation, and the residual femur moves in the muscle envelope and produces pain. 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. 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. Although rigid dressings control the edema and stump position better than soft dressings do, they are cumbersome to apply and do not offer any great advantage in the long term in transfemoral amputations. A well-applied elastic bandage will not slip off the residual limb. Another method of controlling the swelling and reducing discomfort is to apply an elastic shrinker with a waist belt. The shrinkers are made of a oneor two-way stretch material that applies even pressure distally to proximally. The waist belt helps prevent the shrinker from slipping off. The shrinker may be applied at the first dressing change at 48 hours. Postoperative phantom pain is not uncommon and can be reduced by infiltrating the sectioned nerve with bupivacaine (Marcaine) at the time of surgery. 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. This is only done for 3 to 4 days and then discontinued. A controlled study has confirmed the effectiveness of this method and showed that the amount of postoperative narcotic analgesic could be considerably reduced.
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7. Harris WR: Principles of amputation surgery, in Kostuik JP (ed): Amputation Surgery and Rehabilitation- The Toronto Experience. New York, Churchill Livingstone Inc, 1981. 8. Hungerford DS, Krackow KA, Kenna RV: Total Knee Arthroplasty. Baltimore, Williams & Wilkins, 1984, pp 34-39. 9. James U: Maximal isometric muscle strength in healthy active male unilateral aboveknee amputees with special regard to the hip joint. Scand J Rehabil Med 1973; 5:5566. 10. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet Orthot 1985; 9:9-14. 11. Malawer M, Buch R, Khurana J, et al: Postoperative in-fusional continuous regional analgesia. Clin Orthop 1991; 266:227-237. 12. Maquet P: Biomechanics of the Knee. New York, Springer-Verlag, NY Inc, 1980, p 22. 13. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15-26. 14. Steen JJ, Mandrup-Poulsen T, Krasnik M: Wound healing complications following major amputations of the lower limb. Prosthet Orthot Int 1982; 6:105-107. 15. Thiele B, James U, St. Alberg E: Neurophysiological studies on muscle function in the stump of above-knee amputees. Scand J Rehabil Med 1973; 5:67-70. 16. Volpicelli LJ, Chambers RB, Wagner FW: Ambulation levels of bilateral lower-extremity amputees. J Bone Joint Surg [Am] 1983; 65:599-604. 17. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking of amputees: Influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46.
Chapter 20A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 20B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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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. Excessive energy expenditure and an unnatural swing phase of the gait cycle are the results. There is a very fine distinction between knee instability and excessive knee stability. The key to avoiding these two undesirable characteristics and achieving optimum knee stability is an understanding of the biomechanics of prosthetic knee function. In biomechanical terms, there are two descriptions of knee stability or knee control: ( Fig 20B-1.). 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. The degree of involuntary control varies in complexity. 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, which generally extends from the midpoint of the socket proximally to the midpoint of foot contact with the ground. With the weight line anterior to the prosthetic knee axis, increased weight bearing tends to force the knee into extension and locks it against the extension stop. Excessive knee stability, as described earlier, occurs when the prosthetic knee joint is located too far posterior to the biomechanical weight line. Other forms of involuntary knee control are mechanical and include locking knees, weight-activated stance-control knees, and certain hydraulic knee systems. 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. These muscles include the gluteal muscles (primarily the gluteus maximus) and the hamstring muscle group. When these muscles can exert enough force and are consciously fired at the proper time by the amputee, knee stability is achieved in the stance phase of gait. For the stronger and more physically fit amputee, 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. Better muscle tone and coordination are achieved as well. However, voluntary control is not always possible, especially when muscle weakness, hip flexion contractures, and fear, all common to the more elderly and otherwise debilitated amputee, are present. Additional factors that contribute to control of knee stability are initial socket flexion, the trochanter-knee-ankle (TKA) relationship, and ankle-foot dynamics. Earlier, the need for analysis of the range of hip flexion and extension of the residual limb was discussed. The hip extensor muscles contribute to knee stability by pulling the prosthetic knee into extension or by maintaining existing knee extension. The hamstring muscles, which are transected by transfemoral amputation, are believed to function best when stretched just beyond their rest length. It is also known that the only intact hip extensor, the gluteus maximus, is not capable of exerting any significant force until the hip is flexed at least 15 degrees. To achieve some degree of stretching of the gluteus maximus, the prosthetic socket is designed and aligned in a position of "initial flexion." The amount of initial flexion increases as the amputees ability to extend his hip decreases. The only limiting factor is the length of the residual limb. For longer residual limbs, some cosmesis has to be sacrificed as initial flexion is increased. In addition to enhancing voluntary control of knee stability, initial socket flexion decreases the tendency of the amputee to use increased pelvic lordosis to compensate for weak hip extensors. The TKA relationship is best understood as the socket-knee-ankle relationship. To review, the more anterior the socket is placed to the knee joint and ankle, the more stable the knee. In most cases, 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. (Such an alignment device may later be transferred out of the finished prosthesis.) In this ideal situation, the anteroposterior (AP) setting of the socket is determined under dynamic conditions as the amputee's gait is analyzed carefully. The goal is to align the prosthesis so that the amputee uses the minimum amount of "alignment stability" or involuntary knee control necessary, thereby optimizing voluntary knee control for each individual patient. A critical balance between these two biomechanical conditions is required to achieve a safe, yet efficient gait. Ankle-foot dynamics refers to the shock-absorbing and stabilizing abilities of this combined component system of the prosthesis. The most unstable phase of gait for a transfemoral amputee is at heel strike. At heel strike, a moment or torque is created that tends to rotate the shin forward and thus flex the knee, thereby creating an instant of potential knee instability ( Fig 20B-2.). In normal human locomotion, smooth and uninterrupted plantar flexion
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serves to dampen the significant moment initiated at heel strike. In the transfemoral prosthesis, ankle-foot components that more closely replicate normal ankle-foot function contribute to knee stability. The goal is inherent stability throughout mid-stance followed by smooth, uninterrupted, gradually increasing flexion throughout the initial swing phase of gait.
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muscular residual limbs (which are often longer in length) are better able to tolerate this reaction force. Soft, 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. In such cases, 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. The relatively recent advent of the ischial-ramal containment transfemoral socket design provides one solution to this problem. Prosthetic alignment is a significant variable that contributes to trunk and pelvis stability. 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. dynamically by using adjustable alignment devices within the prosthesis ( Fig 20B-6.).
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4. Properly applied pressure is well tolerated by neurovascular structures. 5. Force is best tolerated if it is distributed over the largest available area. Regardless of the fitting method employed, the socket for any amputee must provide the same overall functional characteristics, including comfortable weight bearing, stability in the stance phase of gait, a narrow-based gait, and as normal a swing phase as possible These characteristics will consistent with the residual function available to the amputee. provide the format for a description of transfemoral sockets.
Quadrilateral Socket
The term quadrilateral refers to the appearance of the socket when viewed in the transverse plane ( Fig 20B-7.) because there are four distinguishable sides or walls of the socket. The orientation of the four walls will vary according to the amputee's specific anatomy and the biomechanical requirements of the socket. According to Radcliffe, "the socket is truly more than just a cross-section shape at the ischial level, it is a three-dimensional receptacle for the stump with contours at every level which are justifiable on a sound biomechanical basis." Weight bearing in the quadrilateral socket is achieved primarily through the ischium and the gluteal musculature. This combination of skeletal and muscular anatomy rests on the top of the posterior wall of the socket, which is formed into a wide seat that is parallel to the ground. Countersupport, intended to maintain the position of the ischium and gluteals on this posterior seat, is provided by the medial third of the anterior wall of the socket, which is carefully fitted against Scarpa's triangle. The AP dimension of these respective walls is based on anatomic measurements. A common error is to create deep, exaggerated Scarpa's triangle contours. As the concepts of total contact and total surface bearing became better understood, anterior counterpressure was de-emphasized. 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. This suggests that tissue and muscle loading occurs as a supplementary weight-bearing mechanism. The concept of total surface bearing suggests that weight bearing be as evenly distributed over the entire surface area as possible, with the forces and loads being evenly shared by skeletal anatomy, muscle, soft tissue, and hydrostatic compression of residual limb fluids. Incorporation of adduction into the quadrilateral socket depends on the range of motion available, generally a function of the length of the residual limb. The goal is to re-establish the normal adduction angle of the femur with respect to a level pelvis. The quadrilateral socket accomplishes this by contouring the lateral wall in the desired degree of adduction. 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. Proximal to the greater trochanter, the lateral wall is contoured into and over the hip abductor muscle group to discourage abduction. As previously discussed, 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, the contour of the medial wall of the socket is flat in the sagittal plane along the proximal 4 in. of the socket before reversing into a smooth flare directed away from the residual limb and toward the perineum. Careful attention to this proximomedial socket contour is absolutely essential for stance-phase comfort in 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.). The achievement of normal swing phase is dependent upon several factors. Obviously, proper suspension enhanced by careful matching of residual-limb and socket contours aids in achieving a normal swing phase. Proper socket contours for actively functioning muscles (primarily the rectus femoris and gluteus maximus) also affect swing-phase tracking in the sagittal plane. The depth of the rectus femoris channel, in the transverse view, will vary depending on proximal circumference and muscular firmness of the residual limb, as well as femoral anteversion. The posteromedial wall angle varies from 5 to 11 degrees, depending on the muscular density of the proximoposterior aspect of the residual limb ( Fig 20B-9.,A and B). If the AP dimension of the lateral half of the quadrilateral socket is too tight, as viewed transversely, 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."
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The distal end of the socket must match the contour of the distal end of the residual limb and provide adequate distal contact, or else edema and other skin problems will develop. The concept of the "U.S. quadrilateral socket" was borrowed from Europe and refined through significant biomechanical analysis and research conducted in the United States. The original concept also continued to develop independently in Europe. During the decade of the 1980s, several European-style quadrilateral socket casting brims became available in the United States. When compared with the U.S. quadrilateral brims, the transitions from the four socket walls were smoother and less abrupt. The medioproximal wall was slightly lower and increased comfort in the perineum. In the transverse view, these European brims featured a larger AP dimension balanced by a smaller mediolat-eral dimension as compared with typical U.S. quadrilateral shapes. Although the biomechanical principles remained the same, these subtle changes began to influence U.S. quadrilateral techniques at about the time that the "ischial containment" socket initiated new concepts in transfemoral socket theory.
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may occur and decrease the effectiveness of the gluteus medius. 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. The resulting "bony lock" between the ischium, trochanter, and laterodistal aspect of the femur provides a much more stable mechanism for acceptance of perineal biomechanical forces. Two clinical results are increased comfort in the groin and better control of the pelvis and trunk ( Fig 20B-11. ,A and B). Stance stability may be enhanced by extensive contouring posterior to the femoral shaft; this allows more effective transmission of the movements of the femur to the prosthesis. Swing-phase suspension is critical and is usually achieved by suction. As with the quadrilateral socket, proper contours allow for smooth swing-phase tracking. Rotational control is provided by the proxiomedial brim and its bony lock against the ischium, the shape and channels of the anterior wall, and the post-trochanteric contour of the lateral wall seen in transverse view ( Fig 20B-12. ,A and B). Socket rotation control for very fleshy residual limbs with poor muscle tone is best achieved with an ischial containment socket.
1. Mature residual limb (frequent socket changes not anticipated) 2. Medium to long residual limb (where a significant portion of the wall will be left exposed and flexible) 3. 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.
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1977) has crept into popular consciousness. Recently, however, some semblance of order has begun to emerge (Pritham, 1988; Schuch, 1988) and attention has come to be focused on the role of the ischium. 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. Further, 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. In a similar vein, Michael contends "that these new designs represent evolutionary rather than revolutionary advances." In reality, 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. The conclusions of a panel of physicians, prosthetists, and engineers who participated in an international workshop on transfemoral fitting and alignment techniques follows: No specific contraindications were noted for any socket design. Some advocated not changing successful quadrilateral socket wearers. Quadrilateral sockets are most successful on long, firm residual limbs with firm adductor musculature. Ischial containment sockets are more successful than quadrilateral sockets on short, fleshy residual limbs. Ischial containment sockets are the better recommendation for high-activity sports participation. Lack of agreement existed on the best recommendation for the bilateral transfemoral amputee. Flexible wall sockets are not linked to any one philosophy of transfemoral socket design. Total flexible brims are essential to the success of "maximal" ischial-ramal containment sockets. There are several additional factors to be considered to a lesser degree. One concern regarding the ischial containment technique is the difficulty some prosthetists have reported in efficiently obtaining a successful fit. Repeated test or trial sockets are the norm in this technique; in contrast, more than one initial test socket is rarely necessary with the quadrilateral technique. 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, thereby compromising socket fit. Both of these concerns are being reduced with experience and new materials. Thermoplastics are now being extruded for use in prosthetic socket construction that are specially designed to resist both tearing and shrinkage. As experience gained in both thermoplastics techniques and ischial containment fitting techniques is further disseminated, these concerns should cease to be a consideration. Indeed, 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.
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from wood or polyurethane foam covered with a reinforcing, plastic-laminated outer skin. In this design, the strength is obtained by the outer plastic lamination through which the weight load is transmitted. The cosmesis or leg shape is integral to the system because the thigh, shank, 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 endoskeletal form of prosthesis is constructed of an inner tube or pylon (of aluminum, titanium, and/or carbon fiber epoxy) through which the weight load is transmitted. The knee units are usually interchangeable, at least within the manufacturer's system. The cosmesis, considered by most to be superior to exoskeletal prostheses, is provided by an external soft foam cover shaped to the individual amputee's anatomy and measurements. The cosmetic covering may be additionally covered with skin-colored hosiery or custom-sprayed with one of the "skinlike" finishes available. The increasing compatibility of components from all manufacturers greatly enhances prosthetic prescription options. Hybrid endoskeletal prostheses utilizing several different manufacturers' components are quite common, and in some cases, a mix of endoskeletal and exoskeletal components may be beneficial.
Prosthetic Feet
This topic has been previously discussed in detail in the transtibial chapter of this Atlas. However, there is one special consideration for the transfemoral amputee. Since heel strike though midstance on the transfemoral prosthesis is the most difficult period for knee control, an ankle-foot combination that dampens the knee flexion torque moment generated at heel strike can be an important consideration. This is particularly true for the elderly or otherwise debilitated amputee. Use of an ankle-foot combination that allows true plantar flexion within the ankle mechanism (single-axis foot, multiaxis foot, other ankle components), as opposed to simulated plantar flexion (solid-ankle feet), provides better absorption of shock and torque generated at heel strike, thereby decreasing potential knee instability. The more quickly the foot achieves foot flat, the greater the knee stability. 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.
Single-axis Knee
This knee consists of a simple hinge mechanism. It is mechanically simple, and stance stability is dependent on alignment stability (involuntary control) and amputee muscle contraction (voluntary control). The simplicity of design and low maintenance of this knee mechanism leads to its popularity and frequent use. The primary disadvantage of this knee design is its lack of mechanical stability ( Fig 20B-16. ).
Polycentric-axis Knee
This knee mechanism usually consists of a four-bar linkage that provides more than one point of rotation. The design is mechanically complex and provides a changing instantaneous center of rotation between the prosthetic thigh and shank, depending on the relative amount of flexion or extension of these components ( Fig 20B-17. ). This results in the advantage of varying mechanical stability throughout the gait cycle, with enhanced stability during heel strike and decreased stability at toe-off, thus allowing for easier initiation of swing phase ( Fig 20B-18. ). Additional advantages of the poly-centric design are the inherent shortening of the shank during flexion, which improves foot clearance in swing phase, and the ability to rotate the shank under the knee during sitting, which enhances sitting cosmesis for very long ( Fig 20B-19. ,A and B). residual limbs
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As noted by Mooney and Quigley, Polycentric knees are generally used on three categories of amputees. The first is the knee disarticulation amputee, in whom the high instant center of rotation is advantageous, so that the polycentric knee will swing under the thigh when the amputee sits, allowing the appearance of equal thigh and shank lengths compared to the sound limb. 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. The third group of amputees benefitting from the polycentric knee mechanism is those individuals with weak hip extensors. The historical disadvantage of polycentric knees is the increased weight and bulk due to the numerous linkage mechanisms and greater amount of moving parts. This disadvantage has been reduced with the advent of newer materials such as carbon fiber, titanium, and aircraft aluminum. Currently there are lightweight polycentric knee components available in both children's and adult sizes ( Fig 20B-20. ,A and B).
Friction Control
Knee swing is dampened by some form of mechanical friction, usually applied to the axis of rotation. 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. This is the most commonly used system for control of swing phase, primarily due to its simplicity and dependability. 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.
Extension Assist
In the simplest form, an extension assist is a spring that is compressed during knee flexion in initial swing, uncoils during late swing, and propels the shank into full extension, thereby reducing the effort expended by the amputee. Extension assistance also prepares the prosthetic limb for initial stance support by ensuring full knee extension at terminal swing, before initial stance.
Pneumatic Control
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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. As described by Mooney and Quigley, this Mechanism consists of a piston rod that is attached to the thigh section of the prosthesis behind the knee bolt. Knee flexion forces the piston down into the cylinder, which in turn forces air through a bypass channel at the bottom of the cylinder. The air travels upward within and around the sides of the cylinder, through a port at the top of the cylinder, and back into the central cylinder above the piston. 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. An adjustment knob is turned clockwise or counterclockwise to either decrease or increase this port opening. Decreasing the opening provides greater restriction of the amount of air passing through the port and, therefore, greater swing-phase control. Setting this opening too small would make the swing too stiff, possibly preventing adequate knee flexion and speed during swing phase. Pneumatic control is more responsive to varying walking speeds and is a more advanced form of swing control than friction is. Because air is compressible, it acts as an extension assist within the pneumatic unit. Some pneumatic units also have coil spring-type extension assists built into them. Disadvantages of pneumatic units include increased necessity for maintenance, increased weight, and increased expense. However, they are simpler, lighter, and less expensive than hydraulic units.
Hydraulic Control
The principles of hydraulic control are similar to those of pneumatic control, the difference being the medium: liquid is used rather than air. Hydraulic units also utilize a cylinder and piston rod arrangement as described earlier. The liquid provides resistance to motion depending on its viscosity and temperature. Silicone oil is used in most prosthetic hydraulic units because it minimizes viscosity changes with temperature, thus avoiding stiffness in cold weather and looseness in hot weather. Hydraulic control achieves nearly normal knee action over a wide cadence range. 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 design provides normal heel rise and extension in the swing phase independent of walking speed. The programmed flow is obtained by a special pattern of internal ports, check valves, and needle valves to meet normal walking requirements. Independent adjustments of flexion and extension control are available on most hydraulic units and are easily adjusted by the prosthetist and, in some instances, the amputee. The hydraulic knee mechanism is indicated for amputees who can take advantage of the cadence response function. Teen and adult males are commonly hydraulic users; however, there are active females who enjoy the benefits as well. Disadvantages are the same as those of pneumatic units, but to a greater degree: need for increased maintenance, increased weight, and increased expense. Two hydraulic systems that provide more than simply swing-phase control are worthy of special mention. The "Hydra-Cadence" hydraulic system is an entire knee, shank, ankle, and foot system that is hydraulically linked at the knee and ankle. 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 heel height of the foot is adjustable through the hydraulic mechanism of the ankle and allows for patient changes and adjustments. The knee and shank swing control is hydraulic. Although quite advanced in design and function, the Hydra-Cadence is quite heavy and expensive and has been associated with decreasing durability and reliability during recent years. 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. The hydraulic control of swing phase is fundamentally the same as that described earlier; there are separate adjustments for
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flexion (initial swing) and extension (terminal swing), and the range of adjustments is greater than in other hydraulic units. Provision of stance-control options is what makes this system uniquely functional. The design provides a high resistance to knee flexion, unless the amputee generates a hyperextension moment about the knee that occurs naturally when rolling over the ball of the prosthetic foot after midstance. The hyperextension moment, which can only occur when the knee is safely extended, results in disengagement of the high flexion resistance and permits the knee to flex easily to begin the swing phase. As the knee nears maximum flexion and the speed of bending decreases to zero, the higher level of resistance is reinstated. Thus, if during extension of the shank the toe is stubbed, the high resistance to flexion is available to aid in stumble recovery. Release of the high flexion resistance can also be accomplished voluntarily by an amputee who is standing and wishes to sit down quickly. He simply extends his residual limb while maintaining the foot in contact with the floor, thus generating the hyperextension moment necessary to release the high flexion resistance. 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 yielding speed in weight bearing is easily adjustable to accommodate the amputee's weight and needs. 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 is useful for situations requiring maximum knee stability such as rough terrain or standing and fishing from a pitching boat. The S-N-S unit is the most reliable and durable of the hydraulic systems. This fact coupled with its significant variety of functional options makes it the most widely used hydraulic system. It too has the disadvantages of extra weight and additional expense ( Fig 20B-22. ).
Function-Enhancement Components
There are three additional components available that provide additional and useful functions.
Torque Absorbers
A torque-absorber component is designed to allow transverse rotations about the long axis of the prosthesis. Without such a component, these forces are transmitted as shear forces between the residual limb and the socket. This component is particularly useful for bilateral amputees and is especially indicated for any amputee participating in golf, tennis, and other sports and activities demanding rotational movements.
Suspension Variants
Improper suspension results in poor gait, decreased safety, and increased skin problems. Secure and dependable suspension enhances proprioception and provides the feeling that the prosthesis is more a part of the wearer.
Suction Suspension
Suction suspension is usually accomplished by the use of an air expulsion valve at the distal
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end of the socket combined with a precisely fitted socket. Negative air pressure suspends the prosthesis during swing phase. The socket is sealed around the residual limb directly against the skin, without the use of prosthetic socks. The prosthesis is donned by one of two methods. Most commonly, the amputee pulls his residual limb into the socket by applying a length of open-ended stockinette around his residual limb, putting the end of the stockinette through the valve hole at the distal end of the socket, and pulling the residual limb down into the socket. In the process of pulling the residual limb completely into the socket, the stockinette is gradually removed from the socket. This donning procedure requires some skill and effort. Balance problems, upper-limb deficiencies, strength deficiencies, heart problems, and other such conditions preclude this method of donning and have traditionally been considered contraindications for suction suspension. An alternative and easier method of donning a suction socket is with the use of hand creams or lotions. Lotion is spread either on the residual limb or inside the socket, and the amputee pushes into the socket. After the limb is completely into the socket, the valve is applied and suction achieved. Within a short period of time the lotion is absorbed into the skin. This method of donning a suction socket has allowed its use by amputees who traditionally would have been excluded from consideration for this suspension. Generally, suction suspension is indicated for amputees with smooth residual limb contours. Volume fluctuations such as weight gain or loss or fluid retention problems are contraindications for suction sockets. With the advent of ischial containment sockets, even very short amputation limbs can often be successfully fitted with suction as a primary suspension. Additional auxiliary belt suspension is generally prudent. Suction suspension can be used along with any of the other forms of suspension. Suction suspension of transfemoral prostheses provides the best proprioception. The suspension is applied directly to the residual limb, as opposed to belts around the waist; the skin is in direct contact with the socket, and the movements of the limb are transmitted to the prosthesis without lost motion. Disadvantages include difficulty in obtaining such a precise fit with some amputees and occasional loss of suction in sitting or other positions. Other disadvantages include no medium for absorbing perspiration, skin shear, and the requirement of weight and volume stability. Partial suction suspension in which the above principles are utilized with a thin prosthetic sock or nylon sheath sometimes eliminates or reduces the disadvantages.
Soft Belts
There are two types of soft suspension belts available, either as primary or auxiliary suspension. The traditional form of soft belt is the Silesian belt or bandage. As the category implies, it is a flexible, soft belt usually made of leather, cotton webbing, or Dacron materials. 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, where it achieves most of its suspension. Anteriorly, it attaches at either a single point or, in some cases, double attachment points ( Fig 20B-23. ,A). This belt provides a comfortable and positive form of suspension of the prosthesis and is simple to use. The disadvantages of the Silesian belt are hygiene, especially if it is not removable for washing, and the discomfort associated with constrictive waist belts. 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. This suspension belt fits around the proximal 8 in. of the prosthesis and then around the waist and fastens anteriorly with Velcro ( Fig 20B-24. ). It is quite comfortable and forgiving due to its elasticity. It provides very positive suspension and enhances rotational control of the prosthesis. Disadvantages include body heat retention and limited durability.
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generally reserved for cases where rotational control or mediolateral stability is needed.
Case Presentations
Following are five case presentations, including one prosthetic recommendation, plus the rationale for each case. Clearly, other good recommendations are also possible. The intent is to exemplify several typical amputee cases as encountered in everyday prosthetic practice. Case 1.-A 29-year-old woman presents with a long left transfemoral amputation at the supracondylar region of the femur. She has no other health problems, has normal range of motion and strength, and is athletically and socially active. Her preferred sports are tennis and racquetball. She is employed as an attorney's assistant. Recommendation.-A quadrilateral suction socket is recommended with either a rigid laminated plastic socket or a thermoplastic flexible socket with semiflexi-ble socket retainer. An endoskeletal component system with soft-cover cosmesis, a four-bar polycentric knee with either pneumatic or hydraulic control, a torque absorber, and a dynamic-response foot are also suggested. Rationale. -There are no contraindications for an ischial containment socket. However, quadrilateral sockets are usually quite successful in the young and muscular amputee with a long residual limb. Suction suspension is ideal for active amputees and is enhanced by a long, muscular residual limb. A flexible socket system is more forgiving for the active athlete and thus more comfortable. The cosmesis afforded by an endoskeletal prosthesis with soft cover meets the social and vocational needs of this amputee. The four-bar polycentric knee provides inherent stability during the critical stance phases of activity, is smooth in swing, and is compatible with long amputations that might not have room beneath for other knee components. Either pneumatic or hydraulic knee control is essential for active athletes with varying cadences, and the dynamic-response foot, designed for the active amputee, provides better propulsion and response during all activities. Case 2.-A 78-year-old man presents with a right transfemoral amputation and a history of peripheral vascular disease secondary to diabetes mellitus. His left lower limb has vascular disease involvement and is weak and insensate. He has decreased strength and range of motion of the residual limb. He is plagued with failing eyesight as well. He is retired and interested in household ambulation. Recommendation.-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. A lightweight endoskeletal component system of titanium or carbon graphite epoxy with a manual locking knee and either a lightweight solid-ankle, cushion-heel (SACH) foot or multiaxis foot and ankle is also advised. Rationale. -Stability is a primary concern due to the combination of weakness and poor vision. Minimization of weight reduces effort involved in ambulation. Case 3.-A 15-year-old boy presents with a right transfemoral amputation at the proximal third of the femur secondary to cancer 6 years ago. He is very healthy
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and active now and participates in junior varsity basketball and baseball, as well as being an avid hunter and fisherman. He is reportedly "growing like a weed." Recommendation.-An ischial containment, 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. An endoskeletal system with hydraulic knee control, preferably swing and stance control, is advised, along with a carbon graphite epoxy strut shank-ankle-foot (e.g., Flex-Foot) for maximum dynamic response. An endoskeletal-type torque absorber in the shank above the graphite shank-ankle-foot should be considered. Rationale. -An ischial containment, suction socket is indicated by both the short residual femur and high activity level. The flexible socket enhances comfort and suspension. The optional auxiliary suspension provides confidence for high-demand activities. The endoskeletal construction readily accommodates linear growth, and the swing-and-stance (e.g., Mauch SN-S) hydraulic knee control offers many options, including a knee-locking option when hunting and ambulating in rough terrain. The graphite epoxy shank-ankle-foot provides maximum possible dynamic response for demanding sports activities in addition to dependable durability, and the torque absorber reduces shear stresses to the residual limb. Case 4.-A 24-year-old woman presents with a very short left transfemoral amputation caused by a motor vehicle accident 2 years ago. Her short residual limb is significantly scarred, has poor muscle tone, and lacks rotational stability. She is currently wearing her first prosthesis, which is a quadrilateral socket with a hip joint, pelvic band, and waist belt. It has a single-axis friction knee. She complains of inability to control the prosthesis and the knee. She also complains about the heavy feeling of the prosthesis. She is currently finishing college and is interested in dating and dancing. She has not been able to consider a more demanding activity level. Recommendation.-An ischial containment, flexible thermoplastic suction socket with a semiflexible thermoplastic socket retainer is advised, as well as auxiliary suspension provided by a soft TES or Silesian belt. An endoskeletal system of ultralight components and soft-cover cosmesis is recommended, along with a weight-activated stance-control knee and a multiaxis ankle foot. Rationale. -Although perhaps difficult to fit in this case, the suction suspension should be attempted to reduce the sensation of a heavy, clumsy prosthesis. An ischial containment socket will provide better mediolat-eral and rotational stability, both difficult to achieve given her femur length and poor muscle tone. The foot and knee mechanisms enhance stability while allowing active function. Case 5.-A 38-year-old male presents with a muscular, midthigh, left transfemoral amputation. The cause of the amputation was a mine explosion in the Viet Nam War. He has worn several prostheses, all quadrilateral socket designs. He works as a framing carpenter and climbs ladders and scaffolding. Heat and perspiration are a problem; therefore he requests a socket fit with prosthetic socks. He is very strong and agile and needs to depend on his prosthesis for his work. Recommendation.-A quadrilateral socket, thin cotton sock fit with a valve for partial suction is advised. Silesian belt suspension is preferred. An exoskeletal design, Mauch swing-andstance hydraulic-control knee, and a simple, maintenance-free, conforming foot such as a solid-ankle flexible-endoskeleton (SAFE) foot should be considered. Rationale. -The quadrilateral socket is familiar to this amputee and, when properly fitted, is quite adequate for a muscular, midthigh residual limb. 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. The exoskeletal construction is durable for vocational needs. The Mauch S-N-S hydraulic knee provides stability and safety options meeting vocational needs. The foot is simple and durable and conforms well to varying terrain.
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components will continue to be developed. The fundamental goals of comfort, function, and cosmesis are unchanged. Through the use of new materials, components, and designs, the transfemoral amputee can now achieve a higher activity level than was possible before. References: 1. Anderson M, Bray J, Hennessey C: Prosthetic Principles - Above-Knee Amputations. Springfield, Ill, Charles C Thomas Publishers, 1960, pp 129-146. 2. Anderson M, Sollars RE: Manual of Above-Knee Prosthetics for Physicians and Therapists. Los Angeles, Prosthetics Education Program, UCLA School of Medicine, 1957, pp 86-104. 3. Anderson M, Sollars RE: Manual of Above-Knee Prosthetics for Prosthetists. Los Angeles, Prosthetics Education Program, UCLA School of Medicine, 1957, pp 95-111. 4. Berger N: The ISNY (Icelandic-Swedish-New York) flexible above-knee socket, in Donovan RG, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989, pp 20-23. 5. Fishman S, Berger N, Krebs D: The ISNY (Icelandic-Swedish-New York University) flexible above-knee socket. Phys Ther 1985; 65:742. 6. Green MP: Four bar linkage knee analysis. Orthot Pros-thet 1983; 37:15-24. 7. Hall CB: Prosthetic socket shape as related to anatomy in lower extremity amputees. Clin Orthop 1964; 37:32-46. 8. Hoyt C, Littig D, Lundt J, et al: The UCLA CAT-CAM Above-Knee Socket, ed 3. Los Angeles, UCLA Prosthetics Education and Research Program, 1987. 9. International Society for Prosthetics and Orthotics: In Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment (Appendix C) Copenhagen, International Society for Prosthetics and Orthotics, 1989. 10. Kristinsson O: Flexible above-knee socket made from low density polyethylene suspended by a weight-transmitting frame. Orthot Prosthet 1983; 37:25-27. 11. Kristinsson O: Flexible sockets and more, in Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989, pp 15-19. 12. Long I: Allowing normal adduction of femur in above-knee amputations, technical note. Orthot Prosthet 1975; 29:53-54. 13. Long I: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet Orthot 1985; 9:9-14. 14. Mauch Laboratories Inc: Manual for the Henschke-Mauch Hydraulic Swing-N-Stance Control System. Dayton, Ohio, February 1976. 15. Michael JW: Current concepts in above-knee socket design. Instr Course Led 1990; 39:373-378. 16. Mooney V, Quigley MJ: Above-knee amputations, section II, prosthetic management, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981. 17. Moreland JR, Bassett LW, Hanker GJ: Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg [Am] 1987; 69:745-749. 18. Pritham CH: Above-knee flexible sockets, the perspective from Durr-Fillauer, in Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989; pp 24-29. 19. Pritham CH: Biomechanics and shape of the above-knee socket considered in light of the ischial containment concept. Prosthet Orthot Int 1990; 14:9-21. 20. Pritham CH, Fillauer C, Fillauer K: Experience with the Scandinavian flexible socket. Orthot Prosthet 1985; 39:17-32. 21. Radcliff CW: A short history of the quadrilateral above-knee socket, in Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989, pp 4-12. 22. Radcliff CW: Biomechanics of above-knee prostheses, in Murdoch G (ed): Prosthetic and Orthotic Practice. London, Edward Arnold, 1970, pp 191-198. 23. Radcliffe CW: Comments on new concepts for above-knee sockets, in Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989, pp 31-37. 24. Radcliffe CW: Functional considerations in the fitting of above-knee prostheses. Artif
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Limbs 1955; 2:35-60. 25. Radcliffe CW: The Knud Jansen Lecture, above-knee prosthetics. Prosthet Orthot Int 1977; 1:146-160. 26. Redhead RG: Total surface bearing self suspending above-knee sockets. Prosthet Orthot Int 1979; 3:126-136. 27. Sabolich J: Contoured adducted trochanteric-controlled alignment method: Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15-26. 28. Saunders JBM, Inman VT, Eberhart HD: The major determinants in normal and pathological gait. J Bone Joint Surg [Am] 1953; 35:543-558. 29. Schrader EW: Hydraulic damping programs knee action over cadence range. Design News December 9, 1964. 30. Schuch CM: Modern above-knee fitting practice. Prosthet Orthot Int 1988; 12:77-90. 31. Schuch CM: Report from international workshop on above-knee fitting and alignment techniques. Clin Prosthet Orthot 1988; 12:81-98. 32. Schuch CM: Thermoplastic applications in lower extremity prosthetics. J Prosthet Orthot 1990; 3:1-8. 33. University of California, Los Angeles, School of Medicine, Department of Surgery, Orthopedics; Continuing Education in Medicine and Health Sciences, ProstheticsOrthotics Education Program: Total Contact Socket for the Above-Knee Amputation, ed 5. September 1976. 34. Wilson AB Jr: Brief history of recent development in above-knee socket design, in Donovan R, Pritham C, Wilson AB Jr (eds): Report of ISPO Workshops, International Workshop on Above-Knee Fitting and Alignment. Copenhagen, International Society for Prosthetics and Orthotics, 1989, pp 2-3. 35. Wilson AB Jr: Limb Prosthetics, ed 6. New York, Demos Publications, 1989.
Chapter 20B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 21A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
SURGICAL TECHNIQUES
The basic surgical techniques outlined here may require selective modification because of limb scarring, draining sinus tracts, or the location of a tumor. In most instances, however, the techniques are followed as presented.
Hip Disarticulation
The technique of hip disarticulation as described by Boyd is the basic procedure in general use. In developing his technique, Boyd attempted to minimize blood loss by transecting muscles at either their origin or insertion, these areas being relatively avascular. 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, which begins just malignancies. 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.,A). Posteriorly, 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. From this point, the incision swings anteriorly and proximally to join the beginning of the incision. After ligation and division of the femoral vessels and transection of the femoral nerve, the superficial muscles about the anteromedial aspect of the hip are transected at their origin on the pelvis. The iliopsoas and the short external rotator muscles are divided at their insertions on the femur. The obturator artery is carefully ligated and divided, and the obturator nerve is transected ( Fig 21A-1.,A). 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. The hamstring muscles are detached from their origin on the ischial tuberosity, and the sciatic nerve is ligated and divided. The hip joint capsule is then circumferentially incised and the liga-mentum teres divided to complete the disarticulation ( Fig 21A-1.,B). The wound is closed by suturing the gluteus maximus to the remnants of the adductor muscles and approximating the skin edges ( Fig 21A-1.,B).
Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists
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Transpelvic Amputation
This formidable procedure is performed almost exclusively for treatment of malignant tumors about the hip and pelvis. Numerous methods have been described, but the operative technique follows the same general pattern in each of the various methods. For purposes of
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will be outlined.
The patient is positioned on the operating table in the lateral position with the sound side down. In this position the abdominal contents fall away from the part of the pelvis to be removed, thus eliminating the need for excessive retraction of the abdominal viscera. The operation is divided into three parts: anterior, perineal, and posterior, performed in that order. 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.,A). The abdominal muscles and the inguinal ligament are detached from the iliac crest, and the fossa between the iliacus muscle and the peritoneum is dissected. The inguinal ligament and rectus abdominis muscle are severed from the pubis and retracted medially along with the spermatic cord and the bladder. This provides exposure of the external iliac artery and vein, which are ligated and divided, and the femoral nerve, which is divided ( Fig 21A-2.,B). 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. After stripping the perineal muscles from the rami, the ligaments and fibrocartilage of the pubic symphysis are completely divided ( Fig 21A-2.,C). After the anterior and perineal portions of the procedure are completed, the initial anterior incision is continued posteriorly along the iliac crest to the posterosuperior iliac spine. 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. The aponeurosis of the gluteus maximus is divided in line with the skin incision, and this muscle is elevated with the overlying fat and skin as a large flap. The sciatic nerve is then identified, ligated, and divided. The ilium is then divided adjacent to the sacroiliac joint and rotated laterally to expose the intrapelvic structures ( Fig 21A-2.,D). After ligating and dividing the obturator vessels and nerves, the psoas and the levator ani muscles are transected, completely freeing the ilium and entire lower limb ( Fig 21A-2.,E). The wound is closed by suturing the gluteal flap to the abdominal muscles and approximating the skin edges ( Fig 21A-2.,F).
Postoperative Treatment
After surgery the soft tissues of the amputation site should be firmly supported. 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. Resolution of edema from the surgical site is quite rapid after treatment by either of these postoperative management techniques. After an initial enthusiastic application of an immediate postsurgical prosthetic fitting to hip disarticulations and transpelvic amputations, many surgeons discovered that the available prosthetic components of this system do not permit comfortable sitting, nor do they provide a satisfactory gait. Furthermore, suspension of the temporary prosthesis is rather cumbersome. These problems, plus rapid maturation of these amputation stumps when treated in the conventional manner, have led most surgeons to discontinue using the immediate postsurgical prosthetic fitting technique for amputations at the hip disarticulation and transpelvic levels. When a soft compression dressing is used, the patient is mobilized from bed as soon as comfort allows- usually on the third or fourth postoperative day. In younger individuals, standing in parallel bars can be instituted at this time and rapidly followed by crutch ambulation. Stump wrapping is continued until a definitive prosthesis is fit, often at 6 to 8 weeks after surgery. References: 1. Boyd HB: Anatomic disarticulation of the hip. Surg Gynecol Obstet 1947; 84:346-349. 2. Gordon-Taylor G, Munro RS: Technique and management of "hindquarter" amputation. Br J Surg 1952; 39:536-541. 3. King D, Steelquist J: Transiliac amputation. J Bone Joint Surg 1943; 25:351-367. 4. Lazarri JH, Rack FJ: Method of hemipelvectomy with abdominal exploration and temporary ligation of common iliac artery. Ann Surg 1951; 133:267-269. 5. Pack GT, Ehrlich HE: Exarticulation of the lower extremities for malignant tumors; hip joint disarticulation (with and without deep iliac dissection) and sacroiliac disarticulation (hemipelvectomy). Ann Surg 1946; 123:965-985. 6. Sarondo JP, Ferre RL: Amputacion interilio-abdominal. Ann Orthop Traumatol 1948; 1:143.
Chapter 21A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 21B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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. Often shoulder straps were required for suspension. Gross pelvic thrust was required to propel the prosthesis, and a vaulting gait was common. A radical departure, later termed the "Canadian" design, was introduced by McLaurin in 1954 ( Fig 21B-2.). This unique approach demonstrated the feasibility of using unlocked hip, knee, and ankle joints that relied on biomechanics to achieve stance-phase stability while permitting
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flexion at the hip and knee during swing phase. This is now the standard for prosthetic fitting worldwide, and locking joints are very rarely necessary. A molded plastic socket encloses the ischial tuberosity for weight bearing, extends over the crest of the ilium to provide suspension during swing phase, and affords excellent mediolateral trunk stability by fully encasing the contralateral pelvis. The prosthetic hip joint is attached to the socket anteriorly, and this results in excellent stance-phase stability plus good swing-phase flexion.
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mechanisms bilaterally must be avoided. Since it is impossible for the amputee to simultaneously unload both artificial limbs, sitting with two stance control knees becomes nearly impossible. A third type that has proved advantageous for this level of amputation is the polycentric (fourbar) knee. Although slightly heavier than the previous two types, this component offers maximum stance-phase stability. Because the stability is inherent in the multilinkage design, it does not erode as the knee mechanism wears during use. In addition, all polycentric mechanisms tend to "shorten" during swing phase, thus adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb. Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral Patients with all levels of amputation, up to and including translumbar amputee. (hemicorporectomy), have successfully ambulated with these components. At first glance, a manual locking knee seems a logical choice. However, experience has shown that this is rarely required and should be reserved as a prescription of last resort. Only additional medical disabilities such as blindness will require this mechanism. Unlocking the knee joint in order to sit requires the use of one hand in the unilateral case; expecting a bilateral amputee to cope with dual locking knees and dual locking hips is unrealistic. Furthermore, in the event of a fall backwards, fully locked joints may prevent the amputee from bending his trunk to protect his head from impact. For many years, the use of fluid-controlled knee mechanisms for high-level amputees was considered unwarranted since these individuals obviously walked at only one (slow) cadence. The development of hip flexion bias mechanisms and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage of fluid control for the hip-level amputee. It is well accepted that any fluid-control mechanism (hydraulic or pneumatic) results in a smoother gait. Motion studies conducted at Northwestern University have confirmed that a more normal gait for the hip dis-articulation/transpelvic amputee is also produced. 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. In addition, a more rapid cadence was also possible. The preferred mechanism has separate knee flexion and extension resistance adjustments. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. In essence, the limb steps forward more rapidly. As the shank moves into extension, 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 fluid-controlled knee results in a hip flexion bias ( Fig 21B-7.). Richard Lehneis et al. have reported on a coordinated hip-knee hydraulic linkage using a modified Hy-drapneumatic unit. This adaptation provides a hip extension bias and has resulted in a smoother gait ( Fig 21B-8.). Finally, a number of new components have been developed recently that combine the characteristics of some of the above classes of knee mechanisms. For example, Teh Lin manufactures a "Graphlite" knee consisting of a polycentric unit with pneumatic swing-phase control in a carbon fiber receptacle. Such "hybrid" designs are expected to increase over the next few years.
FOOT MECHANISMS
Traditionally, the solid-ankle cushion-heel (SACH) foot has been recommended for the Canadian hip disarticulation design due to its moderate weight, low cost, and excellent durability. So long as the heel durometer is very soft, knee stability with this foot has generally been quite acceptable. In those cases where slightly more knee stability is desired, a single-axis foot with a very soft plantar flexion bumper is preferred. Added weight, maintenance, and cost plus reduced cosmesis are the liabilities of this component.
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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. In addition to accommodating uneven ground, absorbing some of the torque of walking, and protecting the patient's skin from shear stresses, multiaxis feet seem to decrease the wear on the other prosthetic mechanisms as well. In the last 5 years, more sophisticated foot mechanisms have reached the market, and all have been demonstrated to function successfully for the high-level amputee. 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. foot. All are characterized by a softer, more flexible forefoot that results in a smoother rollover for the patient. The SAFE version offers some transverse rotation as well. In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes more stable during late stance phase. The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. 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. shearing force that disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot. Dynamic-response feet, which provide a subjective sense of active push-off, can also be used to advantage for the hip-level amputee. The Carbon Copy II, Seattle foot, Springlite, and Flex-Foot have all been successfully utilized for this type of patient. They seem to provide a more rapid cadence, as noted by one long-term hip disarticulation wearer, who stated after receiving a Seattle foot, "For the first time in my life I can pass someone in a crowd." Once again, the interaction between the foot and knee must be carefully monitored. In general, the more responsive the foot mechanism, the more important the knee unit resistances become. Many clinicians prefer fluid-controlled knees, or at least one with powerful friction cells. Otherwise, much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. 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. In addition to foot mechanisms, several ankle components have recently reached the American market. These can be paired with most of the feet mentioned above to add additional degrees of motion as desired. Examples include the SwePro ankle from Sweden, The Blatchford (Endolite) Multi-Flex ankle from England, and the Seattle ankle. Torque-absorbing devices are often added to hip dis-articulation/transpelvic prostheses to reduce the shear forces transmitted to the patient and components. Ideally, they are located just beneath the knee mechanism ( Fig 21B-9.). 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). The major justification for such a component is that the high-level amputee has lost all physiologic joints and, hence, has no way to compensate for the normal rotation of ambulation. Finally, transverse-rotation units or positional rotators originally developed for the Oriental world have become available worldwide. Installed above the knee mechanism, these devices permit the amputee to press a button and passively rotate the shank 90 degrees or more for sitting comfort ( Fig 21B-10. ). They not only facilitate sitting cross-legged upon the floor but also permit much easier entry into restaurant booths and other confined areas. This component is particularly advantageous for entering and exiting automobiles.
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to assist suspension or rotary control or to provide partial weight-bearing surfaces. Due to the success of ischial containment transfemoral sockets, the importance of precise contours at the The same principles can ischium and ascending ramus is now more widely recognized. ( Fig readily be applied to hip disarticulation sockets to increase both comfort and control 21B-11. ). We prefer to have the amputee simulate weight bearing during the plaster impression technique to create as precise a mold as possible. However, in contrast to the technique advocated by Otto Bock, 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. A sling suspension system should be utilized, in addition, to firm up redundant soft tissue for obese individuals or transpelvic amputees. (A casting platform alone will suffice for many hip disarticulates, especially those of slight build.) 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. ). If the distance from the iliac crest to the ischial tuberosity is too large in the mold, the socket will piston up and down with every step. Prior to the removal of the plaster mold, the ischial tuberosity area may be highlighted by adding more plaster splints while cupping the ischium firmly in the palm of the hand. The goal of casting is to create an exact replica of the pelvis including the often neglected areas inferior to the lateral, anterior, and posterior aspects of the iliac crest. During model rectification, relief must be provided for the inferior pubic ramus and pubic tubercle as well as the proximal edge of the iliac crests. The transpelvic socket requires careful attention to the distal contours for proper weight bearing. In addition to using the sling casting technique to firm the tissues, it is useful to contour the area of the contralateral gluteal fold precisely. Although this can be done by hand, a racing-style bicycle seat makes a useful adjunct when casting ( Fig 21B-13. ). This contour may add a measure of gluteal bearing on the contralateral side. More importantly, it prevents the hemipelvis from slipping through the inferior border of the socket and adds significant weight-bearing stability. 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, 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. In like manner, the anterodistal trim line should be as close to the midline as tolerable lest the panniculus protrude hernia-like during weight bearing. 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, as noted by Lyquist, it should not be overdone. Gentle contouring with the palm of the hand, combined with the sling suspension provides sufficient compression. Many materials are suitable for socket fabrication. As is the case with other levels of lowerlimb amputation, the most commonly utilized socket material is a rigid thermosetting resin: An increasing trend toward more flexible thermoplastic materials is polyester or acrylic. One of the authors (J.W.M.) has fitted evident, as in other aspects of prosthetic practice. more than two dozen polypropylene/polyethylene copolymer sockets for hip-level amputation over the past decade with good long-term results in durability, comfort, and patient acceptance ( Fig 21B-14. ). The recent advent of laminating silicone rubbers allows even more flexibility than do available thermoplastics. As was noted earlier, the resulting comfort and range of motion has been associated with significantly higher rates of prosthetic usage. Although the fabrication is complex and difficult and the finished result slightly heavier than thermoplastic designs, favorable patient response and good durability recommend further development and more widespread application of this technique. The senior author (T.v.d.W.) has fitted 35 silicone rubber sockets over the past 2 years. 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. ).
Suction Suspension
Nearly 40 years ago, Hutter reported a single case of successful fitting of a transfemoral
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suction socket to a hip disarticulate with a mass of redundant tissue distal to the ischium. The senior author (T.v.d.W.) has personally fitted three such cases recently ( Fig 21B-16. ). Each was able to ambulate successfully and to retain full suction suspension with only the assistance of a thin, elastic Silesian belt despite the total absence of any femur. 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. 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. This approach warrants further follow-up and evaluation to determine its practicality.
CONCLUSIONS
Although wearing a transpelvic or hip disarticulation prosthesis may be cumbersome, when fitted within a few weeks of amputation, the initial acceptance rate appears to be similar to that for transfemoral amputation. Immediate postoperative fitting is technically feasible but rarely performed today. Long-term wearing rates increase significantly when sockets are comfortable, flexible, and carefully aligned. In view of the magnitude of loss at this level, application of newer, sophisticated joint and foot mechanisms is often helpful. Every case requires review on its own merits; careful attention to socket design, components, and alignment ultimately determines the effectiveness of the prosthesis. References: 1. Banzinger E: Hip disarticulation prosthesis for infants (abstract). J Assoc Child Prosthet Orthot Clin 1988; 2. 23:37. 3. Brittain HA: Hindquarter amputation. J Bone Joint Surg 1949; 31:404-409. 4. Campbell J, Childs C: The S.A.F.E. foot. Orthot Prosthet 1980; 34: 3-17. 5. Coley BL, Higinbotham NL, Romieu C: Hemipelvec-tomy for tumors of bone: Report of fourteen cases. Am J Surg 1951; 82:27-43. 6. Dankmeyer CH Jr: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. Orthot Prosthet 1981; 35:11-18. 7. Davis BP, Warner R, Daniel R, et al: The problem of fitting a satisfactory prosthesis following hemipelvectomy. Inter-Clin Info Bull 1964; 3:5-9. 8. Desio MA, Leonard JA: Above-knee prosthesis for hip disarticulation (abstract). Arch Phys Med Rehabil 1986; 67:667-668. 9. Foort J: Construction and fitting of the Canadian-type hip-disarticulation prosthesis. Artif Limbs 1957; 4:39-51. 10. Foort J: Some experience with the Canadian-type hip-disarticulation prosthesis. Artif Limbs 1957; 4:52-70. 11. Foort J, Radcliffe CW: The Canadian-Type Hip-Disartic-ulation Prosthesis. Project Berkeley, University of California, Prosthetic Devices Research Project, 1956. 12. Friedmann LW: Comments and observations regarding hemipelvectomy and hemipelvectomy prosthetics. Orthot Prosthet 1967; 21:271-273. 13. Giaccone V, Stack D: Temporary prosthesis for the hip-disarticulation amputee. Phys Ther 1977; 57:1394-1396. 14. Gillis L: A new prosthesis for disarticulation at the hip. J Bone Joint Surg 1968; 50:389391. 15. Glattly HW: A preliminary report on the amputee census. Artif Limbs 1963; 7:5-10. 16. Greene M: Four bar knee linkage analysis. Orthot Prosthet 1983; 37:15-24. 17. Hampton F: A hemipelvectomy prosthesis. Artif Limbs 1964; 8:3-27. 18. Hampton F: A Hemipelvectomy Prosthesis. Chicago, Northwestern University Prosthetic Research Center, 1964, p 32. 19. Haslam T, Wilson M: Hip Flexion Bias, Concept 80. Houston, Medical Center Prosthetics, 1980. 20. Huang CT: Energy cost of ambulation with Canadian hip disarticulation prosthesis. J Med Assoc State Ala 1983; 52:47-48. 21. Hutter CG: Improved type of hip-disarticulation on prosthesis. J Bone Joint Surg [Am] 1953; 35:745-748. 22. Hutter CG: Suction-socket prosthesis for a hip-disarticulation amputee. J Bone Joint Surg [Am] 1953; 35:230-232. 23. Imler C, Quigley M: A technique for thermoforming hip disarticulation prosthetic sockets. J Prosthet Orthot 1990; 3:34-37. 24. Iwakura H, Abe M, Fujinaga H, et al: Locomotion of the hemipelvectomy amputee. Prosthet Orthot Int 1979; 3:111-114.
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25. Jay GR, Sabolich L: A bilateral above-knee/hip disarticulation fitting. Inter-Clin Info Bull 1972; 11:9-12. 26. Jensen JS, Mandrup-Poulsen T: Success rate of prosthetic fitting after major amputations of the lower limb. Prosthet Orthot Int 1983; 7:119-122. 27. Johansson H, Olerud S: Traumatic hemipelvectomy in a ten-year-old boy. J Bone Joint Surg [Am] 1971; 53:170-172. 28. Klasen HJ, Ten Duis HJ: Traumatic hemipelvectomy. J Bone Joint Surg [Br] 1989; 71:291-295. 29. Koskinen EVS: Hemipelvectomy for malignant tumours of bone: A study with preoperative arteriographic examination of the growth. Ann Chir Gynaecol 1967; 56:917. 30. Krajbich I, De Bari A, Hubbard S, et al: Surgical and prosthetic-orthotic treatment of patients with unilateral congenital or early childhood hip disarticulation or hemipelvectomy (abstract). J Assoc Child Prosthet Orthot Clin 1988; 23:37. 31. Lee CM, Alt LP: Hemipelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity. Ann Surg 1953; 137:704-717. 32. Lehneis HR, et al: Prosthesis management of the cancer patient with high level amputation. Orthot Prosthet 1981; 35:10-28. 33. Lehneis HR, et al: Prosthetics Management for High Level Lower Limb Amputees. New York, Institute of Rehabilitation Medicine, 1980. 34. Leppanen RE: A temporary prosthesis for hip disarticulation. Phys Ther 1969; 49:987990. 35. Levesque CM, Gauthier-Gagnon C, Beauregard M: An endoskeletal hip disarticulation prosthesis for the toddler. J Prosthet Orthot 1991; 3:120-124. 36. Littig DH, Lundt JE: The UCLA anatomical hip disarticulation prosthesis. Clin Prosthet Orthot 1988; 12:114-118. 37. Lyquist E: Canadian-type socket for a hemipelvectomy. Artif Limbs 1958; 5:130-132. 38. Lyquist E: New hip joint for Canadian-type hip-disarticulation prosthesis (technical note). Artif Limbs 1958; 5:129-130. 39. Madden M: The flexible socket system as applied to the hip disarticulation amputee. Orthot Prosthet 1985; 39:44-47. 40. Marx HW: Some experience in hemipelvectomy prosthetics. Orthot Prosthet 1967; 00:259-270. 41. McLaurin CA: Hip Disarticulation Prosthesis, Report No. 15. Toronto, Canada, Prosthetic Services Centre, Department of Veterans Affairs, 1954. 42. McLaurin CA: The evolution of the Canadian-type hip disarticulation prosthesis. Artif Limbs 1957; 4:22-28. 43. McLaurin CA, Hampton F: Diagonal Type Socket for Hip Disarticulation Amputees. Chicago, Northwestern University Prosthetic Research Center, Publication V.A.-V1005 M 1079, 1961. 44. Meester GL, Myerley WH: Traumatic hemipelvectomy: Case report and literature review. J Trauma 1975; 16:541-545. 45. Michael J: Component selection criteria: Lower limb disarticulations. Clin Prosthet Orthot 1988; 12:99-108. 46. Michael J: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987; 11:154-168. 47. Michael J: Overview of prosthetic feet. Instr Course Lect 1990; 39:367-372. 48. Murphy EF: Danish experience with Canadian HD (technical note). Artif Limbs 1958; 5:132-133. 49. Nader M, et al: Polycentric, Four Bar Linkage Knee Joint, Technical Information Bulletin No. 45. Duders-tadt, West Germany, Otto Bock Industries, 1986, p 3. 50. Nilsonne U, Hjelmstedt A, Hakelus A. Surgical problems in hemipelvectomy. Acta Orthop Scand 1968; 39:161-170. 51. Ockenfels PA: Management and construction procedure of bilateral split-bucket type hip disarticulation prosthesis. Orthot Prosthet 1968; 22:29-36. 52. Oppenheim WL, Tricker J, Smith RB: Traumatic hemipelvectomy-The tenth survivor: A case report and a review of the literature. Injury 1978; 9:307-312. 53. O'Riain M: Clinical Data on Floor Reaction Forces- Shear (report). Royal Ottawa Rehabilitation Center, 1985. 54. Pack GT, Ehrlick H: Hip joint exarticulation and sacroiliac disarticulation. Ann Surg 1946; 123:965-985. 55. Pinzur MS, et al: An easy-to-fabricate modified hip disarticulation temporary prosthesis (technical note). Orthot Prosthet 1986; 40:58-60. 56. Radcliffe CW: The biomechanics of the Canadian-type hip-disarticulation prosthesis. Artif Limbs 1957; 4:29-38.
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57. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15-26. 58. Sabolich J, Guth T: The CAT-CAM-HD. A new design for hip disarticulation patients. Clin Prosthet Orthot 1988; 12:119-122. 59. Seaton DG, Wilson LA, Shepherd WG: Clinical trial of the diagonal socket prosthesis for hip disarticulation amputation. Inter-Clin Info Bull 1972; 11:1-8, 17. 60. Shurr DG, Cook TM, Buckwalter JA, et al: Hip disarticulation: A prosthetic follow-up. Orthot Prosthet 1983; 37:50-57. 61. Simons BC, Lehman JF, Taylor H, et al: Prosthetic management of hemicorporectomy. Orthot Prosthet 1968; 22:63-68. 62. Solomonidis SE, Loughran AJ, Taylor J, et al: Biomechanics of the hip disarticulation prosthesis. Prosthet Orthot 1nt 1977; 1:13-18. 63. Svetz WR, Wagner C, Clark MW: A young hemipelvectomy patient. Inter-Clin Info Bull 1976; 15:9-13. 64. Tuil P: The hip disarticulation prosthesis as developed by the O.I.M. Noord Nederland. Clin Prosthet Orthot 1988; 12:109-113. 65. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. Orthot Prosthet 1984; 38:29-33. 66. Van Vorhis RL, Childress DS: Kinematic aspects of the Canadian hip disarticulation prosthesis: Preliminary results in Murdock G (ed): Amputation Surgery and Lower Limb Prosthetics. Oxford, England, Blackwell Scientific Publications, 1988. 67. Vitali M, Harris EE, Redhead RG: Amputees and their prostheses in action. Ann R Coll Surg Engl 1967; 40:260-266. 68. Wade FV, Machsood WA: Traumatic hemipelvectomy: A report of two cases with rectal involvement. J Trauma 1965; 5:554-562. 69. Waters RL, et al: Energy costs of walking of amputees: The influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:46. 70. Werne S: Two cases of hindquarter amputation. Acta Or-thop Scand 1954; 23:90-99. 71. Wise RA: A successful prosthesis for sacro-illiac disarticulation (hemipelvectomy). J Bone Joint Surg [Am] 1949; 31:426-430. 72. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. Phys Ther 1971; 51:144-151. 73. Zettl JH, Van Zandt ML, Gardner J: The hip-disarticulation and short above-knee immediate postsurgical adjustable pylon prosthesis. Bull Prosthet Res 1970; 10:64-69. 74. Zettl JH, Van Zandt ML, Gardner J: The immediate postsurgical adjustable pylon prosthesis for the hip-disarticulation and short-above-knee amputee. Inter-Clin Info Bull 1971; 10:7-10, 16.
Chapter 21B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 22A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
PATIENT SELECTION
Ablation of the caudal 50% of the human body has been named by the level of amputation, translumbar amputation (TLA), and by the extent of amputation, hemicorporectomy. Regardless of the nomenclature, this operative procedure is extensive in its loss of structure and function. Fortunately, due to advances in surgical reconstruction, physical and social rehabilitation, prosthetic materials and fitting, and functional aids to the handicapped, the ravages of the operative procedure can be ameliorated. Unlike all other amputations, TLA involves the loss of structures used in functions other than mobility and manipulation. The sphincteric and storage functions of the anus and rectum and urogenital diaphragm and bladder are lost. Sexuality is severely diminished due to loss of both internal and external endocrine and reproductive organs. The extensive known, anticipated, and guaranteed postoperative problems charge the surgeon and the support team with the task of careful patient selection, preoperative patient and family education, and absolute clarity in description of the risks and benefits. TLA cannot be planned and executed in a short period of time. 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. Patients must be given latitude in deciding on the operation, and it may be anticipated that a patient will cancel or delay the planned TLA. The surgeon and rehabilitation team must be sensitive to this reluctance and respond with further supportive and educational input. Coercion, intimidation, 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. As a group, patients who become eligible for TLA have a disease process that is recurrent or chronic. The recurrent group is made up of patients with low-grade, nonmetastatic tumors in whom there is an excellent chance for long-term cure. These might include low-grade chondrosarcoma, sacral chordomas, giant-cell tumors, or vascular neoplasms (massive hemangiomas or arteriovenous malformations). Patients with significant spinal cord injury resulting in paraplegia, loss of potency, insensate anal sphincter, chronic urinary tract disease due to a neurogenic bladder, and severe pressure ulcers may rarely be candidates for TLA. Despite the functional losses and significant structural distortion, few patients would consider loss of these cumbersome limbs and dysfunctional structures. The importance of "looking whole" even when the whole is defective is primary. The need for intactness of the body becomes one of the major driving forces in the patient's rehabilitation. The rehabilitation must be structural and functional. An evaluation of the extent of the primary disease should include an exhaustive search for metastases or proximal local growth. Current diagnosis of the intrathecal extension of sacral tumors includes a magnetic resonance imaging (MRI) study. MRI is sensitive to changes induced by radiation therapy and can differentiate between tumor and radiation changes. The infiltration of the paraspinal muscles by tumor can be identified, as well as soft-tissue masses encroaching on the nerve roots and dural sac. Patients in whom the disease cannot be encompassed are not candidates for translumbar amputation.
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.
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SURGICAL TECHNIQUE
The strategy for the surgical portion of the operation can be divided into three sections: soft tissue, bony and neural, and vascular. The latter two are definitive commitments, 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. The integrated operative team includes an anesthesiologist, neurosurgeon, orthopaedic surgeon, urologist, reconstructive surgeon, and surgical oncologist. The intraoperative findings will dictate the degree of involvement of each of these specialists. Adequate amounts of blood and blood products or alternatively a system for intraoperative blood loss collection and reinfusion should be prepared. Hemodynamic monitoring with arterial and central venous catheters is secured. Positioning of the patient after intubation will depend on the plans for the individual patient as described in the text. An incision is outlined and extends anteriorly from the most posterior aspect of the iliac crest, along the inferior edge of the anterior abdominal wall at the level of the inguinal crease along the pubic bone to the pubic symphysis, and in a mirror image pattern on the contralateral side. The muscles of the anterolateral abdominal wall are divided from their bony insertions, and the inferior epigastric artery and vein are divided. In the male, the spermatic cords are left with the specimen. The abdomen is then opened. An exploration can be performed to assess the intra-abdominal extent of the tumor and potential sites of metastases, including the periaortic nodes above the planned level of transection (L3-4), paraspinal soft tissues, and the liver parenchyma. If any suspicious findings are noted, biopsies can be performed before any irreversible steps are taken. After the resectability of the tumor is confirmed, the anterior flap is reflected superiorly by dividing the balance of the anterior abdominal muscles, and attention can be directed toward division of the intra-abdominal vascular structures and soft tissues. The ureters are identified at or above the level of the common iliac vessels. Consideration of tumor location, previous radiation therapy, and planned urologic reconstruction will dictate the level of ureteral division. Care is taken to preserve the entire length of the ureter with its enveloping blood supply. 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. At the time of ureteral division, large ligaclips or a tie is placed on the proximal portion of the ureter to allow dilatation prior to reconstruction. The aorta and vena cava are mobilized above their bifurcation and below the renal artery and veins. If necessary the inferior mesenteric artery can be divided. Mobilization of the great vessels will invariably require division of one or two of the lumbar vessels and the right gonadal artery. After complete mobilization, the aorta is cross-clamped by placing a vascular clamp approximated 2 cm cephalad to the planned division site. Communication between anesthesiologist and surgeon is required at this point to ensure precise evaluation of changes in arterial blood pressure, urine output, and central venous or left ventricular end diastolic pressure (pulmonary capillary wedge pressure). Acute hypertensive changes may require stepwise clamping with the addition of peripheral vasodilators (nitroglycerine) and mild volume reduction (diuresis). The aorta is trans-sected sharply and the distal end oversewn. The proximal portion of the aorta is closed with a running 3-0 monofilament vascular suture. The vascular clamp is released one or two clicks and any additional hemostasis secured with interrupted sutures. Rarely, sutures and pledgets may be required due to atherosclerotic changes or injury from previous radiation therapy. The vena cava is clamped and divided in a similar manner. Often, a thinner suture material (4-0 monofilament) can be used for the closure. Communication with the anesthesiologist is critical in anticipating and monitoring the sudden loss of venous return. With the completion of mobilization and division of the aorta and vena cava, attention is turned to the right and left sides of the retroperitoneum. On the right, the gonadal vein and, on the left, 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. The base of the small-bowel mesentery with the right and ileocolic vessels, cecum, and right colon are mobilized cephalad in a fashion similar to a right retroperitoneal lymph node dissection. 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. Care must be taken in dividing the sigmoid colon at its most distal, viable extent. This is especially important if the inferior mesenteric artery has been ligated at its takeoff from the aorta. The paired structures of the retroperitoneum, including the sympathetic trunk, psoas muscle, and genitofemoral and
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femoral nerves, are divided. 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. If any doubt exists regarding the level of tumor infiltration, a biopsy should be performed to ensure that the soft-tissue margin is pathologically negative. The division of the bony structures (vertebral bodies, transverse processes, and spinous process) and the du-ral sac with the spinal cord can be approached in one of two ways. 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 surgical procedure should begin with a posterior-element laminectomy from approximately T1l to L3. This initial exploration can be extended to include opening of the dura, division of the cauda equina (at the Ll-2 level), and repair of the cephalad dural division. Meticulous hemostasis is essential to prevent an epidural hematoma. 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 division of the bony and neural elements is the final step in the TLA. When this approach is used, the disk space is identified at the planned level of the TLA. The disk is removed or divided sharply with a knife and the dural sac identified anteriorly. The sac is opened and the neural elements ligated and divided. The final division of the transverse process and spinous process is performed with an osteotome. Significant bleeding can occur at this point from the spinal artery and veins. If not easily controlled, packing with cottonoid sponges can tamponade the vessels and allow for better exposure of these vessels by completing the softtissue division. The posterior skin and remaining musculature is rapidly divided. The specimen is removed from the operative field and meticulous hemostasis secured along the dura, in the paravertebral muscles, and along the skin edge. 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. 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. The result is a 350- to 700-mL continent reservoir that requires catheter drainage approximately every 5 to 6 hours. 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. After initial healing, no ostomy bag is required, and the difficulty in fitting the patient in the bucket prosthesis is reduced. After adequate mobilization of the distal portion of the colon and re-examination of vascular integrity, an end colostomy is formed in a comfortable position. This will usually be in the central or left upper portion of the anterior abdominal wall flap. Care must be exercised in planning a stoma that will be not compressed by the upper edge of the prosthetic bucket. The flap closure is performed in layers approximating the well-defined fascia of the anterior abdominal wall to the lumbodorsal fascia with interrupted, permanent suture material. The subcutaneous tissues are closed with interrupted absorbable suture and the skin with metal staples or monofilament suture. The colostomy and urinary pouch stoma can then be matured and all wounds covered with appropriate dressings or drainage bags. 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.). In cases where large amounts of skin are to be removed, flap reconstruction with myocutaneous or fascial cutaneous flaps can be considered. Occasionally, tissue can be preserved from one of the lower limbs. One such flap utilizes the skin, subcutaneous tissue, ( Fig 22A-2., Fig 22A-3., Fig 22A-4., and Fig and muscle perfused by the femoral artery 22A-5.). 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.
COMPLICATIONS
The complications of TLA are primarily related to flap formation, urinary reconstruction, and the extensive surgical procedure, ( Table 22A-1.). The anterior flap suffers from distal ischemia due to the division of the inferior epigastric artery and vein. In addition, 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, or approximately 25% to 30% of the volume). 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 division of
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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. In the postoperative period, the patient's positions are limited to supine and lateral ones due to new stoma formation, the need for respiratory support on the ventilator, and hemodynamic monitoring. This increases the shear and compressive pressure on the posterior and lateral aspects of the flap. It is important to remove all posterior bony elements to minimize pressure points on the flap. A variety of specialized beds have been designed to reduce pressure areas and shear effect. 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. These beds serve primarily to automatically shift the patient's position and prevent pressure, shear, and friction. An unusual postoperative problem has been hypertension. This occurs during the first postoperative week and often requires a combination of diuretics, central a-adrenergic stimulators, peripheral a- and -blockers and angiotensin I-converting enzyme inhibitors. Although this was thought to be due to volume expansion during surgery, even after a return to correct preoperative volume status (adjusted for new body size), the hypertension persists indefinitely. Problems with the urinary diversion system occur both in the acute and chronic postoperative period. The initial problems are related to urinary leaks from the conduit and site of ureteral implantation. These are treated with diversion and drainage, and usually do not require formal revision. In the chronic phase, problems are related to urinary tract infections, chronic reflux and metabolic (prevented by the nonrefluxing ureteral implantation in the Indiana pouch), problems related to pouch bicarbonate wasting that result in hyperchlore-mic metabolic acidosis.
POSTOPERATIVE MANAGEMENT
The early postoperative period is marked by redistribution of the large volumes used in the intraoperative replacement of blood and fluid losses. The blood loss may range from 3,000 to 8,500 mL, and replacement with packed red cells, whole blood, and fresh frozen plasma is required. Care is taken to prevent pulmonary overload and renal dysfunction by utilizing volume assessment with central venous or pulmonary artery catheters. Hypertension can be a problem for unknown reasons but is hypothesized to be due to changes in the distribution of the intravascular volume. Following ex-tubation, patients begin a slow re-education to the upright position. They must overcome significant deficits in balance and transfer. The bed is initially equipped with a trapeze device to encourage the patients to look around and strengthen the upper part of their body. The sense of being able to move from side to side and arising from the supine position has psychological benefits. Sitting upright is accomplished by graduating through a series of semirecumbent, sequentially increasing positions. Care must be taken not to put excessive pressure or shear on the stump suture line. Upper-limb strength-training exercises are required to provide adequate power for transfer and locomotion. These exercises all begin in the bed with range of motion, light weights, and use of the trapeze. They are progressed to self-mobilization in the wheelchair and a self-propelled gurney stretcher. Because of pain and positioning, the wheelchair is difficult to maneuver early in the postoperative period. The patients utilize the gurney, which they can operate in a prone position. This is normally their first method for self-mobilization and travel outside their room. Patients are generally able to carry out this activity 1 to 2 months postoperatively. With additional education in transferring, gain of self-confidence, and fitting in the bucket prosthesis, the patients begin to use the wheelchair (standard or electric) as their primary source of mobility (see Fig 22A-6.,A-D). Nutritional maintenance in the preoperative and early postoperative period can be a difficult problem. Those patients with severe pain or chronic infections may be malnourished when first evaluated. This is due to decreased intake and increased metabolic demands. Intravenous alimentation (either total or supplemental) may be started preoperatively and carried through to the postoperative period. 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, i.e., urinary diversion or colostomy formation), the majority of patients are not achieving this nutritional goal until about 3 to 4 weeks postoperatively. The use of centrally administered high glucose and amino acid mixtures with
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supplemental lipids can bridge the nutritional hiatus during the return of bowel function, 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. Almost all patients undergoing TLA have had pain as a significant component of the disease process. In some, this pain was one of the major motivating factors to undergo the surgery. Postoperative pain can be divided into two categories: incisional and phantom. The former, incisional pain, is related to flap closure and ostomy formation. The sequential use of intravenous narcotics (morphine), 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. Phantom pain is far more complex an entity and may require a variety of pharmacologic (oral and epidural agents), mechanical (changes in position and massage) and electrical stimulatory (TENS, transcutaneous electrical nerve stimulation) modalities for control.
FOLLOW-UP EVALUATION
The primary surgical procedure and the initial recovery require about a 2-month hospitalization. During this period, the patient has had the ablative surgery and care for any initial postoperative problems. 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). The basic techniques for bed-wheelchair transfers have been mastered. The initial bucket and a cosmetic prosthesis for the lower limbs are being fashioned. The steps in preparing and fitting the prostheses are outlined elsewhere (see Chapter 22B). Return to the mainstream requires that the patient be able to move not only within the home environment but also into the community. 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.). Of course, all controls must be designed for hand use, including those for acceleration, braking, and direction indicating. Even with all these features, only a small number of translumbar amputees are able to be completely independent outside of the home. Maneuvering on uneven surfaces and grass, across curbs, and in inclement weather is difficult and at times frightening for these patients. Psychological as well as physical problems are present. Early in the preoperative evaluation and throughout the postoperative convalescent and rehabilitative phases, the patient will need an advocate and support person. A clinical social worker skilled in interpersonal and family dynamics must provide this critical support for the acute problems and during difficult transitions. For younger patients, it is important to counsel them regarding employment options, possibility for further education, and anticipated difficulties in social interactions. Patients in whom the operation was performed for malignant disease must be evaluated for recurrence according to standard methods. Unfortunately, in a significant number, the tumor will recur with a likelihood of incurable metastatic disease.
SUMMARY
TLA is a structurally and functionally feasible ablative procedure. The preoperative preparation must include an extensive search for metastatic disease and discussion with the patient and family of the risks, expected benefits, and long-term results. The health care team includes nurses, social workers, physical and occupational therapists, a dietician, and physicians. Operative preparation includes adequate blood and blood product availability and coordination of the multispecialty operative team. Early postoperative problems are large fluid volume shifts, flap ischemia, and difficulties with the urinary diversion. Rapid involvement of the patient and family in the rehabilitative process, which includes mobilization, feeding, and socialization, is critical. Long-term goals of driving, education, employment, and interpersonal relations should be discussed and sought. The specter of recurrent disease is present and makes long-term follow-up evaluation essential. References: 1. Ahlering TE, Weinberg AC, Razor B: A comparative study of the ileal conduit, Kock pouch and modified Indiana pouch. J Urol 1989; 142:1193-1196. 2. Ahlering TE, Weinberg AC, Razor B: Modified Indiana pouch. J Urol 1990; 145:1-3.
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3. Aust JB, Page CP: Hemicorporectomy. J of Surg Oncol 1985; 30:226-230. 4. Larson DL, Liang MD: The quadriceps musculocutaneous flap: A reliable, sensate flap for the hemipelvectomy defect. Plast Reconstr Surg 1983; 72:347-353. 5. Ling D, Lee JKT: Retroperitoneum, in Stark DD, Bradley WG (eds): Magnetic Resonance Imaging. St Louis, Mosby-Year Book, 1983; pp 1156-1163. 6. Terz JJ, Schaffner MJ, Goodkin R, et al: Translumbar amputation. Cancer 1990; 65:2668-2675.
Chapter 22A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 22B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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, infection, or cancer. It requires the full cooperation of both the professionals involved and the amputee himself to achieve success. Prior to performing the operation, the surgeon will ensure that the patient understands both the outcome of the procedure and the potential for rehabilitation. Ideally, 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. the body due to primary dependence on the upper limbs for mobility following amputation. Since translumbar amputation (TLA) has only been performed in recent decades and is There is a tendency for the prosthetist, therefore rarely encountered in clinical practice. therapist, and physician to feel overwhelmed when faced with this challenge ( Fig 22B-1.). However, prior experience with paraplegics is very good preparation for working with the TLA survivor. In fact, 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. Donning, doffing, standing, and sitting techniques are all similar for both paraplegic and translumbar patients. Furthermore, the literature reports numerous cases of successful prosthetic fitting following TLA, including instances of independent household and limited community am-bulation. The prosthetic management of a translumbar amputee involves several key decisions, including the choice of a static or ambulatory system, componentry options, and suspension techniques. All are important factors in developing a prescription and treatment plan and require close consultation with the prosthetist. One key factor is the amputee's interest in and physical potential for ambulation. As would be expected, depression as well as significant medical complications are commonly encountered ; both can preclude ambulation until resolved. Physical barriers to prosthetic fitting can include gross obesity, inability to tolerate an upright posture, and poor upper-limb strength. A semireclined custom seating system may be considered in such cases.
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.
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SITTING PROSTHESIS
Most authors advise provision of a static sitting support system prior to consideration of This ambulatory prostheses, and many variants have been detailed in the literature. nonambulatory system is used after primary healing is complete and while the rehabilitation options are being analyzed. The static sitting prosthesis is a good diagnostic tool for assessing amputee tolerance and cooperation. Greater acceptance will occur if the amputee is allowed to fully acclimate to the sitting device prior to the introduction of an ambulatory system.
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Initially, the sitting device has a level distal surface to enhance safety and stability ( Fig 22B2.). Once comfort and a few hours' tolerance for sitting upright have been achieved, 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. The specific contour of the rocker depends upon such factors as body weight, torso height, and arm length and is best determined by dynamic alignment of the prosthesis during hand walking. 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. objects without tipping over and yet allow an easy weight shift to initiate ambulation. Prior to casting for the prosthesis, 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. 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. tissues carefully in the position they will occupy in the final prosthesis. 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.
SOCKET DESIGN
The socket design for the translumbar amputee must precisely identify weight-bearing and relief areas by using multiple transparent test socket procedures. The major weight-bearing area is the thorax assisted by containment of the abdominal tissues. Several areas need pressure relief, including the inferior borders of the scapulae, any prominent spinous processes, the axillae, and the brachial plexus complex. 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. The socket design must also accommodate the ostomy stomas and allow free access to these sites for self-care. The most common design utilizes "mail slots" to allow the collection bags to remain outside the socket, free of the pressures induced by weight bearing. Any openings in the socket must be carefully limited, or the abdominal skin will protrude. In some cases, 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. With flat drainage bags, it may be possible to omit the colostomy opening, provided that the amputee can defecate daily when not wearing the prosthesis. Simons et al. follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. have summarized the goals of socket design for the translumbar amputee as
Independent transfer in and out of the socket ( Fig 22B-3.) 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, even when leaning forward or back in the socket 10. Acceptable cosmesis 11. Ease in cleansing socket areas in contact with the body Due to the limited surface area available for weight bearing, total contact is the best approach Although earlier reports speculated about to reduce the pressure per square centimeter. the possibility of interfering with respiration, a paper by Grimby and Stener noted only minimal change in vital capacity with a new prosthesis designed to reduce rib contact. It is usually advisable to unweight the prosthesis at frequent intervals by pushing up with the arms, Over a period of analogous to the advice given paraplegics to avoid skin breakdown. weeks or months, 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. been noted in the literature.
AMBULATORY PROSTHESES
Having accomplished this degree of independence, some amputees will request prosthetic
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legs for cosmetic purposes or to permit limited ambulation. Davis et al. 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." was fitted with his final prosthesis, his attitude toward life changed dramatically .... Legs, even in a wheelchair, apparently made a difference for which there was no substitute . . . ," Although ambulation with crutches or a walker is feasible, transfers will be more cumbersome with prosthetic legs attached. Rather than encumbering the sitting prosthesis, it may be preferable to prescribe a separate ambulatory prosthesis with a new socket. Dankmeyer and Doshi have reported a clever alternative (illustrated in Fig 22B-6.) whereby the ambulatory prosthesis fastens on top of the sitting device, thus allowing the amputee to leave the legs behind in the chair when transferring. Goals for dynamic alignment include stability of knees and hips, gentle heel strike, and smooth rollover during stance phase. The gait pattern may be swing-through using forearm As is the case with paraplegia, it is the upper portion crutches or swing-to using a walker. 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, provided that transverse rotation units are incorporated into the prosthesis. Due to the small number of cases reported, it is not possible to recommend particular components. Each clinic team must therefore make an individual determination based upon their experience and judgement. Successful ambulation has been reported with either free or locking hips joints; polycentric, stance-control, or locking knees; and either articulated or solidankle foot mechanisms ( Fig 22B-4.). Although successful exoskeletal fittings have been reported in the past ( Fig 22B-5.), most recent cases utilize realignable endoskeletal componentry because of its versatility and light Due to the ease of interchangeable components, endoskeletal designs permit weight. clinical verification of various foot, ankle, knee, and hip joint combinations during gait training ( Fig 22B-6.). It is also possible to add components sequentially. Initially, 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. Length can be increased in increments, as the patient's balance and strength permit, with hip and knee joints added as the amputee progresses. Suspension of the prosthesis is critical if the stresses of swing-through ambulation are to be tolerated. Over-the-shoulder suspenders have proved to be the best option for this type of prosthesis. Care must be taken not to pinch any protruding flesh where the suspenders cross the proximal edge of the socket.
CONCLUSION
The survival period for translumbar amputees may sometimes be limited but has increased steadily as medical care has advanced; survival for more than 20 years has been documented. It is the mission of the clinic team to enhance quality of life during whatever time remains. This is accomplished by providing the greatest possible independence and freedom, including employment and ambulation to whatever degree the amputee is capable. The primary factors in the successful rehabilitation of the translumbar amputee are motivation and compliance: the highly motivated individual will succeed despite the difficulties. J. Bradley Aust performed the first successful TLA in 1961; the amputee found work in a nursing home and survived until 1980. Aust summarizes his long-term experience with this procedure in a recent paper as follows: "Freed of the nonfunctioning lower half, the patient is released from the dead weight holding him down, relieved of his chronic infection and/or cancer, and experiences a new mobility, sense of well-being, and renewed enthusiasm for life." The obvious loss of more than half of the body mass notwithstanding, numerous successful fittings following TLA attest to the potential for rehabilitation of the person faced with this singularly difficult challenge.
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References: 1. Aust JB, Page CP: Hemicorporectomy. J Surg Oncol 1985; 30:226-230. 2. Baker TC, Berkowitz T, Lord GB, et al: Hemicorporectomy. Br J Surg 1970; 57:471476. 3. Dankmeyer CH Jr, Doshi R: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. Orthot Prosthet 1981; 35:11-18. 4. Davis SW, Chu DS, Yang CJ: Translumbar amputation for nonneoplastic cause: Rehabilitation and follow-up. Arch Phys Med Rehabil 1975; 56:359-362. 5. DeLateur BJ, et al: Rehabilitation of the patient after hemicorporectomy. Arch Phys Med Rehabil 1969; 50:11-16. 6. Easton JKM, Aust JB, Dawson WJ, et al: Fitting of a prosthesis on a patient after hemicorporectomy. Arch Phys Med Rehabil 1963; 44:335-337. 7. Frieden FH, Gertler M, Tosberg W, et al: Rehabilitation after hemicorporectomy. Arch Phys Med Rehabil 1969; 50:259-291. 8. Friedmann LW, Marin EL, Park YS: Hemicorporectomy for functional rehabilitation. Arch Phys Med Rehabil 1981; 62:83-86. 9. Grimby G, Stener B: Physical performance and cardiorespiratory function after hemicorporectomy. Scand J Rehabil Med 1973: 5:124-129. 10. Leichtentritt KG: Rehabilitation after hemicorporectomy. Am J Proctol 1972; 23:408413. 11. Mackenzie AR, Miller TR, Randall HT: Translumbar amputation for advanced leiomyosarcoma of the prostate. J Urol 1967; 97:133-136. 12. Miller TR, Mackenzie AR, Karasewich EG: Translumbar amputation for carcinoma of the vagina. Arch Surg 1966; 93:502-506. 13. Miller TR, Mackenzie AR, Randall HT, et al: Hemicorporectomy. Surgery 1966; 59:988993. 14. Miller TR, Mackenzie AR, Randall HT: Translumbar amputation for advanced cancer: Indications and physiologic alterations in four cases. Ann Surg 1966; 164:514-521. 15. Pearlman SW, McShane RH, Jockimsen PR, et al: Hemicorporectomy for intractable decubitus ulcers. Arch Surg 1976; 111:1139-1143. 16. Simons BC, Lehman JF, Taylor N, et al: Prosthetic management of hemicorporectomy. Orthot Prosthet 1968; 22:63-68. 17. Terz JJ, Schaffner MJ, Goodkin R, et al: Translumbar amputation. Cancer 1990; 65:2668-2675. 18. The most radical procedure. Inter-Clin Info Bull 1966; 5:22-23. 19. Williams RD, Fish JC: Translumbar amputation. Cancer 1968; 23:416-418.
Chapter 22B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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.
PRESURGICAL MANAGEMENT
Initial Patient Contact
This time provides an opportunity for the therapist to introduce himself to the patient and, in conjunction with other qualified members of the rehabilitation team, to prepare the patient for the events to come. Specifically, the therapist will attempt to develop a professional rapport with the patient and earn his trust and confidence. This period also offers the therapist an excellent opportunity to explain the time frame of the rehabilitation process. Fear of the unknown can be extremely frightening to many patients; therefore, having the comfort of knowing what the future holds as well as what will be expected of them can ease the process. A visit from another amputee who has been successfully rehabilitated can assist in this process. The visiting amputee should be carefully screened by appropriate personnel and should have a suitable personality for this task. Additional considerations should be given to similarities between level of amputation, age, gender, and outside interests. If available, any information on various prostheses or videos showing recreational activities may benefit the patient. The therapist must also keep in mind how much information the patient is psychologically prepared to hear. Many hospitals have affiliations with local support groups, where amputees visit other amputees to help them throughout the healing process. The pragmatic aspect of the therapist's responsibilities presurgically will include discussing the possibilities of phantom limb sensation and discomfort, joint contracture prevention, as well as overall functional assessment. If the patient so desires, a prosthesis may be introduced at this point to satisfy curiosity.
Funding for digitization of the Atlas of Limb Prosthetics was provided by the Northern Plains Chapter of the American Academy of Orthotists & Prosthetists
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POSTSURGICAL MANAGEMENT
Evaluation
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Mental Status
An accurate assessment of the patient's mental status can lend insight into the likely comprehension level for future prosthetic care. The therapist should be concerned with assessing the patient's potential to cognitively perform activities such as donning and doffing the prosthesis, residual-limb sock regulation, bed positioning, skin care, safe ambulation, and other functional activities of the amputee. If the patient does not possess the necessary level of cognition, family members and/or friends should become involved in the rehabilitation process to help ensure a successful outcome.
Range of Motion
A functional assessment of gross upper-limb and sound lower-limb motions should be made. A measurement of the residual limb's range of motion (ROM) should be recorded for future reference. Joint contractures are complications that can greatly hinder the amputee's ability to ambulate efficiently with a prosthesis; thus extra care should be taken to avoid them. The most common contracture for the transfemoral amputee is hip flexion, external rotation, and abduction, while knee flexion is the most frequently seen contracture for the transtibial amputee. 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. This may affect the manner in which the prosthesis is fabricated.
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. This will help determine the patient's potential skill level to perform activities such as transfers, wheelchair management, and ambulation with and without the prosthesis.
Sensation
Evaluation of the amputee's sensation is useful to both the patient and therapist alike. The therapist can gain insight into the possible insensitivity of the residual limb and/or sound limb. This may affect proprioceptive feedback for balance and single-limb stance, which in turn can lead to gait difficulties. The patient must be made aware that decreased pain, temperature, and light touch sensation can increase the potential for injury and tissue breakdown.
Bed Mobility
The importance of good bed mobility extends beyond simple positional adjustments for comfort or to get in and out of bed. 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. If the patient is unable to perform the skills necessary to maintain proper positioning, assistance must be provided. As with most patients, adequate bed mobility is a basic requirement for higher-level skills such as bed-to-wheelchair 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. Coordination assists with ease of movement and the refinement of motor skills. Both balance and coordination are required for weight shifting from one limb to another, thus improving the potential for an optimal gait. After evaluating mental status, ROM, strength, sensation, balance, and coordination, 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.
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Transfers
Transfer skills are essential for early mobility. Additional functional transfers such as toilet, shower, and car transfers must also be assessed before discharge to more completely determine the patient's level of independence. For transtibial amputees who are not ambulatory candidates, a very basic prosthesis may be indicated for transfers only.
Wheelchair Propulsion
The primary means of mobility for a large majority of amputees, either temporarily or permanently, will be the wheelchair. The energy conservation of the wheelchair over prosthetic ambulation is considerable with some levels of amputation. Therefore, wheelchair skills should be taught to all amputees during their rehabilitation program.
Prosthetic Management
The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. As a rule, solid plastic materials are cleaned with a damp cloth and foam
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materials with rubbing alcohol. 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.
Sock Regulation
Sock regulation is of extreme importance to prevent pistoning from occurring. The patient should carry extra socks at all times in case of pistoning or extreme perspiration. A thin nylon sock (sheath) should cover the residual limb to assist in reducing friction at the residuallimb/socket interface. Stump socks are available in assorted plies or thickness that permit the patient to obtain the desired fit within the socket. Socks should be applied wrinkle free, with the seams horizontal and on the outside to prevent additional pressure on the skin.
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, (2) assist in shaping, (3) help counteract contractures in the transfemoral amputee, (4) provide skin protection, (5) reduce redundant-tissue problems, (6) reduce phantom limb discomfort/sensation, and (7) desensitize the residual limb with local pain. Controversy does exist concerning the use of traditional elastic bandaging vs. the use of residual-limb shrinkers. Currently, many institutions prefer commercial shrinkers for their ease and reproducibility of donning. Advocates of elastic bandaging state that more control over pressure gradients and tissue shaping is provided. Regardless of individual preference, application must be performed correctly to prevent (1) circulation constriction, (2) poor residual-limb shaping, and (3) edema ( Fig 23-2. and Fig 23-3.).
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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.
Range of Motion
Prevention of decreased ROM and contractures is a major concern to all involved. Limited ROM can often result in difficulties with prosthetic fit, gait deviations, or the inability to ambulate with a prosthesis altogether. The best way to prevent loss of ROM is to remain active and ensure full ROM of affected joints. Unfortunately, not all amputees have this option, and therefore, proper limb positioning becomes important. The transfemoral amputee should place a pillow laterally along the residual limb to maintain neutral rotation with no abduction when in a supine position. If the prone position is tolerable during the day or evening, a pillow is placed anteriorly under the residual limb for 20 to 30 minutes, two to three times daily, to maintain hip extension. Transtibial amputees should avoid knee flexion for prolonged periods of time. A stump board will help maintain knee extension when using a wheelchair. 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.). Amputees who have already developed a loss of ROM may benefit from many of the traditional therapy procedures such as passive ROM, contract-relax stretching, soft-tissue mobilization, myofascial techniques, joint mobilization, and other methods that promote increased ROM.
Functional Activities
Encouraging activity as soon as possible after amputation surgery helps speed recovery in several ways. First, it will offset the negative affects of immobility by promoting movement through the joints, muscle activity, and increased circulation. Second, the patient will begin to re-establish personal independence, which may be perceived as threatened due to limb loss. Finally, the psychological advantage derived from activity and independence will continue to motivate the patient throughout the rehabilitation process.
General Conditioning
A decrease in general conditioning and endurance are contributory factors leading to difficulties in learning functional activities and prosthetic gait training. Regardless of age or present physical condition, a progressive general exercise program should be prescribed for every patient beginning immediately after surgery, continued throughout the preprosthetic period, and finally incorporated as part of the daily routine. The list of possible general strengthening/endurance exercise activities is long: cuff weights in bed, wheelchair propulsion for a predetermined distance, dynamic residual-limb exercises, ambulation with an assistive device prior to prosthetic fitting, loweror upper-limb ergometer work, wheelchair aerobics, swimming, aquatic therapy, lowerand upper-body strengthening at the local fitness center, and any sport or recreational activity of interest. The amputee should select one or more of these, begin participation to tolerance, and progress to 1 hour or more a day. The advantages of participation extend well beyond improving the chances of ambulating well with a prosthesis. The individual has the opportunity to experience and enjoy activities thought impossible for an amputee. If difficulties are experienced, 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.
Bed Mobility
The severely involved patient may be taught to utilize a trapeze, side rail, or human assistance when learning bed mobility. This practice, however, should not be employed for the general amputee population because, while easier initially, continued use of these methods will only hamper the future rehabilitation process. Regardless of age, each patient should be taught a safe and efficient manner in which to roll, come to sitting, or adjust their position. Log rolling, followed by side lying to sitting or supine lying on elbows to long sitting, are two acceptable methods that incorporate all the necessary skills for efficient bed mobility.
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Transfers
Once bed mobility is mastered, 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, tub, and car. 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. In most cases, 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. As the patient's single-limb standing balance improves, more advanced transfers may be taught to improve the patient's independence. In cases where an immediate postoperative or preparatory prosthesis is utilized, weight bearing through the prosthesis can assist the patient in the transfer and provide additional safety. Bilateral amputees who are not fitted with an initial prosthesis transfer in a "head-on" manner. The wheelchair approaches the mat or chair, with the front of the chair abutting the transferring surface. The patient then slides forward onto the desired surface by lifting the body and pushing forward with both hands. Until adequate strength of the latissimus dorsi and triceps is attained for this transfer, 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.).
Wheelchair Propulsion
Wheelchair mobility is the first skill that will give the amputee independence in the world outside of the hospital room. The degree of skill and mastery of the wheelchair varies depending on age, strength, and agility. Basic skills such as forward propulsion, turns, and preparation for transfers, i.e., parking and braking, should be taught immediately. Later, advanced wheelchair skills should be taught: ascending and descending inclines, wheelies, floor-to-wheelchair transfers, and curb jumping. The time dedicated to wheelchair skills is dependent on the degree to which the amputee may potentially require the wheelchair. Bilateral and older amputees may require greater use of the wheelchair, while unilateral and younger amputees will be more likely to utilize other assistive devices when not ambulating with their prosthesis. Because of the loss of body weight anteriorly the amputee will be prone to tipping backward while in the standard wheelchair. Amputee adapters set the wheels back approximately 5 cm, thus moving the amputee's center of gravity forward to prevent tipping, especially when ascending ramps or curbs.
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While safety is a primary factor in selecting an appropriate assistive device, mobility is a secondary consideration that cannot be overlooked. The criteria for selection should include (1) unsupported standing balance, (2) upper-limb strength, (3) coordination and skill with the assistive device, and (4) cognition. A walker is chosen when a amputee has fair to poor balance, strength, and coordination. If balance and strength are good to normal, forearm crutches may be used for ambulation with or without a prosthesis. A quad or straight cane may be selected to ensure safety when balance is questionable while ambulating with a prosthesis.
Single-Limb Standing
Weight acceptance in the prosthesis is one of the most difficult challenges facing both therapist and amputee. Without the ability to maintain full single-limb weight bearing and balance for an adequate amount of time (0.5 seconds minimum) the amputee will exhibit a number of gait deviations, including (1) decreased stance time on the prosthetic side, (2) a shortened stride length on the sound side, or (3) lateral trunk bending over the prosthetic limb. Strength, balance, and coordination are the primary physical factors influencing singlelimb stance on a prosthesis. Additionally, fear, pain, and lack of confidence in the prosthesis must be considered when an amputee is demonstrating extreme difficulty in overcoming weight bearing on the prosthesis. It is important to recognize the need to promote adequate weight bearing and balance on the prosthesis prior to and during ambulation. 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, this skill can be employed with relatively little difficulty. The stool-stepping exercise is an excellent method by which this skill may be learned. Have the amputee stand in the parallel bars with the sound limb in front of a 10- to 20-cm (4- to 8-in.) stool (or block), its height depending on the patients level of ability. Then ask the amputee to step slowly onto the stool with the sound limb while using bilateral upper-limb support on the parallel bars. 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. Initially, the speed of the sound leg will increase when upper-limb support is removed, but with practice the speed will become slower and more controlled, thus promoting increased weight bearing on the prosthesis ( Fig 23-10. ).
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The amputee's ability to control sound-limb advancement is directly related to the ability to control prosthetic limb stance. The following are three contributing factors that may help the amputee achieve adequate balance over the prosthetic limb. First, control of the musculature of the residual limb is necessary to maintain balance over the prosthesis. Second, the patient must learn to utilize the available proprioceptive sensation at the residual-limb/socket interface to control the prosthesis. Third, the amputee must visualize the prosthetic foot and its relationship to the ground. New amputees will find it difficult to understand this concept at first but will gain a greater appreciation as time goes on.
Pelvic Motions
The pelvis, with the body's center of gravity, moves as a unit in four directions: it displaces vertically, shifts laterally, tilts horizontally, and rotates transversely. Each of these motions can directly affect the amputee's gait and result in gait deviations or increased energy consumption during ambulation. 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. 1. Vertical displacement is simply the rhythmic upward and downward motion of the body's center of gravity. The knee must flex 10 to 15 degrees during foot flat, and full extension must be obtained during midstance. The transtibial amputee has the ability to flex and extend the knee during the stance phase of gait. 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. ). 2. Lateral shift occurs when the pelvis shifts from side to side approximately 5 cm (2 in.). The amount of lateral shift is determined by the width of the base of support, which is 5 to 10 cm (2 to 4 in.), depending on the height of the individual. 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. Because of this, 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, which leaves inadequate space for the prosthetic limb to follow a natural line of progression. The result is an abducted or circumducted gait with greater-than-normal lateral displacement of the pelvis toward the prosthetic side. While more frequently observed in transfemoral amputees, this altered base of support may also be seen with transtibial amputees ( Fig 23-12. ). 3. Horizontal dip of the pelvis is normal up to 5 degrees; anything greater is considered a gluteus me-dius gait. Usually, this is directly related to weak hip abductor musculature, more specifically, the gluteus medius. Maintenance of the residual femur in adduction via the socket theoretically places the gluteus medius at the optimal length-tension ratio. However, if the limb is abducted, the muscle is placed in a compromised position and is unable to function properly. 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. ). 4. Transverse rotation of the pelvis occurs around the longitudinal axis approximately 5 to 10 degrees to either side. This transverse rotation assists in shifting the body's center of gravity from one side to the other. In addition, 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. Knee flexion during toe-off is created by other influences as well, including plantar flexion of the foot, horizontal dip of the pelvis, and
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gravity. No prosthetic foot permits active plantar flexion, and horizontal dip greater than 5 degrees is abnormal; therefore restoration of transverse rotation of the pelvis becomes of great importance in order to obtain sufficient knee flexion ( Fig 23-13. ). Normalization of trunk, pelvic, and limb biomechanics can be taught to the amputee in a systematic way. First, independent movements of the various joint and muscle groups are developed. Second, the independent movements are incorporated into functional movement patterns of the gait cycle. Finally, all component movement patterns are integrated to produce a smooth normalized gait. One suggested method of training is as follows: 1. Strengthening of all available musculature by dynamic residual-limb exercises (see "Preprosthetic Exercise"). 2. Proprioceptive neuromuscular facilitation (PNF), Feldenkrais, or any other movement awareness techniques may be performed for trunk, pelvic, and limb re-education patterns. These exercises encourage rotational motions and promote independent movements of the trunk, pelvic girdle, and limbs. 3. Pregait training exercises (see "Pregait Training"). 4. Sound-limb stepping within the parallel bars is performed with the amputee stepping forward and backward, heel rise to heel strike, with both hands on the bars. 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. 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, which in most cases is close to normal for that individual ( Fig 23-14. ). 5. Prosthetic-limb stepping in the parallel bars is similar to the activity described above except that the amputee uses the prosthetic limb. As the therapist palpates the ASIS, in many cases a posterior rotation of the pelvis will be observed. This is often the result of the amputee's attempt to kick the prosthesis forward with the residual limb. The pelvis rotates posteriorly, just as it would if someone were kicking a football.It is important that the amputee feel the difference between the pelvic motion on the prosthetic side and the sound side. 6. To restore the correct pelvic motion, the amputee places the prosthetic limb behind the sound limb while holding on to the parallel bars with both hands. The therapist blocks the prosthetic foot to prevent forward movement of the prosthesis. Rhythmic initiation is employed to give the amputee the feeling of rotating the pelvis forward as passive flexion of the prosthetic knee occurs. As the amputee becomes comfortable with the motion, he can begin to move the pelvis actively, eventually progressing to resistive movements when the therapist deems them appropriate ( Fig 23-15. ). 7. Once the amputee and therapist are satisfied with the pelvic motions, the swing phase of gait can be taught. The amputee is now ready to step forward and backward with the prosthetic limb. Attention must be given to the pelvic motions, that the line of progression of the prosthesis remains constant without circumducting, and that heel contact occurs within boundaries of the base of support ( Fig 23-16. ). As the amputee improves, release the sound-side hand from the parallel bars and eventually both hands. There should be little if any loss of efficiency with the motion, but if there is, revert to the previous splinter skill. 8. Return to sound-limb stepping with both hands on the parallel bars. Observe that the mechanics are correct and that the sound foot is not crossing midline as heel strike occurs. When ready, have the amputee remove the sound-side hand from the bars. At this time, there may be an increase in the speed of the step, a decrease in step length, and/or lateral leaning of the trunk. This is a direct result of the inability to bear weight or balance over the prosthesis. Cue the amputee in remembering the skills learned while performing the stool-stepping exercise (see "Pregait Training"). After adequate skill is perfected, 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. ). 9. When each of the skills described above is developed to an acceptable level, the amputee is ready to combine the individual skills and actually begin walking with the prosthesis. Initially, begin in the parallel bars with the therapist and amputee facing each other, the therapist's hands on the amputee's ASISs, and the amputee holding onto the bars. As the amputee ambulates within the bars, the therapist applies slight resistance through the hips to provide proprioceptive feedback for the pelvis and musculature of the involved lower limb.
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10. When both the therapist and the amputee are comfortable with the gait demonstrated in the parallel bars, the same procedure as described above is practiced out of the bars, with the amputee initially using the therapist's shoulders as support and progressing to both hands free when appropriate. The therapist may or may not continue to provide proprioceptive input to the pelvis ( Fig 23-18. ). As the amputee begins to ambulate independently, 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. 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. When adequate weight bearing through the prosthetic limb has been achieved, have the amputee begin to take longer steps with the sound limb and slightly shorter steps with the prosthetic limb. This principle also applies when increasing the cadence. When an amputee increases his speed of ambulation, the prosthetic limb often compensates by taking a longer step, thus increasing the asymmetry. By simply having the amputee take a longer step with the sound limb and a moderate step with the prosthetic limb, increased speed of gait is accomplished without increased asymmetry. 11. Trunk rotation and arm swing are the final missing components in restoring the biomechanics of gait. During human locomotion, the trunk and upper limbs rotate opposite the pelvic girdle and lower limbs. Trunk rotation is necessary for balance, momentum, and symmetry of gait. Many amputees have a decreased trunk rotation and arm swing, especially on the prosthetic side. This may be the result of fear of displacing their center of gravity too far forward or backward over the prosthesis ( Fig 23-19. ). Normal cadence is considered to be 90 to 120 steps per minute, or 2.5 mph. Arm swing provides balance, momentum, and symmetry of gait and is directly With acceleration of gait, arm swing influenced by the speed of ambulation. excursion becomes greater, thus permitting a more efficient gait due to increased forward momentum. Similarly, amputees who walk at slower speeds will demonstrate a diminished swing excursion and hence less gait efficiency. Restoring trunk rotation and arm swing is easily accomplished by utilizing rhythmic initiation or passively cueing the trunk as the amputee walks. The therapist stands behind the amputee with one hand on either shoulder. As the amputee walks, the therapist gently rotates the trunk. When the left leg steps forward, the right shoulder is rotated forward and vice versa. Once the amputee feels comfortable with the motion, he can actively take over the motion. 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. Most patients can be progressed to the point of ambulating out of the parallel bars. At that time, the amputee must practice ambulating with the chosen assistive device and maintaining pelvic rotation, an adequate base of support, equal stance time, and equal stride length, all of which can have a direct influence on the energy cost of walking. Trunk rotation will be absent in amputees utilizing a walker, but those ambulating with crutches or a cane should be able to incorporate trunk rotation into their gait.
Variations
Naturally, the time and degree of prosthetic training required is individual to each amputee, depending on many factors such as age and motivation, as well as the cause and level of amputation. Syme ankle disarticulates have a major advantage over transtibial amputees due to the ability to bear weight distally. This allows them to have better kinesthetic feedback for placement of the prosthetic foot. Because of this kinesthetic capability and the increased length of the lever arm, minimal prosthetic gait training is required. Although Syme ankle disarticulates are able to progress rapidly with weight shifting and other basic gait skills, they may require practice to attain equal stride length and stance time. Knee disarticulates have several advantages over transfemoral amputees, including a longer lever arm, enhanced muscular control, improved kinesthetic feedback, and greater distal-end weight bearing. Although these advantages do provide an opportunity for decreased rehabilitation time, the knee disarticulate must learn all the same skills as a transfemoral amputee. 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
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and foot/ankle assembly. 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. Amputees of all levels should be educated in residual-limb sock regulation, knowledge of pressure and relief areas, care of the prosthesis, and residual-limb donning and doffing techniques.
Step By Step
This method is essentially the same for all levels of amputees. When ascending stairs, the body weight is shifted to the prosthetic limb as the sound limb firmly places the foot on the stair. The trunk is slightly flexed over the sound limb as the knee extends and raises the prosthetic limb to the same step. The same process is repeated for each step. When descending stairs, the body weight is shifted to the sound limb, which lowers the prosthetic limb to the step below primarily by eccentric contraction of the quadriceps muscle. Once the prosthetic limb is securely in place, body weight is transferred to the prosthetic limb, and the sound limb is lowered to the same step.
Crutches
When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use
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Curbs
The methods described for stairs are identical for curbs. Depending on the level of skill, the amputee can step up or down curbs with either leg.
Uneven Surfaces
A good practice with gait training is to have the amputee ambulate over a variety of surfaces, including concrete, grass, gravel, uneven terrain, and varied carpet heights. Initially, the new amputee will have difficulty in recognizing the different surfaces secondary to the loss of proprioception. To promote an increased awareness, spending time on different surfaces and becoming visually aware of the changes help to initiate this learning process. Additionally, 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.
Sidestepping
Sidestepping, or walking sideways, can be introduced to the amputee at various times throughout the rehabilitation program. 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. During early rehabilitation this skill provides the amputee with a functional exercise for strengthening the hip abductors and, later in the rehabilitation process, with an opportunity to progress into multidirectional movements.
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 weight line falls posterior to the knee, and this causes a
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flexion moment with possible buckling of the knee. 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. The prosthetic foot is placed well behind the sound limb, with the majority of the body's weight being born on the prosthetic toe, thus keeping the weight line anterior to the knee. The sound limb is then brought back, usually at a slightly faster speed and a somewhat shorter distance. The trunk is also maintained in some flexion in order to maintain the weight forward on the prosthetic toe. With a little practice most amputees become quite proficient in backward walking.
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, elevators, or just simply turning around are often overcome by "hip-hiking" the prosthesis and pivoting around the sound limb. This method is effective but hardly the most aesthetic means of maneuvering. When turning to the sound side, two key factors for a smooth transition should be remembered: first, maintain pelvic rotation in the transverse plane, and second, perform the turn in two steps. Simply move the prosthetic limb over the sound limb 45 degrees, rotate the sound limb 180 degrees, 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. ). 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, thus preventing knee flexion. For example, by crossing the sound limb 45 degrees over the prosthetic limb, the weight line is automatically thrown forward. The prosthetic limb is rotated as close to 180 degrees as possible without losing balance (135 degrees is usually comfortable), and the turn is completed by stepping in the desired direction with the sound limb. If necessary, 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. ). One exercise that will reinforce turning skills is follow the leader, where the amputee follows the therapist who is making a series of turns in all directions and with various speeds and degrees of difficulty. The level of skill in turning will vary among amputees. All functional ambulators should be taught to turn in both directions regardless of the prosthetic side. Those with poor balance may be limited to unidirectional turns and require a series of small steps to complete the turn.
Tandem Walking
Walking with a normal base of support is of prime importance. However, tandem walking can assist with balance and coordination and improve prosthetic awareness for the amputee. Place a 5- to 10-cm (2- to 4-in.)-wide strip on the floor. The amputee is asked to walk in three different ways: first, with one foot to either side of the line; second, heel to toe with one foot in front of the other; and third, 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.
Braiding
Braiding (cariocas) may be taught either in the parallel bars or in an open area depending upon the person's ability. Simple braiding is one leg crossing in front of the other. As the amputee's skill improves, the prosthetic limb can alternate, first in front of and then behind the sound limb, and vice versa. As ability improves, the speed of movement should increase. With increased speed the arms will be required to assist with balance, and likewise, trunk rotation will increase, 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,
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hopping, and other skills. Single-limb squatting is considerably more difficult but can help improve balance and strength. When first attempting this skill, half squats with a chair underneath the individual are recommended in case balance is lost.
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. During falling, amputees must first discard any assistive device to avoid injury. They should land on their hands with the elbows slightly flexed to dampen the force and decrease the possibility of injury. As the elbows flex, they should roll to one side, further decreasing the impact of the fall. 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. From this position the amputee has the choice of remaining quadruped or assuming a sitting posture.
Floor to Standing
Many techniques exist for teaching the amputee how to rise from the floor to a standing position. 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. Depending on the type of amputation and the level of skill, the amputee and therapist must work closely together to determine the most efficient and safe manner to successfully master this task.
Running Skills
For most amputees, the inability to run is the single most common factor limiting participation in recreational activities, and yet it is the most desired skill. 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. Rarely, if ever, is running taught in the rehabilitation setting. Running, as with all gait-training and advanced skills, takes time and practice to master. If the amputee is exposed to the basic skills of running during rehabilitation, then the individual may make the decision to pursue running at a later date. 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. At ground contact, the hip on the amputated side should be flexed and moving toward extension with the knee flexed and the prosthetic foot passively dorsiflexing. 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. As the center of gravity passes over the prosthesis during the stance phase, the ipsilateral arm should be fully forward (shoulder flexed to 60 to 90 degrees), while the contralateral arm is simultaneously extended. Extreme arm movement can initially be difficult for the amputee concerned with maintaining balance. During late mid-stance to toe-off, 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, the force produced by hip extension should deflect the keel so that additional push-off will be provided by the prosthetic foot. Forward swing and the float phase are periods when the hip should be rapidly flexing and elevating the thigh. The arms should again be opposing the advancing lower limb, with the ipsilateral arm backward and the contralateral arm forward. During foot descent, 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. ). Transfemoral amputees and knee disarticulates traditionally run with a period of double support on the sound limb during the running cycle, commonly referred to as the "hop-skip" running gait pattern. The typical running gait cycle begins with a long stride by the prosthetic leg, followed by a shorter stride with the sound leg. In order to give the prosthetic leg sufficient time to advance, the sound leg takes a small hop as the prosthetic limb clears the ground and moves forward to complete the stride. The speed that a transfemoral amputee runner may achieve will be hampered because every time either foot makes contact with the ground, 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). The result is that each time the foot contacts the ground, forward momentum is decelerated. In other words, with
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every stride the amputee is slowing down when running with the "hop-skip" gait. 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. The transfemoral amputee takes a full stride with the prosthetic leg, followed by a typically shorter stride with the sound leg. With training, equal stride length and stance time may be achieved. 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. Initially, problems that may occur include excessive vaulting off the sound limb to ensure ground clearance of the prosthetic limb, decreased pelvic and trunk rotation, decreased and asymmetrical arm swing, and excessive trunk extension. Again with training, many of these deviations will decrease and possibly be eliminated ( Fig 23-24. ). The transfemoral amputee has an additional consideration when learning to run. To date, no knee system permits flexion during the prosthetic support phase, and this results in the residual limb having to absorb the ground reaction force during initial ground contact. Another problem with present knee units that transfemoral amputees must contend with is maintaining the appropriate cadence during swing. Hydraulic knee units offer the ability to adjust the hydraulic resistance during knee flexion and extension. During running, less resistance in extension permits faster knee extension, while increased resistance in flexion decreases the amount of heel rise with beginning runners. 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. Collectively, these adjustments decrease the amount of time required for the prosthetic swing phase. The "leg-over-leg" running style does permit the transfemoral amputee to run faster for short distances but at a greater metabolic cost. While the "leg-overleg" style is preferred, the hopskip method is often more easily taught and less demanding physically on the amputee. If the sole purpose of instructing running is to permit the individual to move quickly in a safe and sure manner, the hop-skip method is most frequently suggested.
Recreational Activities
By definition, recreation is any play or amusement used for the refreshment of the body or mind. That is to say, the term recreational activities need not exclusively mean athletics such as running or team sports. In fact, many people enjoy recreational activities such as gardening, shuffleboard, or playing cards as a means of socializing or relaxing. A comprehensive rehabilitation program should include educating the amputee on how to return to those activities that are found pleasurable. For example, the therapist can teach physical splinter skills such as weight shifting, necessary to help the amputee participate in shuffleboard, or various methods of kneeling for gardening. In addition, there are many national and local recreational organizations and support groups that provide clinics, coaching, or another amputee who can teach from experience how to perform various higher-level recreational skills. 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.
CONCLUSION
In summary, the physical therapist must work closely with the rehabilitation team to provide comprehensive care for the amputee. An individualized program must be constructed according to the level of ability and skill of each patient. The primary skills of preprosthetic training help build the foundation necessary for successful prosthetic ambulation. 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. Therefore, the primary goal of the rehabilitation team should be to make this transitional period as smooth and successful as possible.
Acknowledgment
We would like to thank Mr. Frank Angulo for his time and talents in creating the illustrations in this chapter. References:
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1. Davis GJ: A Compendium of Isokinetics in Clinical Usages and Rehabilitation Techniques, ed 2. S & S Publishing, La Crosse, Wise, 1985. 2. Eisert O, Tester OW: Dynamic exercises for lower extremity amputees. Arch Phys Med Rehabil 1954; 35:695-704. 3. Murray MP: Gait as a total pattern of movement. Am J Phy Med Rehabil 1967; 16:290333. 4. Murray MP, Drought AB, Kory RC: Walking patterns of normal men. J Bone Joint Surg [Am] 1964; 46: 335-360. 5. Peizer E, Wright DW, Mason C: Human locomotion. Bull Prosthet Res 1969; 10:48105.
Chapter 23 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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prosthetic rehabilitation in the early years improves the general health and social development of these children.
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preparatory prosthetic fitting, and definitive prosthetic fitting. Although managed differently, previous unilateral amputees who later become bilateral and simultaneous bilateral amputees both benefit from early rehabilitation with controlled weight bearing. Improved wound healing, the prevention of contractures, and early mobilization through the use of rigid dressings dominate the immediate and early phases. Maturation of the residual limb by comfortably, increasing weight bearing and initial gait training predominate in the preparatory prosthetic phase. Cosmesis, durability, and final gait training become important considerations in the definitive prosthetic phase. Increased sophistication of current fitting techniques, materials, 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.
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Soft compression dressings supplemented by an elastic bandage or shrinker sock are less effective in achieving rapid wound healing. Residual-limb edema associated with discomfort and phantom pain is frequently evident with this form of patient treatment. It delays the recovery period unnecessarily and invites further complications in the form of joint contractures and general physical decompensation, especially in the geriatric patient.
Definitive Prosthesis
Definitive prostheses are sometimes erroneously called "permanent" or "final" prostheses. These are misnomers since all prostheses wear out mechanically or require replacement due to deteriorating fit. 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. High-strength, 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. Improved combined biomechanical fitting principles and static and dynamic test socket procedures with flexible socket construction further enhance patient comfort and acceptance. Radiographs or xeroradiography can isolate or pinpoint residual-limb fitting problems. 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. but also the entire clinic team, who are responsible for formulating the prosthetic prescription. Individual patient needs vary greatly among infants, children, adolescents, adults, athletes, and active and sedentary geriatric amputees. There are different requirements between males and females and important considerations to be made for vocational and recreational activities. Parents, spouses, relatives, and friends of patients also play an important role since they influence patients' expectations and reactions to their prostheses and management. Each new patient requires individual assessment and evaluation to determine his exact personal needs. While many amputation levels are similar or the same, the individual patient requirements are vastly different and must be accommodated to be effective in the overall, total rehabilitation of the patient. A patient must learn to walk before he can expect to run, if this is even physically possible. Bilateral amputations can be of an equal level such as foot, ankle, transtibial, knee disarticulation, transfemo-ral, and hip disarticulation, or any combination of the above. Since it is the surgeon's intent to preserve all joints and all useful length in the residual limb, the
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prosthetist is presented with the challenge of varied amputation level combinations where prosthetic designs must interact effectively.
INFANT AMPUTEES
While statistically a very small group, children with congenital limb deficiencies present major challenges to the entire rehabilitation team. Depending on the full extent of the anomaly, infants may face continuous treatment throughout their lifetime to manage the disability. Early diagnosis, surgical intervention, and prosthetic fitting have been advocated. 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. Even high-level amputees as a result of lumbosacral agenesis have been fitted with specially designed 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. Limited ambulation is accomplished in time, when the socket is mounted on a swivel walker for selfinduced mobility. Following bilateral hip disarticulations, the prosthetic socket is combined with cosmetically enhanced thigh-shank-foot components that allow sitting, standing, and some Often these patients have multiple limited ambulation on the principles of a swivel walker. medical problems that require continued treatment and monitoring and may interrupt prosthetic management. Miniaturized, commercially available prosthetic components are very limited for infants. This requires the prosthetist to design and custom-fabricate what is needed. Some upper-limb components such as manually locking elbow joints can be integrated into lower-limb infant prostheses. Since structural strength requirements are very minimal, plastic tubing can be utilized in endoskeletal designs and results in very lightweight, cosmetic appliances. Recently we have switched to aluminum tubing that is fitted into a larger-size tubing, thus allowing telescoping length adjustments for growth. Our current, typical, initial knee disarticulation infant prostheses consist of flexible This allows for socket replacements due to thermoplastic sockets mounted in rigid frames. growth without remaking the entire prosthesis. 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. A miniaturized version of the total elastic suspension (TES) belt has also proved to be an effective option. Any suspension considerations must resolve the problems of diapers and thus should be moisture resistant and washable. Flexible or rigid pelvic band and hip joint suspension or shoulder harness suspension is seldom indicated in infants. In our experience, 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. needs. The prerequisite is that parents be able to apply the prosthesis correctly. More frequent socket replacements as a result of suction socket fittings are not as significant as anticipated and should not be a deterrent. Recently, the introduction of the hypobaric suspension system has provided another suspension option. 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. This system is appropriate even for infants. The use of stubbies as the initial prosthesis is recommended for all bilateral knee disarticulation or trans-femoral amputees, regardless of age, who are considered candidates for ambulation and who lost both legs simultaneously. Stubbies consist of prosthetic sockets mounted directly over rocker-bottom platforms that serve as feet. The rocker-bottom platforms have a long posterior extension to prevent the tendency for the patient to fall backward initially. The shortened anterior portion allows smooth rollover into the push-off phase. As hip flexion contractures lessen and balance improves, the posterior rocker extensions can be shortened accordingly. The use of stubbies results in lowering of the center of gravity, 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. As the patients confidence and ambulation skills improve, periodic lengthening of the stubbies is permitted until the height becomes nearly comparable with full-length prostheses, at which time the transition is attempted. Knee components are usually omitted for infants since stability and balance are still developing. The majority of infants, children, and young adults with bilateral knee disarticulation or transfemoral amputations can generate the energy required to ambulate when wearing
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stubbies without needing assistive devices such as crutches or canes. Assistive devices may be needed for safety and support once the patient has accomplished the transition to fulllength prostheses. 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. Parents like cosmetically pleasing prostheses, and every effort should be made to achieve this without sacrificing comfort or function. Lightweight exoskeletal designs are also quite acceptable for use in infants, and the choice should depend on what is considered most appropriate for a particular patient and parent.
CHILD AMPUTEES
Most children, including high-level bilateral lower-limb amputees, have very high physical activity levels. They are encouraged to participate in play, sports, and recreation activities like any other child. As a result many of the children place profound physical demands on their prostheses. Prostheses in need of major servicing and repairs are a joy to the entire clinical team, for they denote a very active, well-adjusted child who is using the prostheses to their maximum potential. For this reason, durability must be considered in the design for this active group of amputees. Fortunately, with the introduction of new petrochemical-based materials that are lightweight and strong, the challenge of prosthetic durability can be met better today than ever before. Prosthetic researchers, engineers, suppliers, and manufacturers have finally started to meet the challenge of providing componentry for this very active group of young children. 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.I.N.D. The Aqua-Flex, an all-plastic transfemoral pediatric knee-shin setup from Ford Laboratories in Richmond, British Columbia, Canada, can be used to make a waterproof prosthesis. Many components are still customdesigned and hand-fabricated by prosthetists to meet their individual patients needs. Comfort and control of the prosthesis are directly proportional to good socket retention on the This becomes critical in the bilateral amputee. Thus, it is advisable to use residual limb. suction suspension whenever this is possible in both transfemoral and trans-tibial fittings. The need for slightly more frequent socket replacements is a small price to pay to allow improved function and comfort for the active youngster. The use of the silicone suction socket (3S) technique has been reported and expanded to include all levels of amputation. Hypobaric suspension can also be utilized in children, as well as the conventional suspension systems such as hip control belts, waist belts, and cuff suspensions. Unstable knee joints may require the addition of side joints and thigh lacers or, at a minimum, a patellar tendon supracondylar (PTS) socket design. PTS socket configuration is also useful for short and very short residual transtibial limbs and where pistoning must be held to a minimum, such as in skin graft or burn patients. Whatever system is chosen, it must fill the needs and abilities of the patient and parents without making it technically too complex and thus frustrating. Occasionally a patient with bilateral tibial hemimelia is encountered after bilateral Syme ankle Knee instability and flexion contractures are major disarticulation or transtibial amputations. concerns that frequently accompany these congenital limb deficiencies. Prosthetic prescription should include side joints and thigh lacers, not so much to distribute weight as to provide increased medio-lateral knee stability ( Fig 24A-7.). When the knee flexion contracture exceeds 15 to 20 degrees, special socket modifications and techniques are indicated to accommodate the deformity ( Fig 24A-8.). If the congenital limb deficiency is so severe that knee instability or flexion contractures prohibit prosthetic fitting, then knee disarticulation is required on one or both limbs ( Fig 24A-9.). As discussed in the infant section, 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. 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, crutches, or canes ( Fig 24A-10. ). This high performance level is not always sustainable through adulthood, but diminishes with advancing age when some become marginal users or abandon the prostheses altogether, except for cosmetic use, in favor of wheelchair mobility.
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only. The longer lever arm, balanced thigh musculature, and end-bearing capacity of the knee disarticulation makes bilateral full-length prosthetic use easier than for the bilateral transfemoral amputee, but the principles and training are very similar ( Fig 24A-14. ). The accomplished user of bilateral transfemoral prostheses typically uses a cane and has midthigh or longer amputation levels. This patient was usually involved in recreational or sports activities prior to the amputations, is physically slim and fit, and has high endurance and good motivation. 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. ). Use of a stance-control or manual-locking knee is reserved for the shorter of the residual limbs. Different knee mechanisms can and should be utilized as required, but they must be tested and evaluated during trial ambulation. 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. Larger foot size may improve support and stability. The patient must be able to achieve a seated and standing position independently and in less-than-ideal locations. The amputee must also be trained to return to the standing position from the ground as occasionally would be required after a fall. Bilateral transfemoral prosthetic users require a great deal of gait training by a qualified physical therapist. Negotiation of stairs, inclines, declines, and uneven terrain are complex challenges that must be learned and practiced by the patient to become an accomplished ambulator ( Fig 24A-16. ). The use of SACH There are some possible variations in the rocker bottoms of stubbies. feet with the toes pointing posteriorly has been advocated by some for a smoother gait. We have utilized rocker bottoms incorporating the Greissinger foot multiaxial ankle system ( Fig 24A-17. ) and more recently the Flex Walk Foot fitted to tennis shoes. One triple amputee with a very short transfemoral amputation on one side is capable of briskly walking 2 miles daily for exercise. He prefers stubbies over full-length prostheses, which require much higher energy output, are cumbersome, slow him down, and instill a constant fear of falling ( Fig 24A18. ). This experience is very common with the use of full-length transfemoral prostheses and restricts the majority to ambulation with stubbies only. Adults with acquired bilateral hip disarticulation rarely become effective ambulators, but they still may request special-purpose prosthetic fittings. Specially designed and fitted sockets to allow for more comfortable seating can be provided. Full-length functional prostheses are primarily for cosmetic appearance while seated in a wheelchair, 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. of crutches ( Fig 24A-19. ).
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. In general, dismissing these patients as poor prosthetic candidates is a grave mistake and compromises the rehabilitation potential when immediate postsurgical treatment is delayed. Lack of exercise and mobility will encourage joint contractures, weaken the patient, cause loss of independence, bring on depression, and may even become life-threatening. No patient group benefits more from immediate postsurgical prosthetic fitting, including early fitting of preparatory or definitive prostheses, than the geriatric bilateral amputee. The challenge of rehabilitating these patients is frequently complicated by the presence of other illnesses. Diabetes, chronic infection, kidney disease, cardiovascular disease, respiratory disease, arthritis, and impaired vision are complicating factors that require careful consideration when evaluating patients. Delayed wound healing, slowly healing lesions, and neuropathy warrant additional consideration. Of these complicating factors, diabetes appears to be the leading cause of second limb loss. Fortunately, the time interval between the first and second limb loss, which can be months or perhaps years, makes learning to ambulate easier for the patient than if both limbs are lost simultaneously ( Fig 24A-20. ). Chronologic age alone should not determine whether an amputee is a prosthetic candidate. 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. understand and follow instructions for proper use of the prosthesis, 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. Sometimes patients are wrongly diagnosed as prosthetic noncandidates and denied prostheses. We must give the patient the benefit of the doubt and provide at least
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preparatory prostheses to evaluate ambulation potential. Even if prostheses are used only to assist in transfer activities, they are justified. Preoperative and postoperative patient education is an important adjunct to rehabilitation. Teaching a patient proper hygiene and care of the residual limbs and the prostheses is vital. Amputee support groups, now available in many localities, 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. Older patients require much more time, understanding, patience, and encouragement. They thrive on praise, and even small improvements give encouragement and aid in progress. They are frequently forgetful and need to be reinstructed frequently. Spouses and other family members should be encouraged to participate during fitting and training sessions. Their input is important, and their concerns should be addressed in detail. Prosthesis design and componentry must be based on careful individual evaluation of all pertinent factors. The most sophisticated prosthesis with hydraulic or pneumatic swing-phase control, rotators or torque absorbers, 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. Any type of prosthesis is inappropriate if the patient is unable to don and doff it properly. Bilateral transfemoral prostheses are too difficult to manage for most geriatric patients and, if requested, are primarily for cosmetic effect while using a wheelchair. Even stubbies are often too difficult for this group to master, and it is a very rare exception to find someone willing to try and to succeed in ambulating with them regularly ( Fig 24A-21. ). 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. Socket design must be such that the patient can don and doff the prosthesis independently. For transtibial prostheses, this may require that special pull-on loops be attached to the socket or liner for patients with arthritis of the hands. Similarly, a patient must be able to properly install a wedge suspension system in a PTS design, or other alternatives must be utilized. A neo-prene suspension sleeve is an excellent means of auxiliary socket suspension if the patient can apply it properly. If the patient cannot handle buckles, Velcro closures should be substituted. Side joints and thigh lacers are infrequently required for an unstable knee or very short residual transtibial limb. They greatly complicate donning the prosthesis, and should be avoided if other alternatives exist. Little frustrations can lead to total rejection of the prostheses and must be avoided. The basic rule is to keep them as simple as possible. Although suction socket suspension is the preferred means of suspension, the bilateral geriatric amputee can seldom master the conventional donning technique. An alternative method that merits consideration is use of the liquid-powder, wet-fit method, in which the patient liberally applies a special liquid lubricant that allows donning the prosthesis. This lubricant rapidly dries into a powder that allows retention of the socket by suction. Another option is to provide flexible, roll-on silicone liners that allow donning and doffing while seated. Hyperbaric socket suspension offers another excellent option. The majority of bilateral geriatric transtibial amputees master ambulation with the aid of a walker or cane. 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. ). Prostheses for geriatric amputees should be made as light as possible with contemporary techniques. They should be of relatively simple design and not contain superfluous components that may be of questionable benefit to limited ambulators. Occasionally geriatric patients with bilateral congenital deformities are encountered who have remained active ambulators. For these rare patients, custom-designed prostheses are required. Lightweight construction can prolong prosthetic use and ambulation ( Fig 24A-23. ).
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SUMMARY
The bilateral lower-limb amputee presents complicated problems for mobility and ambulation. The tremendous developments of recent years offer these individuals much greater functional potential. By applying the surgical, prosthetic, and rehabilitation techniques currently available, the bilateral lower-limb amputee can often achieve a remarkable degree of functional ambulation. References: 1. Aitken GT, Frantz GH: The juvenile amputee. J Bone Joint Surg [Am] 1953; 35:659664. 2. Arbogast R, Arbogast JC: The Carbon Copy II-From concept to application. J Prosthet Orthot 1988; 1:32-36. 3. Balakrishnan A: Technical note-tilting stubbies. Prosthet Orthot Int 1981; 5:85-86. 4. Banzinger E: Surlyn socket design for the young child. J Assoc Child Prosthet Orthot Clin 1987; 22:21. 5. Baumgartner R, Langlotz M: Amputee stump radiology. Prosthet Orthot Int 1980; 4:97100. 6. Berlemont M: Notre experience de l'appareillage precoce des amputes des membres inferieurs aux establissements Helio-Marins de Berck. Ann Med Phys 1961; 4:4. 7. Berry D: Composite materials for orthotics and prosthetics. Orthot Prosthet 1987; 40:38. 8. Bild DE, Selby JV, Sinnock P, et al: Lower -extremity amputation in people with diabetes: Epidemiology and prevention. Diabetes Care 1989; 12:24-31. 9. Bodily KC, Burgess EM: Contralateral limb and patient survival after leg amputation. Am J Surg 1983; 146:280-282. 10. Boontje AH: Major amputations of the lower extremity for vascular disease. Prosthet Orthot Int 1980; 4:87-89. 11. Bray J: Total Contact Plastic Suction Socket Manual, ed 6. Los Angeles, UCLA Prosthetic and Orthotic Education Program, 1981. 12. Breakey JW: Prefabricated below-knee sockets for the maturing stump. Bull Prosthet Res 1973; 19:42-51. 13. Burgess EM, Poggi DL, Hittenberger DA, et al: Development and preliminary evaluation of the VA Seattle foot. Rehabil Res Dev 1985; 22:75. 14. Burgess EM, Romano RL, Zettl JH; The Management of Lower Extremity Amputations: Surgery, Immediate Postsurgical Prosthetic Fitting, Rehabilitation, Bulletin TR 10-6. Washington, DC, US Government Printing Office, 1969. 15. Burgess EM, Romano RL, Zettl JH, et al: Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg [Am] 1971; 53:874-890. 16. Campbell J, Childs C: The SAFE foot. J Prosthet Orthot 1980; 34:3. 17. Couch NP, David JK, Tilney NL, et al: Natural history of the leg amputee. Am J Surg 1977; 133:469-473. 18. Dankmeyer CH Jr, Doshi R: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. Orthot Prosthet 1981; 35:11-18. 19. Ebskov G, Josephsen P: Incidence of reamputation and death after gangrene of the lower extremity. Prosthet Orthot Int 1980; 4:77-80. 20. Ekus L: Total suction for toddlers too! J Assoc Child Prosthet Orthot Clin 1987; 22:20. 21. Evans WE, Hayes JP, Vermilion BD: Rehabilitation of the bilateral amputee. / Vase Surg 1987; 5:589-593. 22. Fillauer C: A patellar-tendon-bearing socket with a detachable medical brim. Orthot Prosthet 1971; 25: 26-34. 23. Fillauer CE, Pritham CH, Fillauer KO: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92-103. 24. Fishman S, Edelstein JE, Krebs DE: Icelandic-Swedish-New York above-knee prosthetic sockets: Pediatric experience. J Pediatr Orthop 1987; 7:557-562. 25. Frantz CH, Atken GT: Complete absence of the lumbar spine and sacrum. J Bone Joint Surg [Am] 1967; 49:1531-1540. 26. Gerhardt JJ, King PS, Fowlks EW, et al: A device to control ambulation pressure with immediate postoperative prosthetic fitting. Bull Prosthet Res 1971; 10:153-160. 27. Gerhardt JJ, King PS, Zettl JH: Amputations, Immediate and Early Prosthetic Management. Stuttgart, West Germany, Hans Huber Publishers, 1982. 28. Gottschalk FA, Sohrab K, Stills M, et al: Does socket configuration influence the position of the femur in above knee amputation? J Prosthet Orthot 1989; 2:94-102. 29. Grimm Z: Physical management and functional restoration of the lower extremity
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amputee, in Moore WS, Mal-one JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 229-245. Harris RI: The history and development of Syme's amputations. Artif Limbs 1961; 6:4. Hoyt C, Littig D, Lundt J, et al: The UCLA CAT-CAM Above Knee Socket, ed 3. Los Angeles, UCLA Prosthetics Education Research Program, 1987. Huang C, Jackson JR, Moore NB, et al: Amputation: Energy cost of ambulation. Arch Phys Med Rehabil 1979; 60:18-24. Irons G, Mooney V, Putnam S, et al: A lightweight above-knee prosthesis with an adjustable socket. Orthot Prosthet 1977; 31:35. Jendrzrjezk DJ: Flexible socket systems. Clin Prosthet Orthot 1985; 9:27-30. Keagy BA, Schwartz JA, Kotb M, et al: Lower extremity amputation: The control series. J Vasc Surg 1986; 4:321-326. Kegel B: Prostheses and assistive devices for special activities, in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St Louis, Mosby-Year Book, 1981. Kegel W: The prosthetic shoe. Orthop Technik 1991; 00:449-451. Kegel B, Moore AJ: Load cell, a device to monitor weight bearing for lower extremity amputees. Phys Ther 1977; 57:652-654. Kegel B, Webster JC, Burgess EM: Recreational activities of lower extremity amputees: A survey. Arch Phys Med Rehabil 1980; 61:256-264. Kokegei D, Dotzer R: Prosthetic management of the lower limb after traumatic amputation. Orthop Technik 1991; 42:434-440. Kruger LM: Lower limb deficiencies, in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St Louis, Mosby-Year Book, 1981, pp 522-552. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies. Inter-Clin Info Bull 1973; 12:7-15. Kuchler-O'Shea R, Schwartz M: Prosthetic training of a three-year-old acquired quadrimembral amputee. J Assoc Child Prosthet Orthot Clin 1987; 22:81-84. Lambert CN, Hamilton RC, Pellicore RJ: The juvenile amputee program: Its social and economic value. J Bone Joint Surg [Am] 1969; 51:1135-1138. Lehneis HR: A thermoplastic structural and alignment system for below-knee prostheses. Orthot Prosthet 1974; 28:23-29. Lehneis HR, et al: Prosthetic Management for High Level Lower Limb Amputees. New York, Institute of Rehabilitation Medicine, 1980. Lippert FG III, Burgess EM, Starr TW: Physiologic suspension factors in below-knee amputees evaluation. J Rehabil Res Dev 1983; p. 5. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet Orthot 1985; 9:9-14. Macfarlane PA, Nielsen DH, Shurr DG, et al: Gait comparisons for below-knee amputees using a Flex-Foot versus a conventional prosthetic foot. J Prosthet Orthot 1991;3:150-161. Malone JM, Moore W, Leal JM, et al: Rehabilitation for lower extremity amputation. Arch Surg 1981; 116:93-98. Malone JM, Moore WS, Goldstone J, et al: Therapeutic and economic impact of a modern amputation program. Bull Prosthet Res 1979; 16:1. Manella KJ: Comparing the effectiveness of elastic bandages and shrinker socks for lower extremity amputees. Phys Ther 1981; 61:334-337. Marquardt E: The multiple limb-deficient child, in American Academy of Orthopedic Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St. Louis, Mosby-Year Book, 1981, pp 627-630. Marshall K, Nitschke R: Principals of the PTS BK prosthesis. Orthop Prosthet Appliance J 1967; 21:33. Mauch HA: Stance control for above-knee artificial legs: Design consideration in the S-N-S knee. Bull Prosthet Res 1968; 10:61-71. Mazet R, Schiller FJ, Dunn OJ, et al: The Influence of Prostheses Wearing on the Health of the Geriatric Amputee , Project 431. Washington, DC, Office of Vocational Rehabilitation, Department of Health, Education and Welfare, 1963. McCollough NC, Jennings JJ, Sarmiento A: Bilateral below the knee amputation in patients over fifty years of age. J Bone Joint Surg [Am] 1972; 50:1217-1223. Mensch G: Physiotherapy following through-knee amputation. Prosthet Orthot Int 1983; 7:79-87. Mensch G, Ellis P: Physical therapeutic management for lower extremity amputees, in Bannerjee SN (ed): Rehabilitation Management of Amputees. Baltimore, Williams & Wilkins, 1982, pp 165-236.
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60. Michael JW: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987; 11:154-168. 61. Mooney V, Snelson R: Fabrication and application of transparent polycarbonate sockets. Orthot Prosthet 1972; 26:1-13. 62. Motlock WJ, Elliott J: Fitting and training children with swivel walkers. Artif Limbs 1966; 10:27-38. 63. Mooney V, Harvey JP, MacBride E, et al: Comparison of postoperative stump management: Plaster vs soft dressings. J Bone Joint Surg [Am] 1971; 53:241-249. 64. Nielsen CC, Psonak RA, Kalter TL: Factors affecting the use of prosthetic services. J Prosthet Orthot 1989; 1:242-249. 65. Ohio Willow Wood Co. Carbon Copy System HI. Instructional Course and Manual, Seattle, Wash, 1991. 66. O'Shea R, Schwartz M: Prosthetic gait training for a three-year-old quadrimembral traumatic amputee. J Assoc Child Prosthet Orthotic Clin 1987; 22:21. 67. Pohjolainen T, Alaranta H, Wikstron J: Primary survival and prosthetic fitting of lower limb amputees. Prosthet Orthot Int 1989; 13:63-69. 68. Radcliffe C, Foort J: The Patellar-Tendon-Bearing Be-low-Knee Prosthesis. Berkeley, University of California Biomechanics Laboratory, 1961. 69. Romano RL, Zettl JH, Burgess EM: The Syme's amputation: A new prosthetic approach. Inter-Clin Info Bull 1972; 9:1-9. 70. Russell JE: Congenital absence of sacrum and lumbar vertebrae: A case report. InterClin Info Bull 1977; 16:7-12. 71. Saadah ESM: Bilateral below-knee amputee 107 years-old and still wearing artificial limbs. Prosthet Orthot Int 1988; 12:105-106. 72. Sabolich J: Contoured adducted trochanteric-controlled alignment method (CAT-CAM): Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15. 73. Saunder CG: Computer Aided Socket Design Teaching Manual. Vancouver, Medical Engineering Research Unit, Shannesse Hospital, 1984. 74. Schuch CM: Modern above-knee fitting practice. Prosthet Orthot Int 1988; 12:77-90. 75. Sowell TT: A preliminary clinical evaluation of the Mauch hydraulic foot-ankle system. Prosthet Orthot Int 1981; 5:87-91. 76. Staats T: Advances in prosthetic techniques for below knee amputations. Orthopedics 1985; 8:249. 77. Sullivan RA, Celikyol F: Prosthetic fitting of the congenital quadrilateral amputee: A rehabilitation-team approach to care. Inter-Clin Info Bull 1977; 16:1-6. 78. Swanson VM: Technical note: An alternative below-knee ultra lite technique. J Prosthet Orthot 1991; 3:191-200. 79. Swedish Flexible Socket Technical Manual. Chattanooga, Tenn, Durr Fillauer Inc, 1985. 80. Van der Waarde T: Ottawa experience with hip disarticulation prostheses. Orthot Prosthet 1984; 38:29-33. 81. Varnau D, Vinnecour K, Luth M, et al: The enhancement of prosthetic fit through xeroradiography. Orthot Prosthet 1985; 39:14. 82. Waters RL, Perry J, Antonelli D, et al: Energy cost of walking amputees: The influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46. 83. Watkins AL, Liao SJ: Rehabilitation of persons with bilateral amputations of the lower extremities. JAMA 1958; 166:1585-1586. 84. Weiss M: Myoplasty, immediate fitting, ambulation. Presented at the World Commission on Research in Rehabilitation. Tenth World Congress of the International Society, Wiesbaden, Germany, 1966. 85. Weiss M: The Prosthesis on the Operating Table From the Neurophysiological Point of View: Report of Workshop Panel on Lower Prosthetics Fitting. Washington, DC, National Academy of Sciences, 1966. 86. Whitehouse FW, Jurgensen C, Block MA: The later life of the diabetic amputee: Another look at the fate of the second leg. Diabetes 1968; 17:520. 87. Wilson AB Jr, Schuch MC, Nitschke RO: A variable volume socket for below knee prostheses. Clin Prosthet Orthot 1987; 11:11-19. 88. Wolf E, Lilling M, Ferber I, et al: Prosthetic rehabilitation of elderly bilateral amputees. Int J Rehabil Res 1989; 12:271-278. 89. Wu Y, Brncick MD, Krick HJ, et al: Technical notes: Scotchcast PVC interim prosthesis for below knee amputees. Bull Prosthet Res 1981; 18:40-45. 90. Wu Y, Flanigan DP: Rehabilitation of the lower-extremity amputee with emphasis on a removable below-knee rigid dressing, in Gangrene and Severe Ischemia of the Lower Extremities. New York, Grune & Stratton, 1978. 91. Wu Y, Keagy RD, Krick HJ, et al: An innovative removable rigid dressing technique for
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below-the-knee amputation. J Bone Joint Surg [Am] 1979; 61:724-729. 92. Wytch R, Mitchell CB, Wardlaw D, et al: Mechanical assessment of polyurethane impregnated fiberglass bandages for splinting. Prosthet Orthot Int 1987; 11:128-134. 93. Zettl JH: Experience with endoskeletal prostheses for lower extremities. Bull Prosthet Res 1972; 10:52-66. 94. Zettl JH: Immediate postoperative prostheses and temporary prosthetics, in Moore WS, Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 177-214. 95. Zettl JH: Immediate postsurgical prosthetic fitting: The role of the prosthetist. Am J Phys Ther 1971; 51:144. 96. Zettl JH, Burgess EM, Romano FL: The interface in the immediate postsurgical prosthesis. Bull Prosthet Res 1969;8:10-12.
Chapter 24A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 24B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
WINTER SPORTS
Snow Skiing
The concept of amputee skiing originated in Austria and Germany in 1948. The Swiss subsequently introduced "crutch skiing." In 1967, the National Amputee Ski Association was formed in the United States. Now amputee skiing is being taught in organized classes in most states under the umbrella organization of National Handicapped Sports (NHS). Competitive events are held annually, with regional qualifiers followed by a national event. The unilateral transtibial amputee has two options available for skiing. He can ski with or without a prosthesis. Most transfemoral amputees ski on the intact leg only and use the three-track skiing technique. The bilateral transtibial amputee skis with a four-track technique and uses two prostheses, two skis, and outriggers. The bilateral transfemoral amputee could use short prostheses without knee mechanisms or can switch to a sled or monoski.
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the toe of the prosthetic foot ( Fig 24B-1., A and B). Moving the socket forward has a detrimental effect on cosmesis and causes an anterior bulge on the front of the leg. 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. The skier can now adjust his center of gravity more easily. For the beginning skier a solid-ankle cushion-head (SACH) foot may be adequate. The SACH foot permits the selection of a sufficiently soft plantar flexion resistance, is available in a variety of sizes, and is compatible with virtually every lower-limb prosthesis. For more proficient skiers who desire greater flexibility, 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, which improves control at higher speeds. 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. Flexion and extension at the knee and hip are basic to the activity of skiing and create a rather unusual residual limb-socket interaction. The interface used should offer as much protection and cushioning as possible, such as that provided by the silicone gel insert. The insert acts like a protective layer of fatty tissue and distributes pressure evenly. If displacement of the silicone is of concern, another option is nickelplast. To reduce the reaction time between leg movement and movement of the prosthesis, minimal piston action is important. The skiing prosthesis is often fabricated with a thigh lacer and waist belt pickup strap. Additional suspension techniques are the active sleeve or neoprene sleeve. An inverted figure-of-8 suprapatellar cuff may also be added. These suspension mechanisms also help prevent one from losing a prosthesis while sitting on the chairlift. Some skiers choose to cut a hole in their ski pants, wear the waist belt on the outside of their clothing, and thread the pickup strap through the hole so that they can easily make adjustments to the suspension. A lightweight ski boot is usually recommended. The skiing prosthesis is specialized, and for this reason, a conventional prosthesis is still needed for walking and after ski activity.
Residual-Limb Protection
Those who ski without a prosthesis are advised to pad the residual limb for protection against cold and injury. For transtibial amputees, several stump socks are usually adequate. Transfemoral amputees may prefer to have a modified socket fabricated. This protective device is made to match the knee length of the intact leg, thus making it easier to rest by kneeling and then to get up from the ground. 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.). When skiing, the pylon is detached and stored in a padded backpack, or it can be left in the lodge. While riding the chairlift, exercising the residual limb helps to maintain proper circulation.
Skis
The three-track skier needs a good-quality ski because all body weight is on one ski. A "three-tracker's ski tote" was developed to allow the skier with amputation to carry his ski over the shoulders while using outriggers. The ski tote has a thick felt pad to protect clothing from the ski's sharp edges, three Velcro closure straps (adjustable to any binding length) to hold the ski in place, and a strong, one-piece carrying strap.
Ski Stabilizers
Ski stabilizers are frequently used in four-track skiing and also for skiing with two skis and two poles. They hold the tips of two skis together for those who lack the leg power to do so. Ski stabilizers can be handcrafted with bungie cord or purchased commercially. Even though the skis are hooked together, flexibility of movement is allowed while maintaining a constant position of the skis, approximately 3 or 4 in. apart at the tip of the skis. The skier can do a snowplow, parallel ski, and train. If necessary, ski stabilizers can also be attached to the tail
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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. 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. The outriggers should be adjusted to a length that allows the skis to hang 2.5 to 5 cm (1 to 2 in.) above the snow surface when the skier is standing erect and holding the outrigger handles. The skier should be wearing a ski boot and ski when making this length test. 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). The Flipski changes from a skiing outrigger to a skid-resistant walking crutch ( Fig 24B-4.). The amputee merely squeezes a cord located at the handgrip, and the ski flips up to lock in a vertical position and produce a walking crutch. Metal claws attached to the tail end of the outrigger skis provide additional braking action. Some amputees add a semicircular disk just behind the vertical part of the crutch. When the Flipski is in the walking position, this disk prevents the outriggers from sinking in soft snow. The Flipski makes it easy for the amputee to get around when not actually skiing, and in using them, the skier finds that he has more energy remaining to ski. Manufacturing one's own outriggers is feasible, provided that access to a machine shop is available. When using outriggers, the three-track skier puts considerable pressure on his hands. Blood circulation could become impaired and the hands get very cold. Mittens are suggested since they are warmer than gloves, and hand exercises should be done.
Ski Instruction
Skiing for the Bilateral Transfemoral Amputee. Some bilateral transfemoral amputees are able to ski on short prostheses and skis. Another option is to sit-ski in a lightweight molded fiberglass kayak-like sled ( Fig 24B-5.). The amputee lowers himself into the sit-ski and then adjusts a waterproof cover over the lower portion of the body. Turning is done via a combination of leaning, weight shifting, and the use of short ski poles. A way to practice on land would be to make a "roller sled" and poles, which is essentially a sled ski-skateboard combination. Transferring into a sit-ski from a wheelchair can be difficult, so the skier should practice indoors on a dry surface until the movements are mastered. It is important when sit-skiing to find a hill with a good slope. Without enough momentum it is more difficult to initiate turns with the sled. Another factor to consider is flat areas. The sledder must use the upper part of the body to pull himself through the snow with ski poles. The sledder must cross-country ski to reach the next fall line. The sit-skier usually skis with a partner or "tetherer." The tetherer does not control the ride unless the sit-skier needs help. The sit-skier, particularly when learning in a tethered situation, should avoid crowded ski runs because of the amount of space needed by the sit-skier and tetherer. The sit-skier should be aware that due to his close proximity to the snow, visibility on the mountain is decreased. He should be sure to rest in places that are clearly visible to other skiers. The sit-skier also realizes that he cannot see other skiers as well as standing skiers can. For getting around in wheelchairs on the snow, trail bike tires for wheelchairs are suggested. To provide better friction, short segments of bicycle chain can also be wrapped around the wheelchair wheels. It is possible to load a sit-ski on a chairlift, but this needs to be done with the aid of a lift attendant. When loading the sledder in his sled, the tetherer and one other skier approach the double chairlift. The lift is slowed while the sledder is pushed to the loading area with a skier on either side of him. Neither lifter should be carrying ski poles, and the sit-skier should have his poles inside the sit-ski. Each lifter grabs one side of the sled and lifts it as the chairlift continues to move up from behind. The sledder is set down on the chair alongside the skier who is closest to the lift terminal. The skier closest to the lift line waits for the next chair. The sit-skier should have the chairlift securing mechanism out and ready to use by laying it across his lap. As soon as the sled is on the chairlift, the securing mechanism is attached to the chair from the rear of the sled. The securing mechanism is designed for quick attachment and removal. The fact that the weight of the sit-skier rests far back in the chair ensures a
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safe ride. Each sit-ski is equipped with an evacuation harness should the necessity arise for the sled to be lowered to the ground. When the unloading area is approached, the lift is slowed, the securing mechanism released, and the sit-ski pushed off when it is closest to the ground. The assistant stays slightly behind the sit-skier to prevent the chairlift from hitting the sit-skier in the back of the neck. The assistant may need to help push the sit-ski away from the chair. The instructor holds on to the tethering rope to make sure that the sledder reaches a safe area before beginning down the slope. With practice, many sit-skiers can load and unload from the chairlifts without stopping or slowing the lift. The first thing to learn when sit-skiing is how to turn. Three of the most common methods are (1) spikes or brass knuckles, (2) the kayak method, and (3) the short swing. When using the spike method, short poles are used. The pole is planted with the arm outstretched to the side and slightly behind the skier. As the sled turns, the skier leans forward and then leans and plants the opposite pole to turn in the opposite direction. The kayak method is similar to the short-spike method, but a long pole or two poles tied together are used. Both poles are held by both hands, similar to a kayaking paddle. The swing uses two longer poles and is more difficult. The amputee moves his hips by using the muscles of the lower portion of his torso. It is difficult to do smoothly, and this technique is usually used on steep hills with large moguls. For each technique, the skier needs to lean forward to prevent the ski from spinning and heading the skier down the hill backward. The quickest way to stop the sit-ski is to roll it on its side. The tetherer can also stop the sitski in several different ways. If going at a slow speed, merely snow-plowing will be effective. An alternative stop that can be executed is the swing hockey stop. The tetherer, who is following behind the sit-ski, swings out to the side and down next to the sit-skier. The sitskier will be turned sideways to the ski slope. The sit-skier should choose layered clothing for extra warmth. A T-shirt, long underwear, turtleneck sweater, water-resistant windbreaker, and down parka are recommended. Since sit-skier's hands are often in the snow, waterproof mittens are desirable. Downhill sit-skiers should wear safety helmets. By far the most popular and promising device available at the present time is the monoski ( Fig 24B-6.,A and B). Monoskis were introduced in the United States in 1985. This is a much faster device than the sit-ski. It consists of a bucket or shell that rides on a specially reinforced ski that is capable of withstanding great pressure. The monoskis frame mechanism is constructed of aircraft tubing and cables to provide a suspension over the ski. With the use of short outriggers the user can maneuver the ski to carve a turn. The monoskier can "unweight" himself with an outrigger while being aided onto the chairlift by a ski partner. The frame mechanism pivots upward and allows the seat portion to slide onto the chairlift without interrupting normal operation. The user can unload from the chairlift without assistance from others. Sit-skiing as a competitive event has been in existence in the United States since 1979.
Cross-Country Skiing
The Disabled Nationals Competition now hosts 5-, 15-, and 25-km races. For the skier with a transtibial amputation, a prosthesis with a thigh lacer or Ac-tivsleeve is helpful in providing more control while turning. Most skiers find that using a prosthesis 2 to 3 cm shorter than standard will increase turning power. If the prosthesis is too long, extending the leg backward adequately can be difficult. Another challenge is maintaining control of the ski when it is extended to the rear. This backsliding prevents the skier from keeping on top of his skis and results in a loss of kick and forward leg drive. To avoid backsliding, a piece of elastic nylon can be looped over the top of the foot and attached to the ski at approximately 3.8 cm (1 in.) behind the heel plate. This nylon strap effectively stops the prosthesis from being lifted more than a few inches off the heel plate, thus preventing backsliding ( Fig 24B-7.). While the strap also limits stride length, the skier with lower-limb amputation can compensate for this by developing a strong upper body to obtain a longer stride.
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Selection of terrain is important. Carrying a 6-m (20-ft) length of rope is helpful. If the terrain gets too arduous, the rope can be attached to a partner around the waist, who can then serve as a tow. Cross-country skiing in a sit-ski is a vigorous activity. The ideal surface for sit-skiing is relatively flat, with hard packed snow, and the trail should be 5 to 8 ft wide. For steep, uphill trails, it is helpful to install a rope along the side of the trail so that the skier can pull himself up when necessary. The cross-country sled skier should experiment to determine the most efficient pole length for his needs. Poles vary in length between 50 and 135 cm. Beginning skiers usually use short poles, while experienced skiers prefer longer ones for more push length per stride. Double poling is used- long pushes for flat terrain and short jabs for uphill. For control going downhill, small spikes are mounted on the back of the hand with a Velcro and leather strap.
Snowmobiling
Snowmobiling is possible for most amputees. It is especially appealing because it offers access to remote areas that may not be otherwise accessible. A buddy system is strongly recommended. Most transtibial amputees prefer a snowmobile with a relatively elevated seat. If the seat is too low, the knees have to be bent more than 90 degrees, which causes discomfort in the popliteal area. Keeping one's prosthetic foot on the footrest can be difficult. The ideal footrest provides good support but does not limit leg movement. Many amputees choose to custom-make their own footrests, against which they brace their prosthesis.
WATER ACTIVITIES
Swimming provides a freedom of motion to the physically challenged that they are often deprived of in daily activities. Several options are available: 1. 2. 3. 4. 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.) The swimming leg, which is worn while in the water
The decision to use a prosthesis while swimming depends on the individual. Many amputees perform competitively without a prosthesis. When swimming without a prosthesis, the three intact limbs do most of the work. The backstoke is usually the easiest to accomplish, with the main difficulty being the ability to maintain one's direction of choice. 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. (This does not necessarily mean that one will swim more proficiently with a prosthesis.) In addition, the ability to climb a ladder out of a swimming pool, increased stability when diving, and some protection against injury to the residual limb are other reasons to use a prosthesis. Some people are also embarrassed to appear in public without a prosthesis.
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can easily activate this prosthesis via a ring located in the posterior portion of the device's calf area. The amputee can walk into the water and change the foot from a walking to a swimming mode. The VAPC unit is constructed of polypropylene, so it is waterproof and resists corrosion in salt water. The Kingsley Syme foot, which is ideal for this activity, is fitted to the ankle joint. All other components, such as screws and tubes, are constructed of stainless steel. This leg is available for veterans but is not commercially available. The commercial equivalent to this unit is the Activankle ( Fig 24B-10. ,A-C), which is a multiposition sports ankle designed to allow the amputee to participate more easily in swimming, rowing, and downhill skiing. Materials that are corrosion resistant like Dupont's Delrin and stainless steel are used. A locking pin is used to maintain stability when walking. The pin can be removed to allow full ankle mobility. Activankle can be used with most endoskeletal prostheses and can also be mounted in any Symes-style SACH feet.
Aquatic Wheelchairs
The Turfking chair is designed to be used both on the beach and in the water. When in the water, rear pontoons give lateral stability. Propulsion in the water is by hand-operated flippers. The occupant can also release a small anchor to hold the chair in one place. The backrest can be used as a life vest. The amputee can then swim out of the chair while being tethered to the chair by a 20-ft tether cord. The Turfking can also be used while fishing ( Fig 24B-12. ).
Waterskiing
The transtibial amputee often skis on one ski, with the specialized prosthetic leg placed behind the intact leg. The waterproofed prosthetic leg can be made a little shorter to place weight further back on the ski. The prosthetic knee can be outset and externally rotated to allow space for clearance of the knee of the opposite limb. If using two skis, the prosthetic ski should be kept 3 to 6 in. ahead of the other ski. If the skier starts with the artificial limb trailing behind, it will usually be wrenched off by the force of the water. Another alternative would be to start off on two skis but to place the residual limb in the socket without tightening the suspension mechanism. Once up and stable, the amputee could release not only the second ski but the prosthesis as well. Water ski bras can also be used to provide better control of two skis. Many amputees prefer to ski without a prosthesis. A broad, square-backed ski will give the largest planing area and best stability for a beginning skier. A deep slalom ski fin is helpful. For maximum control, the fin should be placed between the heel of the binding and the rear of the ski. Once up, the residual limb should not wave about but be kept close either to the side or in front of the sound leg. By "hugging" the sound leg, the muscles of the residual limb reinforce those of the sound limb, thus minimizing fatigue. For the bilateral amputee, a commercially available Hydro Slide works well. The Hydro Slide
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resembles a surfboard, and the amputee utilizes it either in the sitting or kneeling position. Other devices designed specifically for the disabled are the monoski ( Fig 24B-13. ), the water ski seat, and the Kanski.
Boating
Skills required for this activity include the amputee transporting himself, equipment, and boat to the launching area, as well as portage and self-rescue. River banks are often steep, rocky, and slippery. Most amputees keep their prostheses on since hopping any distance while carrying equipment is exhausting. For getting into a boat from a wheelchair, a hydraulic hoist (Hydro Hoist) may be useful. The hoist lifts the boat out of the water onto pontoons. Lateral motion of the boat is prevented. The gunwale is now level with the wheelchair seat. The amputee slides from the wheelchair to the gunwale to the pilot's seat. Once in the boat the amputee usually encounters no significant problems. Kayakers may fear being trapped during a capsize because of the protrusion of the prosthetic foot. Because of this, some amputees prefer to strap their prosthesis to the boat rather than to their body. Also for this reason, the amputee may chose to use a peg leg. Some people use a seatbelt to secure themselves. An airplane kind of buckle is recommended, with a rope attached to the buckle release. The rope hangs outside the spray skirt so that when it is pulled, both spray skirt and seatbelt release at the same time. Boarding a canoe is simpler from a sitting than a standing position. The legs are placed in the canoe first, as close to the center as possible, and after that the rest of the body is positioned into the craft. Lowering the seat height slightly may help to lower the center of gravity, thus improving balance. For extra back support, attaching the top portion of a plastic stacking chair to the canoe seat may be useful. For wheelchair users planning overnight trips, it is important to ensure that the wheelchair fits into the canoe being used, that the user is able to transfer the chair into and out of the canoe, and that the wheelchair is secure should the craft capsize. Because canoes are lightweight, even a person confined to a wheelchair can support one end of the craft to help transport it to the water. For rowing, 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. 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. ). Once in the boat, the rower can remove the tubing. This prosthesis is waterproof and buoyant, and its posteroproximal brim is fabricated to allow maximum knee flexion with minimal or no discomfort in the area of the hamstring tendons. For sailing, the British-designed trimaran the Challenger can be handled safely by the physically challenged. A slide hooked onto the main beam connecting the three hulls eases the transfer from wheelchair to cockpit. Virtually no body movement is required to steer the craft because the tiller is within easy reach of the helmsman. The "Able Sailor" is a device that allows the leg-disabled sailor to change sides within a boat without assistance, thus enabling him to helm the boat much as his able-bodied counterpart would. The Able Sailor consists of a contoured seat that sits on a semicircular track and runs on rollers. When the control cord is pulled, the seat runs free to the opposite side of the boat. The seat can be installed or removed from a standard boat without the use of special tools. 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. It is lightweight, built of fiberglass, and easy to install, thus making almost any boat adaptable for sailing by a disabled sailor. It can rotate freely from port to starboard and allow the sailor to tack in a comfortable, safe, and workable environment. Scuba The major challenge is getting oneself and one's equipment to the water. In most cases this requires assistance, although some amputees can manage alone by diving from a boat. When returning to the boat, the diver removes the gear in the water so that people on board the boat can pull it aboard. They then assist the diver into the boat. With an efficient arm stroke, 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
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oxygen than the use of leg muscles. With proper instruction and equipment together with a well-developed arm stroke, the person with amputation can scuba dive well as long as the hands are free. Such individuals are encouraged to use webbed neoprene hand fins. These fins are called "power gloves." Buddy breathing, or sharing air from a single tank, is frequently necessary. For the ablebodied, buddy breathing is done face to face when descending and side by side when swimming. For divers who are unable to propel themselves with their legs, 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. A better prospect is for the divers to position themselves one on top of the other, in piggyback fashion. While the diver on the bottom provides the locomotion, the diver on top manages the breathing apparatus. Even better is the octopus adaptor and other dual regulators that allow both the diver on top and bottom some locomotion.
GOLF
The unilateral lower-limb amputee has relatively few problems playing golf. Bending over to "tee up" requires a greater-than-normal sense of balance. 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. It is very important that the prosthetic shank used have a rotational component. Nylon (DAW) sheaths may also be used to decrease friction and protect the skin at the residual limb-socket interface. Some amputees prefer not to wear golf shoes with spikes because this further decreases their ability to rotate on the prosthetic limb. The Swivel Golf Shoe developed by the War Amputations of Canada has some merit ( Fig 24B-15. ). This is a device built into a regular golf shoe to provide the golfer with more rotation ability on his prosthetic side. The right-handed golfer who has left-leg amputation should begin his swing with the foot rotated inward. The person with a right-leg amputation who is also right-handed is at a disadvantage. He may tend to keep all weight on the left leg during a swing. It may be better for this person to play left-handed. Some amputees prefer to play without their prostheses. 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). In this way the golfer can sit on the seat while bearing some weight on his legs ( Fig 24B-16. ). One can also play from a wheelchair by using a thick pillow under the buttocks. On approaching the green, the golfer gets out of the chair and sits on the ground. Golf can also be played from a sitting position in an electric cart equipped with a swivel seat, or one can play from a standing position while leaning against the golf cart for support. Golfers operating from a seated position should use clubs that have a flatter lie than normal. This reduced angle is helpful because of the flat swing plane induced by the seated position. The amputee golfer should also consider terrain. Walking 18 holes will cover approximately 5 miles, and even riding a cart leaves about 2 miles covered on foot. Electric golf carts are worth considering. The National Amputee Golf Championship event has been in existence for 41 years and fields about 130 participants. The field is broken down into seven divisions based on type of amputation and two special divisions, ladies and juniors. The National Amputee Senior Golf Championship (over 50 years of age) has been in existence for 14 years.
RUNNING
Ten years ago, running was considered an impossibility for the amputee. Diehards were limited to a hop-skip-and-run technique where they begin with one step on the prosthetic leg, followed by two steps on the sound limb. Other runners used crutches but no prosthesis. The technique is similar to running with a prosthesis-crutch, skip; crutch, skip, skip. . . . 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, which has a "pogo stick" effect. The telescoping pylon, which is incorporated into the shank section of a transfemoral prosthesis, functions by absorbing some of the ground impact and by shortening the prosthesis on weight bearing. The knee mechanism used has a stanceand swing-phase control ( Fig 24B-17. ). Subsequent research at the University of Washington showed that lower-limb amputees are
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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. These amputees were running with conventional prostheses. 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, hip, and vertebral column. Restricted range of motion of the intact limb and the knee and hip during swing phase was also seen. 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. For walking, the vertical ground reaction force is rarely greater than body weight. During running, this force reaches two to three times body weight. To reduce some of these difficulties, dynamic-response feet emerged. These feet provide varying amounts of push-off at the beginning of swing phase, thus being much more effective choices for the athlete. The transfemoral amputee Jeff Keith, who completed a cross-country run from Boston to Los Angeles in 1984, was wearing a Seattle foot on his prosthesis. The Activsleeve suspension system is helpful in reducing pistoning for the transtibial amputee ( Fig 24B-18. ,A and B). Activsleeve is made of natural rubber with a ribbed design at the top of the sleeve and a straight tubular design. The ribbed portion creates a seal around the thigh to produce a suction-type suspension, which is very popular with the active amputee population. Activsleeve can be worn as low as 3 to 4 in. above the knee and inhibits water from entering the socket when swimming or showering. Dennis Oehler, an amputee sprinter from the United States, is able to do the 100 m in 11.3 seconds, the 200 in 24.37 seconds, and the 400 m in 56.25 seconds. His 100-m time is within 1.8 seconds of the able-bodied world record ( Fig 24B-19. ). Transfemoral sockets have also improved, so discomfort on the medial part of the brim and rotation of the socket are less of a problem. Amputees are moving toward narrow mediolateral and flexible sockets. For children, 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. The proximal end of the cable is attached to a belt similar to a Silesian bandage, and the distal end is attached to the proximoante-rior shank section of the prosthesis. At toe-off, tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion, similar to the action of the quadriceps muscle ( Fig 24B-20. ). Wheelchair road racing has become a well-established entity, and the design of racing chairs has developed into a fine art. It appears that the three-wheeled sports chair is here to stay ( Fig 24B-21. ). In 1985, Rick Hansen completed his "Man in Motion World Tour" in a wheelchair. Between January and July 1989, Bill Duff wheeled 5,000 miles from Los Angeles to New York and created even more publicity for wheelchair racing. It is now 14 years since wheelchair athletes first entered the Boston Marathon. The 1989 winner was Philippe Couprie, 26 years of age, who won it in 1:36:04. This averages 3 minutes and 40 seconds to the mile. The women's division was won by Connie Hanson, 24 years old, with a time of 1:50:06. In 1977 the time differential between men and women was 1:06:51. In 1989 it was 14:02.
FLYING
There are some 10,000 pilots with physical disability in the nation's skies. Rode Rodewald is a wheelchair pilot who soloed on a trip that took him around the globe in 1984. He was recently inducted into the Colorado Aviator Hall of Fame. Flying requires skill and judgment, but very little strength. Four intact limbs are not necessary. The choice of an aircraft depends on the ability to get in and out. Amputees in wheelchairs do best with a low-wing Piper Cherokee, which has a door beside the wing and a baggage area large enough to accommodate the wheelchair. The Grumman American and Ercoupe also have low wings, but a sliding canopy requires entrance over the side. Struts on high-winged aircraft such as the Cessna 172 interfere with wheelchairs, but an amputee who can stand can move around them. The Cessna Cardinal does not have wing struts and may work well. Other aircraft being flown by amputees include the Mooney Ranger and the Beechcraft Muscatee Bonanza. For those who fly without hand controls, modification of the prosthetic foot may be necessary to prevent the foot from hitting the brake pedal while operating the rudder pedal. The Navy Prosthetics Research Laboratory in Oakland, California, has designed a two-part SACH foot. When flying, the toe section can simply be removed and then replaced for normal walking later on ( Fig 24B-22. ). Another adaptation is to attach a webbing strap to the rudder controls
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SKYDIVING
Most amputees jump without a prosthesis and use protective padding for the residual limb. A detachable pylon is also helpful, especially when navigating on the ground after a jump. Ordinary static line jumping requires no adaptation for disability. For free-fall jumping, the amputee may have difficulty maintaining a stable position because the body surface presented to the air must be symmetrical. The transtibial amputee can either bend both knees to his chest or extend the hips and bend both knees to a right angle. 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. He then jumps in the same way as a transtibial amputee. The use of the arms may also be necessary to prevent spinning. In 1981, a group of amputees called "Pieces of Eight" performed an eight-way free-fall formation. It took them 15 attempts to accomplish, and the formation was held for 4.66 seconds.
HORSEBACK RIDING
Scandinavia and Great Britain pioneered in promoting riding for the handicapped. Now the North American Riding for the Handicapped Association (NARHA) serves about 4,000 riders a year in the United States and Canada. Saddle, bridle, and reins do not require modification, 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. They can buckle to heavy-duty square D's under the saddle skirt slightly behind the D's used for the breastplate or martingale. The main concern with stirrups is that they do not trap the prosthetic foot in a fall. 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. They fit only on English saddles. Western saddles are more stable but do not have the safety stirrup options. Rubber inserts for stirrups and rubber-soled boots may help keep the prosthetic foot in place, especially for transfemoral amputees. Transtibial amputees generally wear a prosthesis for riding. The outside of the prosthesis needs to be checked so that there are no rough edges that could irritate the flank of the horse. Possible modifications to the prosthesis are lowering the popliteal brim, flattening the medial aspect of the calf, and aligning so that the heel is canted inward and the toe upward and outward. Transfemoral amputees can ride with a prosthesis, although the gluteal tissue often gets pinched between the prosthesis and the saddle. A very short residual limb would also be reason for riding without the prosthesis. Transfemoral amputees do need to have the ability to abduct the residual limb at the hip joint. If wearing their 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. A locking device, as on the Mauch S-N-S knee, may also be used to keep the knee flexed at a desirable angle. Amputees with bilateral transfemoral amputations or hip disarticulations usually need buckettype devices- seats with leather sockets. Unilateral amputees need them only rarely. If riding without a prosthesis, the amputee might need some type of "residual-limb stirrup" to facilitate balance on the horse. This socket-stirrup assembly will need to release the limb in a fall ( Fig 24B-23. ). Mounting from a wheelchair may require a ramp (16 by 4 ft with a platform 4 X 6 ft). An ambulatory rider, especially one with left-sided amputation, might need a twoto three-step mounting platform.
BICYCLING
Transtibial amputees ride easily with a prosthesis. 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, although caution is needed to prevent the toe from being trapped.
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Transfemoral amputees have several options. Some avoid using the prosthesis because they feel that it offers no additional power. Others wear the prosthesis for cosmetic needs and use the prosthetic leg as a landing strut. A toe strap is often used on the sound side and the bike operated in a push-pull fashion. Bicycle shoes also help with the upstroke. The Mauch S-N-S hydraulic knee is effective for bicycling. The free-swinging mode is best unless a legstrengthening resistance is required. This can be obtained by using the stance control. Prostheses without hip joints and pelvic bands allow more comfortable straddling of the saddle. Foam-covered endoskeletal prostheses must be protected from pedal damage. A hip disarticulation amputee may chose to ride with his abdomen on the saddle, sound leg on one pedal, opposite hand on the other pedal, and sound-side hand on the handlebars. This is precarious, but works. David Kiefer, a hip disarticulation amputee, has ridden across America twice on his bicycle and has set the world handicapped cross-country record at about 15 days. A good-quality bike with many gear options is obviously desirable. Both hands must be kept on the handlebars while exerting power because the arms and hands compensate for the imbalance of one-legged power. Gear levers must be handlebar mounted and operable with three fingers while the palm and other fingers continue to grip the handlebar. Other options to consider are removing the unused pedal or crank, extra padding on the saddle, and turning the saddle slightly away from the sound leg. The racing handlebar position may be uncomfortable, and conventional handlebars may be better. To prevent friction between limb and socket, Spenco Second Skin (made from a breathable hydrogel) can be held in place with tape and a stump sock. Second Skin is available from most sporting good stores. Hand-powered, hand-controlled tricycles may work for the child amputee. 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. The assembly weighs about 17 lb and fits into most auto trunks ( Fig 24B-24. ). The Rowcycle is a hand-operated mix between a bicycle and a rowing machine that uses arm and back muscles. The cycle seat slides back and forth or can be locked in one position. It is steered by the weight-shift rotation of the seat, which turns the front wheel. The center of gravity is adjustable and allows the rider to "pop wheelies" for quick turns. One size can be used by the child or adult. 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. ). The back rider controls the rear caliper brake with a hand lever. Both riders activate the front hub brake by backpedaling. The front rider pedals with any combination of arms or legs. The front rider can stop and rest, while the back rider continues to pedal. The Handbike, a twowheeled cycle with two small caster wheels projecting from each side of the frame, gives balance and stability to the bike for boarding. For stationary bicycles, the Schwinn Air-Dyne is recommended because it allows arm as well as leg operation, either separately or together. For young children with bilateral limb deficiencies, the skateboard provides a recreational outlet and can be an appealing alternative to the wheelchair.
BASEBALL
Many amputees play baseball, usually with a prosthesis and always on an able-bodied team. Two notable people are Bert Sheppard, a transtibial amputee who successfully pitched for the Washington Senators, and Monte Stratton, a transfemoral amputee who pitched for the Chicago White Sox. Most transtibial amputees play any position, but transfemoral amputees are usually too slow for the outfield. Shortstop could be a difficult position because of decreased lateral mobility. Catcher is a good choice if the amputee has a strong arm, can get down on his haunches with the prosthetic leg to the side, and can get up quickly. Pitcher and first baseman are other possibilities. Batting with the stronger leg behind is best; right-sided amputees may bat left-handed. Some amputees defer to a substitute runner after they get on first base.
BASKETBALL
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The United States Amputee Athletic Association sponsors a tournament featuring six to eight teams for stand-up basketball competition in which conventional rules apply. Since there are so few disabled teams, most people play on able-bodied teams. Most use a prosthesis with a dynamic-response foot and additional prosthetic suspension. The Activsleeve would be a good choice for the transtibial amputee because it creates a suction-type suspension. The transfemoral amputee might consider a total elastic suspension (TES) belt in addition to a suction socket. To protect the skin from friction, it is wise to use a nylon sheath, Spenco Second Skin, or an ointment like Ampu-Balm or Amp-Aid. Occasionally an amputee will play by hopping without a prosthesis, but probably not for a whole game. 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 new sport well suited to wheelchair players and able-bodied alike is bankshot basketball. It is a pure shooting sport that involves no running or contact. The player moves along a course made up of 12, 15, or 18 baskets on variously shaped backboards, each requiring a different and increasingly difficult shooting strategy. The game can be played alone or competitively.
BOWLING
An ambulatory amputee can bowl by standing at the foul line or using a twoto four-step approach. Steps may be short and jerky. 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. When handedness and prosthesis are opposite, the bowler may prefer to stand with feet together about a meter behind the foul line and lean forward to advance the ball. A prosthesis similar to that described for rowing may be helpful. This type of prosthesis would also work for the sport of curling.
SOCCER
Amputee soccer ( Fig 24B-26. ) originated in the Seattle area and has now expanded into national and international competitions, with teams coming from England, Canada, the Soviet Union, El Salvador, and Brazil. The 1991 championships were held in the Soviet Union. Players use standard Canadian forearm crutches and no prosthesis. A "pogo stick"-type crutch is in the prototype stages of development. This crutch will help absorb some of the force absorbed by the upper limbs and has more padding than a regular crutch. Goal keepers are arm amputees.
GARDENING
Gardening usually requires kneeling, which is difficult to achieve because the prosthetic ankle does not allow sufficient plantar flexion. Once in the kneeling position, the upper portion of the body seems to be pushed forward, and gardeners with transtibial amputations may feel pressure in the popliteal fossa area. One solution is to use planter boxes supported so they can be reached at waist level or, for those in wheelchairs, at a lower level. Knee pads can be fabricated by a pros-thetist. The pad for the sound leg should be thicker to raise the hips and allow more toe clearance on the prosthetic side. Homemade pads can be constructed from foam rubber in a heavyweight plastic bag and sealed with waterproof tape. A kneeling stool called an Easy Kneeler is available. When turned over it becomes a portable seat.
SKATING
The transtibial skiing prosthesis can be adapted for roller or ice skating. The suspension system on the prosthesis needs to be secure to support the extra weight of the skating boot. The skating boot may be difficult to put on without a nylon hose or plastic bag over the prosthetic foot to help it slide. The Hein-A-Ken Skate Aid, a walker-type device, can be helpful to the beginning skater ( Fig 24B-27. ). There is a 28-in. children's model and a 35-in. adult model. The outrigger skate aid is another possibility ( Fig 24B-28. ). A figure skating blade is mounted
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to a forearm or similar crutch. Two of these outriggers improve support and balance. Skates on the lower limbs maintain continual contact with the surface, while the outriggers are used for propulsion. Ice sledding is a good alternative for the bilateral amputee.
MOUNTAIN CLIMBING
Climbing is possible, with or without a prosthesis. If a prosthesis is used, a nylon sheath is invaluable for decreasing friction. An ankle unit such as the stationary-ankle, flexibleendoskeleton (SAFE) foot may be useful because it adapts well to uneven terrain. For the trans-tibial amputee, ice climbing crampons can be adapted to clip to the prosthetic shank, such as those used by the bilateral transtibial amputee Hugh Herr in all his expeditions. Transfemoral amputees generally prefer to climb without their prosthesis and to rely on specially adapted forearm crutches for added grip and stability, such as those used by Don Bennett when he climbed Mount Rainier. Sarah Doherty, a hip disarticulation amputee, followed Mr. Bennett's challenge a few years later. In August 1984, she went on to climb Alaska's Mt. McKinley, the highest point in North America. Her crutches featured a convex basket with spikes at the lower end that are used as crampons ( Fig 24B-29. ,A). A modified ice pick is attached to the forearm portion of the crutch ( Fig 24B-29. ,B). The ice pick is covered with a sheath when not in use. This crutch was modified by Drew Hittenberger, C.P. 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. Levesque and Gauthier-Gagnon have designed a transfemoral prosthesis for rock climbing. It provides grip close to the knee by using an additional prosthetic foot close to the knee joint, as well as full outward rotation of the leg for grip on the medial border of the shoe. It is made of titanium components to reduce weight and features a conventional socket, multiaxial pelvic band and thigh rotation system placed under the socket to increase mobility, a protruding foot just above the knee axis, a modular polycentric knee, and a SACH foot ( Fig 24B-30. ). 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. Croucher has received the Man of the Year Award and the International Award for Valour in Sport.
RACKET SPORTS
Most amputees wear a prosthesis, preferably one with considerable rotation capabilities. For tennis, doubles play reduces the amount of running required. Wheelchair tennis and racquetball are two of the most up and coming wheelchair sports. Wheelchair tennis tournaments have been held since 1975, and in 1980, the National Foundation for Wheelchair Tennis was formed. In this sport, it is very easy for the able-bodied and disabled to play together. The only modification of the rules is that the wheeler gets two bounces before he has to return the ball.
COMPETITIVE SPORTS
The first World Amputee competition was held in 1979 in Stoke Mandeville, England. Competition in the United States began in 1981. Events usually include swimming, track and field, weight lifting, air pistol, volleyball, and table tennis. Other events may include sit-down volleyball, lawn bowling, stand-up basketball, and pentathlon. For swimming, no prosthesis is allowed. For discus, javelin, or shotput, a prosthesis is worn if the competitor wears one for everyday use. No crutches or other assistive devices are allowed. Individuals with bilateral transfemoral amputations who are wearing prostheses may throw from behind a hip-high barrier, but the discus, javelin, or shotput must be airborne before contact is made with the barrier. For high jump, wearing a prosthesis is optional, but the competitor must take off from ground level on one foot. Arnold Boldt is an amputee from Canada who dominates in this sport. He is able to jump 1.94 m. For long jump, participants jump without a prosthesis from a standing position at the take-off line. For table tennis, a prosthesis is worn, but crutches are not allowed. Bilateral amputees can compete from a wheelchair.
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For weight lifting, participants are weighed in the nude without prostheses 1 hour before the event. Those with amputation then add l/16th of their body weight for each transtibial amputation, l/9th of their body weight for each transfemoral amputation, and l/6th of their body weight for each hip disarticulation. For amputees who choose to weight lift in nondis-abled events, a good-quality prosthesis is of extreme importance. To do the squat and dead lift, a prosthesis offering a wide base of support is important. While the base of support has to be wide, it also has to remain vertical without causing too much stress on the knee ligaments. The foot needs to have some flexibility so that it stays flat. The prosthesis needs to be fabricated from material that will tolerate the torques and stresses applied to it by the excess weight. Arlon has proved to be a more adequate laminating material than fiberglass or acrylic. For competitive snow skiing, National Handicapped Sports would be the best resource. A division for the physically challenged was added to the National Standard Race (NASTAR) program during the 1985-1986 season. NASTAR enables amputees to compare themselves with others in the world with similar disabilities or to top professional skiers. For wheelchair sports, the Paralympic Games began in 1960, guided by Dr. Ludwig Guttman. The eighth Paralympics were held in October 1989 in Seoul, Korea. Approximately 4,000 athletes from 60 countries participated in the games and established 971 new world records. The next Paralympic event will be in Barcelona, Spain in September 1992. Nassau County, New York, was the site of the 1984 International Games for the Disabled and drew 1,700 participants from 45 countries. In August 1985 the top eight 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. Fifteen hundred-meter exhibition events were also held at the 1990 Goodwill games in Seattle.
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Fitness is for Everyone. Cleveland, NHS/Invacare, Wyse Public Relations. Gorski R: Diving for the deep. Disabled USA 1982; 25-29. Graves JM, Burgess EM: The extra-ambulatory limb concept as it applies to the below-knee amputee skier. Bull Pros-thet Res 1973; 10:126-131. Hittenberger DA: Extra-ambulatory activities and the amputee. Clin Prosthet Orthot 1982; 6:14. Hughes HN, Helmuth G: A modified prosthetic foot for pilots. Orthot Prosthet 1975; 29:33-34. International Perspectives on Adapted Physical Activity. Champaign, Ill, Human Kinetics. Kegel B: Amputee soccer. Phys Ther Forum, 1988; 7:2. Kegel B: Physical fitness. Sports and recreation for those with lower limb amputation or impairment. J Rehabil Res Dev Clin Suppl 1985; 1:1-25. Kegel B: Sports for the Leg Amputee. Redmond, Wash, Medic Publishing Co, 1986. Kegel B, Peterson J: Summer splash. A water sports symposium for the physically challenged. Palaestra 1989; 6:17-19. Kegel B, Webster JC, Burgess EM: Recreational activities of lower extremity amputees: A survey. Arch Phys Med Rehabil 1980; 61:258-264. Kelley JD, Frieden L: Go For It! Orlando, Fla, Harcourt Brace Jovanovich Inc., 1989. Krebs DA: Adaptive Recreation Equipment for the Physically Challenged. Thousand Oaks, Calif, Access to Recreation Inc, 1987. LaBlanc KP: Fabrication of the water-resistant recreation B/K prosthesis. Orthot Prosthet 1983; 37:42-49. Levesque C, Gauthier-Gagnon C: An improved downhill skiing prosthesis. J Prosthet Orthot 1989; 1:104-109. Marano C, Demarco E: New design and construction for a swimming prosthesis. Orthot Prosthet 1984; 38:45-49. McBee F, Ballinger J: Continental Quest: An Account of the First Wheelchair Crossing of North America. Overland Press. McCann BC: Classification of the disabled for competitive sports: Theory and practice. Int J Sports Med 1984; 5(suppl):167-170. McGowan J: Paraplegics and Skydiving: A Personal Guide. St Petersburg, Fla, James McGowan. Mensch G, Ellis P: The Terry Fox running prosthesis. Phys-iother Canada 1984; 36:245-246. Mensch G, Ellis PE: Running patterns of transfemoral amputees-A clinical analysis. Prosthet Orthot Int 1986; 10:129-134. O'Leary H: Bold Tracks: Skiing for the Disabled. Evergreen, Colo, Cordillera Press Inc., 1987. Orr L: Cross country sled skiing. Sports Spokes 1983; 8:18-20. Owens D: Teaching Golf to Special Populations. West Point, NY, Leisure Press, 1984. Paciorek M, Jones JA: Sports and Recreation for the Disabled. A Resource Manual. Indianapolis, Benchmark Press Inc, 1989. Products to Assist the Disabled Sportsman. Lake Zurich, Ill, JL Pachner Ltd., 1990. Riley R: Amputee athlete. Clin Prosthet Orthot 1987; 11:109-113. Rubin G, Fleiss D: Devices to enable persons with amputation to participate in sports. Arch Phys Med Rehabil 1983; 64:37-40. Saadah ESM: Rehabilitation of a below-knee amputee with a diving limb. Clin Rehabil 1989;
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3:269-251. Sabolich J: The O.K.C. above-knee running system. Clin Prosthet Orthot 1987; 11:169-172. Sherrill C: Sport and Disabled Athletes. Champaign, Ill, Human Kinetics, 1986. Simmons R: Reach for Fitness: A Special Book of Exercises for the Physically Challenged. New York, Warner-Books Inc, 1986. Sports, Games and Outdoor Recreation for Handicapped Persons. Washington, DC, National Library Service for the Blind and Physically Handicapped, Library of Congress, 1983. Sports prosthetics. Clin Prosthet Orthot 1987; 3. The Garden and the Handicapped Child. London, Disabled Living Foundation. Thomann J: Flying lite-Ultralight aircraft. Sports Spokes 1983; 8:7. Viau A, Chadderton C: Swivel golf shoes. Fragment 1980; 126:20-21. Water Sports for the Disabled, ed 1. East Ardsley, England, EP Publishing Ltd, 1983. Wing DC, Hittenberger DA: Energy-storing prosthetic feet. Arch Phys Med Rehabil 1989; 70:330-335. CONSUMER LITERATURE Abilities: Canada's Journal of the Disabled. 5090 Explorer Dr, Suite 502, Mississauga, Ontario, Canada, L4W 9Z9. Ability Magazine. Majestic Press Inc, PO Box 5311, Mission Hills, CA 91345. (805) 366-1552. Accent on Living. Cheever Publishing Inc, PO Box 700, Bloomington, IL 61701. (309) 3782961. Disabled Outdoors Magazine. 5223 S. Lorel Ave, Chicago, IL 60638. Mainstream. PO Box 2781, Escondido, CA 92025. Mobility. A Magazine for People With Mobility Impairments. 401 Linden Center Dr, Fort Collins, CO 80524. (303) 484-3800. Outdoors Forever. PO Box 4811, East Lansing, MI 48823. Palaestra. The Forum of Sport, Physical Education, and Recreation for the Disabled. PO Box 10, Carthage, IL 62321. Products to Assist the Disabled Sportsman. JL Pachner Ltd, 33012 Lighthouse Ct, SJ Capistrano, CA 92675. (714) 661-2132. Sports 'N Spokes. Paralyzed Veteran's of America, 5201 North 19th Ave, Suite 111, Phoenix, AZ 85015. (602) 246-9426. S.Q.U.LD. (Scuba Quarterly Undersea International Digest). Handicapped Scuba Association, 116 West El Portal, Suite 104, San Clemente, CA 92672. (714) 439-6128. The Gimp Exchange. National Handicap Motorcyclist Association, 32-04 83rd St, Jackson Heights, NY 11370. Two-Bounce News. National Foundation of Wheelchair Tennis, 3857 Birch St, No. 411, Newport Beach, CA 92660.
RESOURCE LIST
Able Sailor Systems and Hardware, Ltd Colgrims Mede, Aviary Rd Pyrford, Woking, Surrey GU22 8th Great Britain Achilles Track Club 9 East 89th St New York, NY 10128
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(212)967-9300 Activsleeve Rampro, Inc PO Box 3256 Santa Monica, CA 90403 (213) 828-6781 Suspension system helpful in reducing pistoning and suction-type suspension for the transtibial amputee. Adaptive Sports Program Kinesiotherapy Clinic c/o Dr Leonard Groninger University of Toledo 2801 West Bancroft St Toledo, OH 43606 (419) 537-2755 Adolescent Amputee Camp Physical Therapy Department c/o Gay Gregg Children's Hospital of Pittsburgh 125 DeSoto St Pittsburgh, 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. Stevens 1102 Bergan Rd Oreland, PA 19075 American Alliance for Health, Physical Education, Recreation and Dance Programs for the Handicapped c/o Dr Razor, Executive Vice President 1900 Association Dr Reston, VA 22091 (703) 476-3561 American Amputee Foundation, Inc c/o Jack M. East PO Box 250218 Little Rock, AR 72272 (501) 666-2523 American Canoe Association Disabled Paddler's Committee 8580 Cinderbed Rd, Suite 1900 PO Box 190 Newington, VA 22122-1190 (703) 550-7495 American Special Recreation Association c/o John Nesbitt, Ed. D Recreation Education Program University of Iowa Iowa City, IA 52240 (319) 353-2121 American Therapeutic Recreation Association, Inc c/o Peg Conley 3417A Sapula Rd, Box 377 Sand Springs, OK 74063 (904) 644-6014 American Waterski Association Phil Martin, Chairman Disabled Ski Committee 681 Bailey Woods Rd Dacula, GA 30211 American Wheelchair Bowling Association Daryl Pfister N54 W 15858 Larkspur Lane Menomonee Falls, WI 53051 (414) 781-6876 American Wheelchair Pilot's Association c/o Dave Graham 1621 East 2nd Ave Mesa, AZ 85204 (602) 831-4262 American Wheelchair Table Tennis Association Jennifer Johnson 23 Parker St Port Chester, NY 10573 (203) 629-6283 Amputee Competitive Sports U.S. Amputee Athletic Association Jan Wilson, Executive Director PO Box 560686 Charlotte, NC 28256 (704) 598-0407 Amputee Soccer International Bill Barry, Program Administrator, Coaching Director Suite 107, 1110 North 175th St Seattle, WA 98133 (206) 546-3770 Amputee Sports Association c/o George C. Beckmann, Jr 11705 Mercy Blvd Savannah, GA 31419 (912) 927-5406
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Amputees in Motion International c/o Jerry Dahlquist PO Box 1736 Fallbrook, CA 92028 (619) 725-6195 or (619) 723-8003 Baseball Information National Wheelchair Softball Association John Speake, Commissioner PO Box 22478 Minneapolis, MN 55422 (612) 437-1792 Bert Sheppard 8014 Bangor Hesperia, CA 92345 Bicycle Information For Fun Cycles Corporation 966 N. Elm St Orange, CA 92667-5471 (714) 997-1952 Harper Handbike, Harper Mfg 3125 W. Hampden Ave Englewood, CO 80110 (303) 756-4050 Mr. Kenneth Kozole, OTR Clinical Rehabilitation Engineer Rehabilitation Engineering Program Room 1441 Northwestern University 345 E Superior St Chicago, IL 60611 New England Handcycles, Inc 228 Winchester St Brookline, MA 02146 Rifton Equipment Division of Community Playthings Society of Brother, Inc Rifton, NY 12471 (914) 658-3141 Boating Information American Canoe Association Committee for Disabled Paddlers 8580 Cinderbed Rd, Suite 1900 PO Box 1190 Newington, VA 22122-1190 (703) 550-7495 Boating for the Handicapped/Guidelines for the Physically Disabled by Eugene Hedley, Ph.D., 1979 Research and Utilization Institute Human Resources Center Albertsen, NY 11507 Disabled Sailing Association of British Columbia 1300 Discovery St Vancouver, BC V6R4L9 Canada 222-3003 Environmental Travelling Companions (ETC) Fort Mason Center Landmark Bldg C San Francisco, CA 94123 (415) 474-6772 Nantahala Outdoor Center Bunny Johns, Head of Instruction Box 41 Bryson City, NC 28713 (704) 488-2175 Norwegian Arctic Tours PO Box 700 Enfield, NH 03748 Philadelphia Rowing Program for the Disabled (PRPD) Attn: Sean Riordan/Pat Standley 858 Bailey St Philadelphia, PA 19130 (215) 763-5815 Sailing Accessories, Inc 2712 Irwin Rd Redding, CA 96002 (916) 221-7197 Shake-A-Leg PO Box 1002 Newport, RI 02840-0009 (305) 858-5550 (401) 849-8898 Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami, FL 33133 U.S. Association for Disabled Sailors Keith Lark, President Southern California Chapter 901 Fathom Ave Seal Beach, CA 90740 (213) 431-4461
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Wilderness Inquiry 11 1313 Fifth St SE, Box 84 Minneapolis, MN 55414 (612) 379-3858 Boy Scouts of America Scouting for the Handicapped c/o John E. Hunt PO Box 16030 Dallas-Ft Worth Airport Dallas, TX 75261 (214) 659-2000 Breckenridge Outdoor Education Center Mike Mobley, Executive Director PO Box 697 Breckenridge, CO 80424 (303) 453-6422 British Amputee Ski Association Box 1373 Banff, Alberta TOL OCO Canada British Disabled Water Ski Association Warren Wood, the Warren Ashtead, Surrey KT212 SN England California Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido, CA 92025 Canadian Wheelchair Sports Association 1600 James Naismith Dr Gloucester, 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, PA 17011 (717) 761-7400 Committee on Recreation and Leisure President's Committee on Employment of the Handicapped c/o Gerald Hitzhusen, Chairman Washington, DC 20210 (202) 653-5044
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20840 Pacific Highway S Seattle, WA 98198-5999 (206) 878-7457 FAX (206) 824-3038 Two-wheeled tandem bikes. Courage Center 3915 Golden Valley Rd Golden Valley, MN 55422 (612) 588-0811
Cycl-one
Access Designs, Inc. 627 S.E. 53rd Ave Portland, OR 97215 (503) 238-0049 or PO Box 216 Independence, OR 97351 Hand-operated device attached to the wheelchair. Disabled Outdoors Foundation 320 Lake St Oak Park, IL 60302 (312) 284-2206 Eastern Amputee Athletic Association Jack Graff, President Mike Doanals, Vice President 2080 Ennabrock Rd North Bellmore, NY 11710 (516) 826-8340 Easy Kneeler Gardener's Supply Co 133 Elm St Winooski, VT 05404 (802) 655-9006 Kneeling stool for gardening. The 52 Association 350 5th Ave, Room 1829 New York, NY 10118 (212) 563-9797
Flying Information
American Wheelchair Pilots Association c/o Dave Graham 1621 East Second Ave Mesa, AZ 85204 CA Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido, CA 92025 (619) 746-5018 The Soaring Society of America, Inc. PO Box 66071 Los Angeles, CA 90066 (213) 390-4448 Girl Scouts U.S.A. Scouting for the Handicapped Service c/o Cindy Ford 830 Third Ave New York, NY 10022
Golf Information
Amputee Sports Assoc c/o George C. Beckmann, Jr. 11705 Mercy Blvd Savannah, GA 31419 Golf for Life Shirlee C. Hicks 7595 Carlow Way Dublin, CA 94568 (415) 829-9576 (415) 971-2661 International Senior Amputee Golf Society c/o Dale Bourisseau 14039 Ellesmere Dr Tampa, FL 33624 (813) 961-3275 National Amputee Golf Association PO Box 1228 Amherst, NH 03031 (800) 633-NAGA Project Fore, Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon, CA 92021 (619) 442-3425
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Susan J. Grosse Physical Education Specialist Milwaukee Public Schools 7252 West Wabash Ave Milwaukee, WI 53223 (414) 354-8717 Groundgrabbers K and R Specialties 2809 Charles Court NW Rochester, MN 55901 (507) 281-1351 Snow chains for wheelchairs.
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Rising Hill Escondido, CA 92025 (619) 746-5018 International Wheelchair Road Racers Club, Inc Joseph M. Dowling, President 30 Myano Lane Stamford, CT 06902 (203) 967-2231 International Wheelchair Tennis Federation Brad Parks, President 940 Calle Amanacer, Suite B San Clemente, CA 92672 (714) 361-6811 A Man and His Mountains by Norman Croucher Available from David and Charles, Inc North Pomfret, VT 05053 Mission Bay Aquatic Center 1001 Santa Clara Point San Diego, CA 92109 (610) 488-1036 Monoskis Beneficial Designs, Inc 5858 Empire Grade Rd Santa Cruz, CA 95060 (408) 429-8447 Enabling Technologies, Inc 2411 N. Federal Blvd Denver, CO 80211 (303) 455-3578 Innovative Recreation, Inc PO Box 159 Sisters, OR 97759 (503) 549-7022 Magic in Motion 20604 84th Ave South Kent, WA 98032 (800) 342-1579 (206) 872-072 Mobility Systems 861 Robinwood Ct Traverse City, MI 49684 (616) 941-4626 Motorcycling Information The Wheelchair Motorcycle Association, Inc 101 Torrey St Brockton, MA 02401 (617)583-8614
Mountain Climbing
Hittenbergers 106 Lynch Creek Way, Suite 8 Petaluma, CA 94954-2380 (707) 769-9417 A modified ice pick is attached to the forearm portion of the crutch. Georgia Prosthetic, Inc c/o Rick Riley 398 14th St N.W. Atlanta, GA 30318 (404) 873-3725 National Amputee Golf Association PO Box 1228 Amherst, New Hampshire 03031 (800) 633-NAGA National Association of Handicapped Outdoor Sportsmen, Inc RR 6, Box 25 Centralia, IL 62801 (618)532-4565 National Association of Swimming Clubs for the Handicapped 63 Dunnegan Rd Eltham, London SE9 England National Council for Therapy and Rehabilitation Through Horticulture c/o Charles Richman, Executive Director 9041 Comprint, Suite 103 Gaithersburg, MD 20877 (301) 948-3010 National Handicap Motorcyclist Association (NHMA) Bob Nevola, President 35-34 84th St #F8 Jackson Heights, NY 11372 (718)565-1243 National Handicapped Sports Kirk Bauer, Executive Director 451 Hungerford Drive, Suite 100 Rockville, MD 20850 (301) 217-0960 (301) 217-0968 FAX National Ocean Access Project 410 Severn Ave, Suite 107 Annapolis, MD 21403 (301) 2800464 National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs, CO
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80909 (719) 635-9300 National Wheelchair Basketball Association Stan Labanowich 110 Seaton Bldg University of Kentucky Lexington, KY 40506 (606) 257-1623 National Wheelchair Racquetball Association (NWRA) Gary Baker 1 Desavage St Jeannette, PA 15644 (412) 744-3320 or 815 North Weber, Suite 101 Colorado Springs, CO 80903 National Wheelchair Shooting Federation Deanna Greene, President PO Box 18251 San Antonio, TX 78218-0251 National Wheelchair Softball Association Jon Speake, Commissioner 1616 Todd Ct Hastings, 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, Suite 107 Annapolis, MD 21403 (301)280-0464 Nordic Skiing Ted Fay, Nordic Director U.S. Disabled Ski Team PO Box 186 Hanover, NH 03755 (802) 295-3625 North American Riding for the Handicapped Association PO Box 33150 Denver, CO 80233 (303) 452-1212 North American Wheelchair Athletic Association PO Box 26 Riverdale, NY 10471 (212) 7965084 Oita Sports Association for the Disabled c/o Japan Sun Industries Kamegawa Beppu Oita, 87401 Japan Outriggers Enabling Technologies 2411 North Federal Blvd Denver, CO 80211 (303) 455-3578 Physically Challenged Swimmers of America Joan Karpuk 22 William St, #225 South Glastonbury, CT 06073 (203) 548-4500 POINT (Paraplegics on Independent Nature Trips) Shorty Powers, Director 3200 Mustang Dr Grapevine, TX 76051 (817) 481-0119 Power Gloves B.G. Water Sports 530 Sixth St Hermosa Beach, CA 90254 (213) 372-5063 Scuba hand fins. John Barber, CP(C), FCBC, Chief Prosthetist J.A. Pentland Limited 82239 Main St Vancouver, British Columbia V5X 3L7 Canada (604) 324-4011 A swim-scuba prosthesis has also been developed. Project FORE, Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon, CA 92021 (619) 442-3425 Racquetball United States Wheelchair Racquet-Sports Association (NWRA) Gary Baker 1 Desavage St
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Jeannette, PA 15644 (412) 744-3320 Rampro, Inc PO Box 3256 Santa Monica, CA 90403 (213) 828-6781 Activankle, a multiposition sports ankle. Recreation and Athletic Rehabilitation-Education Center c/o Brad Hedrick University of Illinois 1207 South Oak St Champaign, IL 61820 (217) 333-4606 Recreation Center for the Handicapped c/o Janet Pomeroy, Director 207 Skyline Blvd San Francisco, 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, Alberta T6G 2H9 Canada
Riding Information
North American Riding for the Handicapped Assn PO Box 100 Ashburn, VA 22011 Outback Ranch Outfitters Attn: Ken Wick Box 384 Joseph, OR 97346 (503) 432-1721 Winslow Therapeutic Riding Unlimited Virginia G. Mazza, President 3408 S Rte 94 Warwick, NY 10990 (914) 986-6686 Rock Climbing Transfemoral Prosthesis Montreal Rehabilitation Institute Claude Levesque, CP(C) Prosthetics and Orthotics Division 6300 Darlington Ave Montreal, Quebec H3S 2J4 Canada Rowcycle 3188 North Marks, #107 Fresno, CA 93722 (800) 227-6607 Hand-operated device (combination of bicycle and rowing machine). Rowing Ankle Unit Prosthetics Research Study 720 Broadway Seattle, WA 98122 (206) 328-3116 Running Club Achilles Track Club 9 East 89th St New York, NY 10128 (212) 967-9300 Amputee running club. Schwinn Air-Dyne Schwinn Bicycle Co 1856 N Kostner Ave Chicago, IL 60639 (312) 2922900 Scottish Sports Association of the Disabled c/o Scottish Sports Council 1 St. 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, Suite 104 San Clemente, CA 92672 (714) 439-6128 A videotape, "Freedom in Depth," is also available. Robinson, J, and Fox, D: Scuba Diving with Disabilities Leisure Press PO Box 5076 Champaign, IL 61820 (217) 351-5076
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Shake-a-Leg, Inc PO Box 1002 Newport, RI 02840 (401) 849-8898 Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami, FL 33133 Sit-Skis Mountain Man 720 Front St Bozeman, MT 59715 (406) 587-0310 Skating Association for the Blind and Handicapped (SABAH) c/o Sibleys, Boulevard Mall Store Niagara Falls Blvd Amherst, NY 14226 (716) 833-2994
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(517) 882-4608 A device to facilitate ski turning ability and the ski stabilizer. Ski-Tur War Amputations of Canada 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Ski stabilizer device. S.O.A.R. (Shared Outdoor Adventure Recreation) c/o Linda Besant PO Box 14583 Portland, 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, Executive Director 255 East 400 South, Suite 107 Salt Lake City, UT 84111 (801) 363-7130 The Steed Jerry Selness 4724 Point Loma Ave San Diego, CA 92107 (619) 224-2619 A 30-ft sloop for disabled sailors. Swivel Golf Shoe The War Amputations of Canada Armand Viau or Cliff Chadderton 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Canada TES Belt Syncor, Ltd PO Box 540022 Houston, TX 77254-0022 Three Tracker's Ski Tote NHS of California c/o Betty Lessard 5946 Illinois Ave Orangevale, CA 95669 (916) 989-0402 Transfemoral Prosthesis for Skiing Professor Dr Rene F. 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. Trimaran Cheeseman Biffins Boat Yard Staines Bridge Staines, Middlesex England TW1830N Turfking Aquatic Chairs Beach Wheels, Inc 1555 Shadowlawn Dr Naples, FL 33942 (813) 777-1078 Forward Motion Sand-rik PO Box 782 Mechanicsville, VA 23111 (804) 746-4088 Fred Davis, President Box 890 Ketchum, ID 83340 (208) 788-9666 United States Swimming Handbook for Adapted Competitive Swimming (1989) United States Swimming 1750 East Boulder St Colorado Springs, CO 80909 United States Wheelchair Racquet-Sports Association (NWRA) Gary Baker 1 Desavage St Jeannette, PA 15644 (412) 744-3320 United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown, PA 19057 (215) 945-1964 US Amputee Athletic Association Jan Wilson, Executive Director PO Box 560686 Charlotte,
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NC 28256 (704) 598-0407 US Association of Disabled Sailors Southern California Chapter Mike Watson PO Box 15245 Newport Beach, CA 92659 (714) 534-5717 US Rowing Association Adaptive Rowing Committee Richard Tobin 11 Hall Place Exeter, NH 03833 (603) 778-0315 Voyageur Outward Bound School c/o Ted Mooras PO Box 250 Long Lake, MN 55356 The War Amputations of Canada c/o Cliff Chadderton 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Canada Water Ski Devices Magic in Motion c/o Jim Martinson 20604 84th Aves. Kent, WA 98032 (800) 342-1579 Mission Bay Aquatic Center c/o Tod Bitner 1001 Santa Clara Point San Diego, CA 92109 (619) 488-1038 Ski Seat Water Sports Industries 10230 Freeman Ave Santa Fe Springs, CA 90670 (213) 946-1323
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Peter Burwash International, Ltd 1909 Ala Wai, Suite 1507 Honolulu, HI 96815 (808) 9461236 Wilderness Inquiry 11 c/o Greg Lais, Director 2929 Fourth Ave S, Suite O Minneapolis, MN 55408 (612) 827-4001 Winter Park Sports and Learning Center c/o Hal O'Leary PO Box 36 Winter Park, CO 80482 (303) 726-5514, ext 179
Chapter 24B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library
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Chapter 24C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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STRUCTURAL COMPONENTS
As prosthetists grow ever more willing to accept standardized components, manufacturers
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24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library
strive to outdo each other in offering improved devices. This trend has been marked by a shift from exoskeletal wood components, which demand a considerable amount of labor, to endoskeletal components that can be bolted together with a minimum of labor. This development was sparked by the introduction of the Otto Bock modular endoskeletal system some 20 years ago. 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. The original system has been continuously refined and updated with an increasing array of options available. As a result, the design parameters adopted by Otto Bock have become the worldwide de-facto standards for development by other companies. Components that fit into the Otto Bock system and complement it are now being designed by competitors. Paradoxically, standardization has led to increased compatibility of components produced by different manufacturers and has increased the ability to readily mix and match components. Most such structural systems make provision for changing the alignment of the prosthesis without performing major structural changes. These two factors enable the prosthetist to readily vary the prosthesis throughout its life to meet the changing needs of the patient. Newer, more sophisticated materials such as titanium and carbon composite are being used to design systems that are both more robust and lighter in weight. Smaller-size units for children are also being fabricated. It seems likely that future research efforts will be focused on working within the context of the endoskeletal rather than the exoskeletal structure. New and improved methods of providing cosmetic finishing for the structural components are needed. Cosmetic fairings are laborious to shape and fragile and, in transfemoral applications, can impede the proper function of knee control units. Spray-on or paint-on prosthetic skins offer, at best, a partial solution to these problems while creating new ones of their own. Component parts within the endoskeletal system have also received attention. In regard to knee control units, the trend has not necessarily been to develop new units, but rather to adapt exoskeletal designs to the endoskeletal context. Today, an endoskeletal analogue for every exoskeletal knee can be found, including those controlled by hydraulic and pneumatic units. In the process, composite structures of carbon fiber and epoxy have been used to offset the often formidable weight of the control unit. Otto Bock has now introduced a new composite knee incorporating a Mauch S-N-S control unit. Physically active amputees have pressed for prostheses suited to a range of activities more demanding than just walking. The availability of newer materials at reasonable cost, among One general other factors, has led manufacturers to respond to the need with new feet. category, termed dynamic elastic response or energy-storing 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. Although such feet, epitomized by the Seattle Foot ( Fig 24C1.), Carbon Copy II Foot, and Flex-Foot, were originally envisaged as being most suitable for they have found favor with geriatric younger amputees interested in athletic activities, amputees as well. The other group of feet, including the stationary-ankle, flexibleendoskeleton (SAFE) foot, Quantum, and Multiplex, are designed for improved compliance and range of motion at the ankle to adapt more readily to irregular terrain. Decreased weight has also come to be a design parameter to be carefully considered. The development of these feet has been marked not just by a concern with performance but with appearance as well. Feet are now routinely designed with such sculpted details as toes and veins. This attention to cosmetic effect will probably continue and be heightened in the future.
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. 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, they found ever wider application and allowed a reduction in cost. With reasonable costs ensured and with a body of engineering data to work with, it became possible for prosthetic manufacturers to design and produce new components with the new materials. Significant costs in product design have been incurred by manufacturers developing such
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components, and it has only been attractive to the manufacturers to take the risk because of the existence of a market for commercially available components. 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. Market size has grown as a result of the globalization of the prosthetic market. At the end of World War II, it was possible to discern distinctly different national styles of prosthetic fitting and construction. With the growth in standardization, these differences have become less clear. It is now possible to find manufacturers from around the world who are developing ever more sophisticated products from expensive materials, all within a common context. This has, in turn, spurred the pressure to develop an internationally agreed-upon standard for physical strength and performance. These interacting trends will doubtlessly accelerate in the future. Another group of materials primarily used in socket construction has considerably more mundane origins. Thermoplastic polymers such as polyethylene, polypropylene, ionomer, and polycarbonate find their most common applications in such everyday products as packaging, illuminated signs, toys, consumer appliances, and cars. These materials and some of the techniques used to shape them have been borrowed to produce flexible sockets, transparent check sockets, and prostheses themselves. Most of these latter applications have been made by clinical prosthetists working singly or in small groups. They have been abetted in these efforts by their growing sophistication about design principles and the biomechanical basis for prosthetic fitting, as fostered by their improved educational status.
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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. This demands more sophistication about materials and performance upon the part of prosthetists and other clinicians and creates more opportunities for manufacturers. While many of these efforts have been and will be directed to the needs of younger, more active patients, older, more sedentary patients have benefited and will continue to do so from the emphasis on light weight and comfort.
ADVANCED TECHNOLOGY
The foregoing sections have reviewed the developments that have had the most immediate impact on current practice. One other emerging trend, while still in its early stages, promises even more far-sweeping impact on the field. This is the application of the computer-aided design-computer-aided manufacturing (CAD-CAM) concept to prosthetics. In the most basic Automated production of prostheses has been sought for some 20 years. manner, it can be described as consisting of three elements ( Fig 24C-3.). The first is acquisition of dimensional information from the involved body segment. The second is manipulation of this information to generate the specifications for a socket model to be produced by the third element, an automated carver. These last two elements correspond exactly to the CAD-CAM process. Their availability to prosthetics and orthotics only occurred with the widespread availability of personal computers, CAD-CAM software to be run on such personal computers, and the possibility of directing numerically controlled carving machines with them. 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. Commercial units depend on information generated by the prosthetist and entered indirectly into the system. As a result, human error is not eliminated, 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. This means that it is not yet possible to generate true productivity gains. These limitations, 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, have limited their commercial appeal. Nonetheless, a number of installations have been made in the past few years. 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. As noted, the outcome of the CAD-CAM system is a socket model. This model is generally utilized in producing a thermoplastic vacuum-formed socket, by either automated or nonautomated means, to be attached to endoskeletal components to produce a prosthesis. In effect, the trend that began with the prosthetist ceasing to craft elements such as feet, knees, and shins will culminate with relinquishment of any direct hands-on role in producing the socket. The impact that this will have on the nature of prosthetic practice remains to be seen.
COST CONTAINMENT
As in so many areas of medicine, the introduction of new technology to prosthetics has troublesome and contradictory implications for cost containment. 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. Likewise, our ability to fit patients comfortably has increased, and we have been able to provide them with new measures of comfort and function as a result of the application of new materials. These advances, however, have not been without their price. It is costly to adequately educate and train a prosthetist. Many of the new materials are expensive to purchase and to fabricate into finished components. The capital investments needed to work such new materials are high, and the costs of research and product development must be reckoned with. If CAD-CAM comes to be an integral part of clinical prosthetic practice, the capital expense of the equipment will have to be borne as well. The prosthetist of the future will doubtlessly be able to produce more and better prostheses, but the capital expenses at all levels of the delivery system necessary to support this advance will have to be recognized and met. If they are not, the incentives to develop even newer techniques will cease to exist. Coping with the implications of this quandary and answering the questions it raises are likely to play a prominent role in future prosthetic research.
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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. The former will seek to gain competitive advantage by exploiting the possibilities of newly available materials and methods to produce components that are stronger, lighter, and more functional. 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. By common consent, both will work in the context of the endoskeletal structural system. De facto acceptance of Otto Bock's design parameters and the globalization of the market will aid and abet this trend. The need for marketplace incentives and well-educated prosthetists will become even more important. The growing self-assurance and assertiveness of younger, more active amputees will probably also shape developments. This and other factors are likely to lead to more functional feet and knees, prostheses that can be more readily adapted to the varying needs of amputees, and improved methods of providing cosme-sis. However, it must be recognized that as the population ages, the needs of these amputees will change. There is also likely to be a concurrent increase in the number of geriatric amputees. These factors will shift priorities and developmental efforts. Ever more CAD-CAM production systems will be purchased for use in clinical practice. This will accelerate the rate of development of such systems, 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. In all likelihood, 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. All these factors may interact in unexpected ways with the desire of society to curtail the growth of medical expenses. Research efforts could well be shifted from developing newer means of providing prosthetic care to justifying and defending the expense of present methods. 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. One would provide a tolerably comfortable, minimally functional lightweight prosthesis, 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. The other level of care would be provided to patients for whom price is of little concern, with more elaborate attention being paid to such factors as fit and function. References: 1. Abrahamson M, et al: Improved techniques in alginated check sockets. Orthot Prosthet 1987; 40:63. 2. Alaranta H, et al: Practical benefits of Flex-Foot in be-low-knee amputees. J Prosthet Orthot 1991; 3:179. 3. Arbogast R, et al: The Carbon Copy II-From concept to application. J Prosthet Orthot 1988; 1:32. 4. Black L: Orthosil silicone gel for pads and soft insert liners. Orthot Prosthet 1983; 37:58. 5. Burgess E, et al: The Seattle prosthetic foot-A design for active sports: Preliminary studies. Orthot Prosthet 1983; 37:25. 6. Campbell J, Childs C: The S.A.F.E. foot. Orthot Prosthet 1980; 34:3. 7. Childs C, Staats T: The Slipper Type Partial Foot Prosthesis. Los Angeles, UCLA Prosthetics-Orthotics Education Program, 1983. 8. Dietzen C, et al: Suction sock suspension for above-knee prostheses. J Prosthet Orthot 1991; 3:90. 9. Faulkner V, et al: A computerized ultrasound shape sensing mechanism. Orthot Prosthet 1988; 41:57. 10. Fillauer C, et al: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92. 11. Gottschalk F, et al: Does socket configuration influence the position of the femur in above-knee amputation? J Prosthet Orthot 1989; 2:94. 12. Hanak R, et al: Specifications and fabrication details for the ISNY above-knee socket system. Orthot Prosthet 1986; 40:38. 13. Hayes R: A below-knee weight-bearing pressure-formed socket technique. Clin Prosthet Orthot 1985; 9:13.
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14. Hittenberger D: A thermoplastic endoskeletal prosthesis. Orthot Prosthet 1983; 37:45. 15. Hittenberger D: The Seattle foot. Orthot Prosthet 1986; 40:17. 16. Imler C: Imler partial foot prosthesis: IPFP-"The Chicago Boot." Orthot Prosthet 1985; 39:53. 17. Jendrzejxzyk D: Flexible socket systems. Clin Prosthet Orthot 1985; 9:27. 18. Journal of Prosthetics and Orthotics 1989; 1:116-190. (Issue devoted to CAD-CAM.) 19. Journal of Prosthetics and Orthotics 1990; 3:1-54. (Issue devoted to thermoplastic materials in lower limb prosthetics.) 20. Kegel B, et al: Recreational activities of lower extremity amputees: A study. Arch Phys Med Rehabil 1980; 61:258. 21. Klopsteg P, Wilson P: Human Limbs and Their Substitutes. New York, Hafner Publishing Co, 1959. 22. Kohler P, et al: Comparison of CAD-CAM and hand made sockets for PTB patients. Prosthet Orthot Int 1989;. 13:19. 23. Koike K, et al: The TC double socket above-knee prosthesis. Prosthet Orthot Int 1981; 5:129. 24. Kristinsson O: Flexible above knee socket made from low density polyethylene, suspended by a weight transmitting frame. Orthot Prosthet 1983; 37:25. 25. Krouskop T, et al: Measuring the shape and volume of an above-knee stump. Prosthet Orthot Int 1988; 12:136. 26. Long I: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet Orthot 1985; 9:9. 27. Madden M: The flexible socket system as applied to the hip disarticulation amputee. Orthot Prosthet 1985; 39:44. 28. McFarlane P, et al: Gait comparisons for below-knee amputees using a Flex-Foot versus a conventional prosthetic foot. J Prosthet Orthot 1991; 3:150. 29. McFarlane P, et al: Perception of walking difficulty by below-knee amputees using a conventional foot versus the Flex-Foot. J Prosthet Orthot 1991; 3:106. 30. Menard M, et al: Subjective and objective analysis of energy-storing prosthetic foot. J Prosthet Orthot 1989; 1:220. 31. Michael J: Energy storing feet: A clinical comparison. Clin Prosthet Orthot 1987; 11:154. 32. Mooney V, et al: Fabrication and application of transparent polycarbonate sockets. Orthot Prosthet 1972; 26:1. 33. Nielsen D, et al: Comparison of energy cost and gait efficiency during ambulation in below-knee amputees using different prosthetic feet-A preliminary report. J Prosthet Orthot 1988; 1:24. 34. Oberg K: Swedish attempts in using CAD-CAM principles in prosthetics and orthotics. Clin Prosthet Orthot 1985; 9:19. 35. Oberg K, et al: The CAPOD system-A Scandinavian CAD/CAM system for prosthetic sockets. J Prosthet Orthot 1989; 1:139. 36. Pritham C: Biomechanics and shape of the above-knee socket considered in light of the ischial containment concept. Prosthet Orthot Int 1990; 14:9. 37. Pritham C: Workshop on teaching materials for above-knee socket varients. J Prosthet Orthot 1988; 1:50. 38. Pritham C, et al: Experience with the Scandinavian flexible socket. Orthot Prosthet 1985; 39:17. 39. Prosthetics and Orthotics International 1985; 9:3-47. Issue devoted to CAD-CAM. 40. Riley R: The amputee athlete. Clin Prosthet Orthot 1987; 11:109. 41. Roberts R: Suction socket suspension for below-knee amputees. Arch Phys Med Rehabil 1986; 67:196. 42. Sabolich J: Contoured adducted trochanteric controlled alignment method (CAT-CAM): Introduction and basic principles. Clin Prosthet Orthot 1985; 9:15. 43. Schuch M: Modern above-knee fitting practice. Prosthet Orthot Int 1988; 12:77. 44. Schuch M, et al: Experience with the use of aliginate in transparent diagnostic belowknee sockets. Clin Prosthet Orthot 1986; 10:101. 45. Schuch M, et al: The use of surlyn and polypropylene in flexible brim socket designs for below-knee prostheses. Clin Prosthet Orthot 1986; 10:105. 46. Staats T: Advanced prosthetic techniques for below-knee amputations. Orthot Prosthet 1987; 41:46. 47. Staats T, et al: The UCLA total surface bearing suction below-knee prosthesis. Clin Prosthet Orthot 1987; 11:118. 48. Wilson AB Jr: Standards for Lower-Limb Prosthetics. Philadelphia, International Society for Prosthetics and Orthotics, 1978. 49. Foort J, Kay H: Three-Dimensional Shape-Sensing and Reproduction of Limbs and
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Limb Remnants. Washington, DC, National Academy of Sciences, 1975. 50. Topper A, Fernie G: An evaluation of computer aided design of below-knee prosthetic sockets. Prosthet Orthot Int 1990; 14:136. 51. Torburn L, et al: Below-knee amputee gait with dynamic response prosthetic feet: A pilot study. J Rehabil Res Dev 1990; 24:369. 52. Torreros-Moreno R: A reference shape library for computer aided socket design in above-knee prostheses. Prosthet Orthot Int 1989; 13:130. 53. Varnau D, et al: The enhancement of prosthetics through xeroradiography. Orthot Prosthet 1985; 39:14. 54. Wagner J, et al: Motion analysis of SACH vs. Flex-Foot in moderately active belowknee amputees. Clin Prosthet Orthot 1987; 11:55. 55. Wirta R, et al: Effect on gait using various prosthetic ankle-foot devices. J Rehabil Res Dev 1991; 28:13.
Chapter 24C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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GO
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.
PREPROSTHETIC COMPLICATIONS
Delayed Healing
Delayed healing may be related to several factors that can be operative singly or in combination. These include inappropriate amputation-level selection, sub-optimal operative technique, inadequate postoperative management, and infection. A common cause of delayed healing is inappropriate amputation-level selection. This can, to a large extent, be obviated by proper use of the vascular laboratory as an aid in level selection. Noninvasive techniques such as segmental Doppler studies and transcutaneous oximetry (see Chapter 2C). mapping can yield valuable information Delayed healing can also be due to suboptimal operative technique. Handling dysvascular skin with forceps, attempting to close the skin under tension, or placing excessive closure tension on muscle of questionable vascularity can result in ischemic changes leading to dehiscence. Even with minimal closure tension, skin edges may be made ischemic by the placing of too many sutures, especially mattress sutures ( Fig 25-1.,A). It is better to place a few widely spaced sutures and reinforce the wound with adhesive paper strips ( Fig 25-1.,B). There is also little need for subcutaneous sutures in most amputations if good myofascial and fascial closures are done. Removal of skin sutures prior to firm initial healing of the amputation wound may also lead to dehiscence, especially in the immunocompromised or dysvascular patient. Prior to any definitive treatment of dehiscence other than debridement, the patient should be thoroughly reevaluated to determine the reason for wound failure. The preoperative vascular studies should be reassessed to be sure that the level previously selected was correct. If the patient's wound healing potential was not evaluated preoperatively, it should be done at this point. This would include a determination of serum albumin level to ascertain nutritional status and a total lymphocyte count to assess immunocompetency. If these are deficient, further surgery should be delayed until nutrition is normalized. In chronic renal failure, this may not be possible, and one may be forced to proceed without this assurance. 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, it is common to find them smoking within a day or
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two of surgery. Rather than have another immediate failure due to smoking, the surgeon has the option to refuse surgical treatment beyond debridement on these patients if they fail to comply with this request, so long as life is not threatened. If vascular studies and nutritional parameters are normal and the patient stops the use of nicotine, treatment should proceed with the most appropriate technique. Treatment is determined by the length and depth of the dehiscence. If skin separation is minor, the residual limb may be allowed to heal by secondary intention following conservative debridement under adequate antibiotic coverage. Often a temporary fiberglass or plaster of paris cast helps in the healing of such cases. If wound edge separation due to necrosis is confined to the skin, local debridement that avoids trauma to skin of marginal viability is called for. This may be followed by split-thickness skin grafting once adequate granulation tissue forms. 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.,A and B). If infection is the sole cause of dehiscence, the wound should be widely opened for drainage and appropriate antibiotics given. Once the wound is clean and granulating well, the decision can be made to allow healing by secondary intention, with delayed split-skin grafting coverage of granulating areas, or to revise proximally and maintain the same anatomic level if an adequate soft-tissue envelope for the bone can be constructed. In the presence of gross necrosis or failure of the wound to produce adequate granulation tissue, the choice is limited to a revision amputation. If peripheral vascular parameters are poor, before proceeding to a higher anatomic level, for instance, from transtibial to transfemoral, transcutaneous oximetry can be utilized to determine the potential for skin healing slightly more proximally in the same limb segment. Evaluation should begin with baseline transcutaneous oxygen pressure (Tcp0 2 ) determinations on room air at the site of proposed revision. If less than 40 mm Hg, the measurements may be repeated after the patient has been breathing 100% 0 2 at 1 atm for 20 minutes. If Tcp02 values then meet or exceed 40 mm Hg, postoperative hyperbaric oxygen (HBO) therapy may In selected cases, readings can be taken in the hyperbaric chamber while be considered. If Tcp02 levels are still borderline, the patient is breathing 100% 0 2 at 2.4 atm. consideration should be given to amputation at the next higher anatomic level, followed by HBO therapy if Tcp02 readings are borderline at that level. On occasion, 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 next proximal level is a hip disarticulation, with no assurance that this level will heal. If necrosis then recurs, the patient is at great risk of death due to the difficulty of controlling a wound at that level without involving the pelvic structures. It is sometimes best to merely debride high transfemoral wounds in a manner so as to avoid trauma to wound edges of marginal viability. This is done by leaving a residual rim of necrotic tissue approximately 2 to 3 mm in width. In this way, the marginally viable skin beyond the necrosis is not traumatized by the scalpel. This will often stop the inexorable spread of necrosis attendant upon repeated aggressive debridement. This small rim of necrotic tissue should separate spontaneously. Gauze dressings applied moist and removed dry three times daily will encourage the formation of granulation tissue, which will lead to either healing by secondary intention or the production of a suitable bed for a split-skin graft. This is, of course, combined with improvement of nutrition HBO treatments are again a useful adjunct in management if and cessation of smoking. pretreatment test results are favorable. In older dysvascular patients, falls in the early postoperative period are common due to problems with balance, coordination, and weakness during crutch or walker ambulation. Direct falls on a partially healed amputation wound can result in massive dehiscence and leave the bone exposed. Cleansing, debridement, and closure should be done on an emergency basis to prevent infection, flap shrinkage, and prolonged delay in prosthetic fitting ( Fig 25-3.,A and B). This complication is usually prevented by application of a cast to the midthigh with the knee in full extension each week for 3 weeks. 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.
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envelope for the enclosed bone or bones. 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. If the skin cannot slide over the underlying bone, it will not be able to comfortably tolerate shear forces applied by the prosthesis at the interface with the residual limb. If wound closure is to involve split-thickness skin grafting, 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. Exceptions occur in upper-limb amputations, which are not weight bearing, and in children, who do surprisingly well with splitskin grafts once they have matured.
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other is maintaining suction suspension, especially if the scar is depressed. 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, parallel and just distal to the inguinal crease. Repeated application of an elastic bandage has been the time-honored method of shrinking and shaping a residual limb. Unfortunately, less-than-expert application of the bandage will produce a poorly shaped residual limb, generally with distal edema ( Fig 25-9.). The bandages are meant to be applied on the bias with gradually decreasing pressure as the wrapping proceeds proximally. Since layers of bandage tend to shift with movement, frequent rewrapping is necessary to avoid circumferential constriction and distal edema formation. As a result, many surgeons and prosthetists now recommend the use of an elastic shrinker sock. This sock not only is easy to don and doff but also results in the proper pressure gradient. When first fitted, it should be snug. 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. ). Depending on limb configuration and activity level, the sock may need to be fitted with a waist belt to keep it in place. The sock is briefly removed daily for skin care. Two socks should be supplied so that a clean one can be worn each day to assist in hygienic care of the residual limb. Very muscular or obese amputees may show virtually no shrinkage of their residual limbs by wrapping or shrinker sock usage. In these cases, 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. This technique may also be applied to the standard residual limb as well. This shrinkage includes the removal of edema as well as atrophy of all the soft tissues 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, at which time a new socket will probably be required. Shrinkage may be further enhanced by applying a snug elastic shrinker sock when the preparatory socket is removed each night. 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, a definitive prosthesis may be fitted.
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. Contractures most often occur as a result of the patient keeping the residual limb in a comfortable flexed position. In lower-limb amputees, a variety of contractures may occur. These are serious complications that will interfere with proper prosthetic gait and increase the energy requirements of ambulation. 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. 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. A plastic ankle-foot orthosis fitted with an anterior ankle strap can be similarly used. If, despite these precautions, a contracture later develops, a second percutaneous Achilles tendon lengthening or revision to the Syme ankle disarticulation level may be required. Transtibial amputees, especially those with a short tibial segment, are prone to develop knee flexion contractures in the first or second week postoperatively ( Fig 25-11. ). For this reason, 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. This is replaced weekly for 3 weeks with a full range of knee motion at each change. The patella should be well padded to prevent pressure necrosis of the prepatellar skin. Even with a cast in place, pillows should not be placed under the residual limb, or a hip flexion contracture may be encouraged. Severe knee flexion contractures are virtually impossible to reduce by exercise once they become fixed. In amputations not done for vascular insufficiency, hamstring lengthening and release of the posterior knee joint capsule should be considered. The dysvascular amputee with a short contracted residual limb may be fitted with a bent-knee prosthesis, which is functionally no better and cosmetically inferior to that for a knee disarticulation ( Fig 25-12. ). Occasionally, moderate knee contracture in a proximal-third amputation may be improved by
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fitting a prosthesis with the foot in slight equinus to provide a knee extension moment on foot contact. At the transfemoral level of amputation, a hip flexion-abduction contracture can be devastating because the already high energy requirement for ambulation at this level is further increased by contracture. Again, prevention is the key. During transfemoral amputations, flexion-abduction contracture can be discouraged by a balanced myodesis, 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). Postoperatively, pillows under the thigh are forbidden. Within a few days of surgery, 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. Active extension of the residual limb while flexing the opposite thigh to the chest is also effective. Excessive wheelchair use, which encourages contractures, is discouraged by early walking with crutches or a walker. An alternative approach may be used in anticipation of prosthetic use by vigorous transfemoral amputees. A unilateral hip spica is applied in the operating room immediately following wound closure. Application is easily done by lifting the patient by the opposite leg. The benefits are analogous to those achieved by postoperative casting of transtibial amputees. The hip is aligned to discourage contractures, distal constriction edema from bandaging is avoided, and the wound is protected from shear and direct pressure, thereby reducing pain. At the first cast change, a pylon and foot may be added to convert it to a preparatory prosthesis. At the short transfemoral level, flexion contracture of up to 25 degrees may be accommodated by prosthetic alignment, but hip extensor power, needed for good prosthetic knee stability, is compromised. As one progresses distally to the midthigh level, it is increasingly difficult to compensate prosthetically for a hip flexion contracture. Even then, the resulting cosmesis of the prosthesis will leave something to be desired. More than 15 degrees of hip flexion contracture will require a marked compensatory increase in lumbar lordosis that, even if available, may lead to low back pain. When prescribing a prosthesis in cases with significant flexion contracture of the hip or knee, the patient and family must be forewarned of the relatively grotesque appearance of the prosthesis. Otherwise, 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, they may be very dissatisfied with the prosthesis and reject it. In children, knee and hip flexion contractures can be stretched out by ignoring their presence and fitting the patient with conventional alignment techniques. Spontaneous use will usually stretch the contractures without other special treatment. Contractures also occur in upper-limb amputations. Limitation of glenohumeral abduction and forward flexion is common in short transhumeral amputations. Elbow flexion contracture occurs readily in a short transradial case. Either can be easily prevented by instituting rangeof-motion exercises as soon as postoperative pain has subsided at 5 to 7 days. Gentle muscle-strengthening exercises begun at 2 to 3 weeks postoperatively are also helpful. If contractures become fixed, even an extensive program of stretching may be ineffective and require selective release of contracted muscles to allow fitting of a prosthesis.
POSTPROSTHETIC COMPLICATIONS
Painful Residual Limb
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In this section we will be dealing with causes of residual-limb pain other than phantom pain. Pain in a residual limb can have as many causes as pain in an intact limb. Taking an adequate history and performing a physical examination continue to be appropriate, with inspection, palpation, performance tests, radiography, and other imaging studies used as necessary. Since all persons with acquired amputations have phantom-limb sensation, there is a tendency for patients, families, and physicians not familiar with amputees to consider all pain in the residual limb to be phantom pain. In fact, chronic phantom pain is very rare and presents a specific syndrome of a totally preoccupying pain in a stocking-glove distribution. Another equally poor presumption is that all pain problems are related to a poorly fitting prosthesis, and this results in the making of many unnecessary new limbs. Preamputation traumatic disruption of the interos-seus membrane and proximal tibiofibular joint, with resultant hypermobility of the fibula, can be a cause of pain in the transtibial amputee. Ertl has recommended distal tibiofibular synostosis to prevent or treat this Fusion of the proximal tibiofibular joint is a much simpler procedure that hypermobility. does not require shortening of the residual limb or disturbance of the otherwise satisfactory distal tissues. A common site of discomfort and skin breakdown in a transtibial amputation is over the distalanterior part of the tibia. This is commonly due to inadequate contouring (beveling) of the tibia at the time of amputation. Although this can often be corrected by local socket relief, with or without injection of the local bursa with steroids, surgical revision may be required. Symptomatic spurs from ectopic bone formation of the transected bone may be generated in one of two ways. One is by surgical extension of periosteal stripping onto bone that is to be retained ( Fig 25-13. ). The periosteum should therefore be disturbed as little as possible on any bone that one anticipates keeping. In addition, the approach to the fibula should be extraperiosteal to avoid fibular regeneration. 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. This can be quite massive and may lead to considerable discomfort in the residual limb. Before proceeding to revision, the surgeon should determine exactly those portions that are contributing to discomfort and not disturb all ectopic bone just because it is present. Following any bone transection, the soft tissues should be copiously washed to remove minute bone fragments. If the fibula is inadvertently left longer than the tibia, the resulting distal bony prominence may be weight bearing and tender. Socket modification should be attempted, but surgical revision is often necessary. In very short transtibial residual limbs, if the fibular head and shaft are unduly prominent or hypermobile, the fibular remnant may require complete secondary resection ( Fig 25-14. ). This complication is prevented by routine primary excision of the fibular remnant if amputation is close to the tibial tubercle. In the transtibial amputee, torn knee ligaments may result in painful instability while wearing the standard patellar tendonbearing (PTB) prosthesis. Depending on the degree of instability, it may be controlled by using a supracondylar-suprapatellar or supracondylar prosthesis or a PTB prosthesis with a thigh corset. In transfemoral amputations, if a dynamically balanced myodesis has not been performed, the femur may drift anterolaterally through the soft tissue to present its distal end subcutaneously ( Fig 25-15. ). This will produce local tenderness and even ulceration with or without use of a prosthesis. In the absence of ulceration, prosthetic modifications including socket relief over the bony prominence or anterior filling-in of the socket just above the prominence may be effective. If simple socket adjustments do not produce relief, surgical revision, including myodesis, may be necessary. Pain-producing bone spurs may develop at the cut end of the femur and require similar socket relief or excision ( Fig 25-16. ). Adventitious bursae develop over bony prominences and occasionally need treatment beyond socket relief. Transfemoral amputees may complain of a burning sensation in the ischial weight-bearing area, particularly in the early phases of using a quadrilateral socket. With the increasing utilization of ischial containment sockets and the advent of flexible socket materials, pressure discomfort over the ischium is less common. Nonetheless, the residual limb should be carefully examined at each visit for areas of local inflammation secondary to excessive pressure. Neuroma formation is a natural consequence of nerve section, and all amputees will therefore have several neuromas. 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, they will
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rarely be symptomatic. If a symptomatic mass is suspected of being a neuroma, direct manipulation should produce a Tinel's sign with a tingling discomfort in the peripheral nerve patterns of the missing portion of the limb. If a neuroma is incidentally found by palpation in an asymptomatic residual limb, the amputee should be reassured that it is a normal finding and does not require corrective surgery. Firm fibrous nodules that are only locally sensitive are probably not neuromas. The treatment of neuromas should usually begin with socket accommodation. If this approach is unsuccessful after several attempts, the neuroma should be moved to a deeper site, either by proximal division under moderate tension or by placing the nerve end in bone. 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. In the case of a very short transtibial limb with a symptomatic peroneal neuroma, 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. In some transtibial amputees who have had traumatic disruption of the interosseus membrane and subluxation of the proximal tibiofibular joint, there may be ill-defined pain related to fibular hypermobility producing pressure on the peroneal, tibial, and sural neuromas. Ertl advocated a distal tibial fibular fusion to correct this problem and provide an "end-bearing" bone. It is easier to simply fuse the proximal tibiofibular joint and not shorten the residual limb or disturb its distal soft tissues. In dysvascular patients, a healed skin wound may be associated with considerable ischemia of the underlying muscles and result in intermittent claudication during walking. In these cases, there will be no signs of inordinate prosthetic pressures, and the pain will occur regularly when the patient walks a specific distance. Medication may be prescribed, but the amputee should be assured that refabricating the prosthesis will not help. Whenever late pain occurs in a limb amputated because of tumor, local recurrence is a possibility. The proper course of action depends upon the type of tumor and may range from radiation or chemotherapy to amputation at a higher level. Consultation with an oncologist is essential before proceeding.
Insensitive Skin
Amputees with diminished sensation in the residual limb are seen quite commonly. The
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largest group are diabetics, but other neurologic disorders such as my-elomenigocele, Hansen's disease, and alcoholic neuropathy are also seen. 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, especially during the early phases of prosthetic use. Areas of skin blanching and/or erythema should be noted by the prosthetics team for prompt corrective action. Multiple short periods of daily ambulation will usually allow gradual skin adaptation. The presence of insensate but otherwise normal skin on the residual limb should not be considered an indication for more proximal amputation. It does, however, demand precise prosthetic fitting and attentive follow-up care.
Poor Fit
After a variable period of use, most amputees find that prosthetic fit can no longer be effectively adjusted by further socket padding and additional stump socks. With an excessive number of sock plies, usually 10 to 15, the socket/residual-limb interface is disturbed, as manifested by a reduction in rotational control and an increased tendency to piston. In these cases, the prosthesis no longer fits properly, and a new socket is needed promptly if dangerous, costly skin breakdown is to be avoided. On the other hand, many problems are easily corrected with minor sock or socket adjustments. All team members should therefore be aware of the signs of both loose and tight socket fit, especially at the transtibial level. Evaluation of a residual limb for prosthetic pressures is exactly the same as evaluation of a foot for shoe fitting. One looks for areas of prolonged erythema after walking in the prosthesis, erythema in abnormal places, callus or bursa formation, and local tenderness under erythematous areas. Relative socket looseness will commonly cause excessive direct and shear forces over the tibia and fibula, fibular head, tibial tubercle, and distal end of the patella as the residual limb enters the socket too deeply. This problem is usually related to residual-limb volume decrease by atrophy or weight loss. 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. This problem is often related to wearing excessive sock plies or due to weight gain. Pressure and shear forces result in inflamed and/or ulcerated areas of skin in either case. Another transtibial problem of fit related to distal circumferential shrinkage is usually associated with ill-defined pain in the residual limb. In this case, 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. There is no sign of inordinate prosthetic pressure, but it may be noted, during donning or doffing of the prosthesis, that while there is a snug fit proximally, there is room distally for an examining finger or that a soft insert feels loose. A weight-bearing radiograph of the residual-limb/socket interface is useful to confirm the presence of a distal void. Often, the same situation leads to choking. This problem may sometimes be corrected by filling in the socket posteriorly. Lower-limb edema resulting from renal and/or cardiac disease will adversely affect socket fit. If these amputees are unable to use their prosthesis for any reason, such as any sudden change in their health, it may be impossible to get the socket back on. It is extremely important that they have appropriate shrinker socks to wear in bed. If they are admitted for treatment of their underlying condition, compression of the residual limb should be started promptly while in the hospital rather than being neglected for a period of several days. The edema can become relatively chronic, and resumption of ambulation can be very difficult as one struggles to shrink the residual limb again.
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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, some will have arthritis of the joints proximal to the site of amputation. Superimposed ambulation with a prosthesis may put more strain on the proximal joints, thereby contributing to arthritis pain. 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. Also, the lightest-possible prosthesis should be fabricated to require less forceful contractions of the muscles crossing the hip joint, thus reducing joint compression forces. If pain is not relieved, a total-hip arthroplasty should be considered to maintain function in a prosthesis user. Likewise, transtibial amputees with significant symptomatic hip joint arthritis should not be denied the benefits of hip joint arthroplasty if it is otherwise indicated. 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. Patellofemoral arthritis has not proved to be a major concern. In cases of internal derangement of the knee joint, arthroscopic evaluation and surgery should be considered.
Fracture
Although uncommon, fracture in a residual limb following amputation does occur sufficiently often to warrant a careful design of treatment methods to allow an early, effective return to prosthesis use. By applying current knowledge of the gait cycle and energy expenditure in lower-limb amputees, certain goals in the treatment of late residual-limb fracture become clear. The general principles of fracture management, however, remain the same as in any other individual, but a different approach is allowed due to the reduction in distal limb segment mass and lever arm length. A combined American and Canadian study produced 90 cases with sufficient information to provide both epidemiologic data and some specific recommendations for management. The average age at injury was 50 years, with a fall while wearing the prosthesis as the usual cause of injury. It was notable that knee joints and a thigh corset did not prevent supracondylar fractures in transtibial amputees, nor did a hip joint with a pelvic belt prevent fractures about the hip in transfem-oral amputees. 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. Although manipulation and casting often suffice in two-part intertrochanteric fractures, those amputees with unstable fractures are best served by open reduction and internal fixation. Displaced femoral neck fractures in both groups may be managed either by reduction and internal fixation or by endoprosthetic replacement. Excision of the femoral head alone will lead to an unstable gait. Instead, femoral endoprosthetic replacement or total-hip arthroplasty may be undertaken based on the same criteria as in any patient with otherwise intact limbs. Because of the small residual-limb mass and lever arm length in transfemoral amputees, 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. In transtibial amputees, preservation of knee motion and restoration of limb alignment, especially in more proximal femoral fractures, are paramount. Patients with stable supracondylar femoral fractures can be mobilized rapidly by the use of the cast-brace technique ( Fig 25-19. ). Unstable supracondylar fractures should be fixed primarily, if possible, to preserve knee motion. Severely comminuted supracondylar fractures unsuitable for fixation may be managed by casting with or without preliminary skeletal traction and/or manipulation ( Fig 25-20. ,A and B). Moderate malunion or loss of length at the transtibial level is easily compensated by prosthetic adjustment, but an effort should be made to avoid flexion contracture of the knee, which is much less compensable ( Fig 25-21. ). In displaced intraarticu-lar fractures of the knee, joint congruity should be restored as accurately as possible. In this study, transtibial amputees were more likely to resume the use of their prosthesis than were trans-femoral amputees due to lesser energy demands. Operative scars did not interfere with the fitting or use of prostheses. Only 25% required a prosthesis modification following fracture, and all of these were transtibial amputees. Proximal revision of amputations through the fracture site was not found to be necessary or desirable.
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Fractures of residual upper limbs are very rare. It is recommended that humeral fractures be treated by splinting. If delayed union or nonunion ensues, open reduction, internal fixation, and bone grafting should be considered, especially in transradial amputees. Fractures about the elbow may be managed by open or closed methods so long as treatment is designed to maintain elbow range of motion. In summary, 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.
SUMMARY
Knowledge of the common complications of amputation surgery should lead to their prevention in most cases and their speedy resolution when they occur. The primary goal of complication prevention and management is the successful prosthetic restoration of the amputee. This chapter provides numerous examples of preprosthetic and postprosthetic problems and their possible solutions. The amputation surgeon, working with a dedicated prosthetic team, will be able to use these proposed solutions as a creative starting point to upgrade the care of amputees in the local community. References: 1. Bowker JH, Kazim M: Biomechanics of ambulation, in Moore WS, Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 261-273. 2. Bowker JH, Rills BM, Ledbetter CA, et al: Fractures in lower limbs with prior amputation. A study of ninety cases. J Bone Joint Surg [Am] 1981; 63:915-920. 3. Dickhaut SC, DeLee JC, Page CR: Nutritional studies: Importance in predicting woundhealing after amputation. J Bone Joint Surg [Am] 1984; 66:71-75. 4. Ertl J: Uber amputationsstumpfe. Chirurgie 1949; 20:218. 5. Hauser CJ: Tissue salvage by mapping of skin surface transcutaneous oxygen tension index. Arch Surg 1987; 111:1128-1130. 6. Lind J, Kramhoft M, Bodtker S: The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop 1991; 267:211-217. 7. Matos LA: Enhancement of healing in selected problem wounds, in Mader JT (chairman): Hyperbaric Oxygen Therapy. A Committee Report. Bethesda, Undersea and Hyperbaric Medical Society, 1989, pp 37-44. 8. Matos LA: Personal communication. 9. Wagner FW Jr: Amputations of the foot and ankle, in Moore WS, Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 93-117. 10. Watts HG: Special considerations in amputations for malignancies, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981, pp 459-463.
Chapter 25 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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prostheses have a snugly fitting socket in which air cannot circulate freely, thereby trapping perspiration. The socket provides for weight bearing; uneven loading may cause stress on localized areas of the stump skin. Examples of such stress are intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. With certain prostheses, stump socks are worn for reduction of the friction. In the transfemoral amputee, pressure may be exerted on the adductor region of the thigh, the groin, and the ischial tuberosity, all points of contact with the socket rim. If suction is used for suspension, the stump is subjected to negative pressure as well. In the transtibial amputee, who usually has at least the upper third of the tibia remaining, pressures occur over the anterior portion of the tibia, the sides, and sometimes, the end of the stump. Additional pressures also occur from mechanical rub over the prepatellar and infrapatellar areas. In the older conventional transtibial prosthesis, constriction of soft tissues of the thigh by the thigh corset may cause significant obstruction to venous and lymphatic drainage of the leg. In addition to the effects of pressure and friction, 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. The state of the stump skin is of utmost importance in the amputees' ability to use a prosthesis. If the normal skin condition cannot be maintained despite daily wear and tear, the prosthesis cannot be worn, no matter how accurate the fit of the socket may be.
SKIN HYGIENE
Some amputees fail to adequately wash either the stump or the socket, and hence maceration and mal-odor can result. There has been no unanimity of opinion as to exactly what measures should be used routinely, and some amputees have come to us with varied and often strange ideas about their own hygiene. Poor hygiene may be an important factor in producing some pathologic conditions of the stump skin. If a routine cleansing program is not employed, bacterial and fungal infections, nonspecific eczematization, intertrigo, and persistence of infected epidermoid cysts can eventuate. We have suggested a simple hygienic program with the use of a bland soap or sudsing detergent, and this has often had a preventive or therapeutic effect on a cutaneous disorder. For example, such a simple regimen has been curative for some persistent eczematoid eruptions of the stump skin. Soaps or detergents that contain bacteriostatic or bactericidal agents in addition to their cleansing action help to reduce the possibility of infection. Amputees should be advised in a program and asked to purchase a plastic squeeze container of a liquid detergent containing chlorhexidine gluconate, triclosan, or hexachlorophene. These are relatively inexpensive and available in drugstores throughout the world with and without a prescription. 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. The cleansing routine should be followed nightly or every other night, depending on the rate of perspiration, the degree of malodor, and the bathing habits of the person. The season of the year may also dictate the frequency of cleansing. The stump should not be washed in the morning unless a stump sock is worn because the damp skin may swell, stick to the socket, and be irritated by friction during walking. For the same reason, the best time to cleanse the socket is also at night. Some amputees prefer to use witch hazel or rubbing alcohol compound for the wall of the socket. If a stump sock is worn, it should be changed daily and should be washed as soon as it is taken off before perspiration is allowed to dry in it. If the sock does dry with a "dog-ear," a plastic or rubber ball can be inserted into the base of the sock to give it the correct shape.
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If the amputee continues to wear a malfitting prosthesis, edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket, and this may cause ulceration or gangrene as a result of the impaired blood supply. 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.). It is thought that this disorder is vascular in origin, a venous and lymphatic congestion producing edema and hemorrhage. Superficial erosion of the distal stump skin is not uncommon, and in rare instances deep ulcers can result from continued mechanical injury and poor skin nutrition. Here, therapy by the dermatologist requires teamwork with the orthopaedic surgeon and prosthe-tist. This includes elimination of all mechanical factors contributing to the edema, such as choking by the socket or lack of total contact distally. Continued uneven mechanical rub can produce thickened, lichenified areas on the skin or weeping superficial erosions ( Plate 8., Plate 9., and Plate 10 ). Occasional use of an oral diuretic and a shrinker sock will be advantageous. Excessive negative pressure in a socket can also contribute to circulatory congestion and edema. Treatment should be directed toward better support of the distal soft tissues by restoring distal tissue contact, perhaps by making a pad in the bottom of the socket. Cutaneous disorders common to lower-limb amputees have been classified as well as evaluated and treated in numerous individual cases. Out of the studies, improved methods of treatment are continuing to evolve. The man-machine interface is critical to wearing an inert prosthetic substitute for the limb loss. Every amputee who wears a prosthesis experiences the skin adaptations and problems incident to this intimate interface. 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. The disorders that follow are not only seen in lower-limb amputees but are also seen in upperlimb amputees as well. Newer plastics and metals developed through the United States Space Program are now utilized in the manufacture of prostheses. Although improvements in technology continue, certain cutaneous problems associated with the wearing of a prosthesis continue to occur quite commonly.
CONTACT DERMATITIS
An amputee can have an acute or chronic skin inflammatory reaction caused by contact with an irritant or allergenic substance. 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. Although some elderly amputees have a less pronounced inflammatory response to standard applied irritants than do younger patients, chronic irritant dermatitis is nonetheless frequently seen in older amputees. 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. The socket wall in itself can also produce such allergic contact dermatitis. Amputees may develop delayed hypersensitivity to a variety of substances that come into contact with the skin. Although older patients are less readily sensitized to experimental allergens, 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. Common sensitizers include nickel, chromates (used in leathers), wool fats and especially lanolin found in many moisturizers and skin creams, rubber additives, topical antibiotics such as neomycin, and topical anesthetics such as ben-zocaine or lidocaine. Areas of eczema appearing at the site of contact with an irritant or allergen may be acute, with small blisters and swelling or oozing of the skin, or more often chronic, with scaling and mild redness or erythema. A number of patients with contact dermatitis of the skin of the stump have been observed. In these, 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. ). Varnishes, lacquers, plastics, and resins are frequently used in finishing the inner lining of the socket of leg prostheses. One has to learn about the materials used in the manufacture of prostheses in order to understand and treat the problem adequately. One also has to analyze the different conditions of heat, humidity, and friction within the socket since these are interrelated with the intensity of the reaction. Plastic resins, if incompletely cured in their manufacture, may produce a primary irritant reaction or even cause a specific allergic sensitization. Some amputees will use a foam rubber cushion, others a plastic-covered pad on the bottom of the socket, which can also produce allergic sensitization over a period of time. Many cements and volatile substances used to repair prostheses are also capable of producing either an irritant reaction or allergic sensitization. Any of these agents are capable of producing a contact dermatitis of the stump skin after weeks, months, or even years of
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continued use. In some patients, only a carefully taken history will reveal that the use of a new cream, lotion, lubricant, or cleansing agent coincided with the onset of the dermatitis. In other patients we found that over-the-counter topical antibiotics or skin-"toughening" agents will produce a dermatitis. When contact dermatitis is suspected or diagnosed, every attempt should be made to determine the contactant in order to avoid future complaints. Patch tests are most informative in pinpointing specific substances as the cause of a dermatitis. Since patch testing with strong concentrations of known primary irritants will result in reactions on almost any skin, 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. We have investigated a number of contact dermatitis cases, and some have been due to neomycin, epoxy resins, various cements, Naughahyde, waxes and polishes, and even adhesive tape. Removal of a suspected contactant has resulted in a cure, and subsequent patch testing has identified the offending agent after the acute process subsided. In those instances of contact dermatitis where the irritant has not been obvious and where patch test results have been inconclusive, temporary symptomatic therapy has always alleviated these symptoms. Cool or cold compresses, bland anti-itch lotions, and the topical application of corticosteroids or similar preparations have been beneficial in controlling the process and allowing for improvement. Once an agent causing a given reaction has been identified, it should be avoided as much as possible. 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.
NONSPECIFIC ECZEMATIZATION
Nonspecific eczematization of the stump has been seen in a variety of instances as an acute or chronic persistent, weeping, itching area of dermatitis over the distal portion of the stump. The lesions at times can be dry and scaly ( Plate 12. ), while at other times they become moist without apparent reason. The condition often fluctuates over a period of months or years and may be the source of much anxiety to the amputee. It appears in some patients to be seasonal and in others to be related to continued standing or unusually active episodes. In almost every instance we have tried to find the cause of this recurrent dermatitis through a complete study of the patient: history, physical examination, laboratory tests, and subsequent observation of the clinical course of the condition. In some we have noted the use of a new drug taken orally or some unusual dietary changes. We have been able at times to elicit a significant history of recurrent, 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. In other patients, 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. Here again, temporary symptomatic topical therapy with hydrocortisone or other topical corticosteroid preparations is effective, but the condition frequently recurs unless its cause can be eliminated.
EPIDERMOID CYSTS
A number of authors have described the appearance of multiple cysts, frequently called posttraumatic epidermoid cysts, 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. covered by the upper medial margins of the prosthesis, but they have also been seen in other areas and in transtibial amputees. Usually the cysts do not appear until the patient has worn a prosthesis for months or years ( Plate 13. , Plate 14. , and Plate 15. ). Characteristically, in the transfemoral amputee, 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. Similar plugs may appear over the inferior portion of the buttock where the posterior brim or ischial seat of the prosthesis rubs. Through the process outlined below, some of these plugs may become deeply implanted and develop into small or large cysts. Some lesions may become as large as 5 cm in diameter. They are seen as round or oval swellings deep within the skin, and with gradual and continued enlargement, they become sensitive to touch or pressure. The skin may break down and erode or ulcerate. If irritation by the prosthesis is allowed to continue, the nodular swelling may suddenly break and discharge a purulent or serosanguineous fluid. The sinus discharge may become chronic and thus make it impossible for the patient to use his prosthesis effectively. Frequently, scars can remain after the cysts have eventually healed. If the break takes place within the deeper portion of the skin, subcutaneous intercommunicating sinuses may develop.
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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." Under the continued influence of friction and pressure from the prosthesis, the keratin plug and its underlying epidermis are displaced into the corium. The result is a production of nonspecific inflammation and implanted epidermoid cysts. These cysts can remain quiet for a long period or can, with secondary bacterial invasion by Staphylococcus or Streptococcus, become abscessed and produce the characteristic clinical picture. Either incision and drainage or excision of the chronic, isolated, noninfected nodule may give temporary relief, but there is no completely satisfactory method of treatment. In the acutely infected phase, hot compresses and topical or oral antibiotics selected through bacterial studies and sensitivity tests of the cystic fluid are indicated. As the cyst localizes, incision and drainage may be temporarily beneficial. The chronic problem can, in some patients, be improved or successfully eliminated through evaluation by the prosthetist, followed by proper fit and alignment of the prosthesis. We are currently applying various topical preparations in an effort to prevent or retard the inflammation that follows formation of the keratin plug, which may be the precursor of the epidermoid cyst. We have attempted to develop a stump sock or adductor rim sock for use with the suction suspension prosthesis to prevent cyst formation. Various substances have been tried as socket liners for reduction of friction over the pressure areas, especially over the brim of the socket. Poly-tetrafluoroethylene film (Teflon) has been found satisfactory for this purpose. Cortisone or its derivatives have been injected into the cysts and their channels to reduce the inflammatory reaction. Topical application of corticosteroids in areas of maximum friction have also been tried. Although this reduces inflammation, it provides only temporary symptomatic relief. In our own experience, there is still no completely satisfactory method of treatment, and each and every patient is a therapeutic challenge.
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INTERTRIGO
Intertriginous dermatitis is an irritation of skin surfaces that are in constant apposition, and between which there is hypersecretion and retention of sweat. The condition usually occurs in the inguinal or crural areas, 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. Continued friction and pressure from the socket may result in lichenified or pigmented skin. The thickened skin may subsequently itch or burn depending upon the rub. A chronic disorder may develop with deep, painful fissures and secondary infection along with eczematization. Hygienic measures to cleanse the apposing folds and the use of drying powders or mild drying lotions can be beneficial. Frequently the problem can be corrected by proper prosthetic fit and alignment.
TUMORS
Tumors of the stump skin can be benign or malignant. Viral verrucae or warts have been seen frequently on the stump skin and are treated by cauterization. Simple cutaneous papillomas ( Fig 26-3.) are easily removed, and we have seen numerous cutaneous horns on stump skin. All of these are treatable by using a local anesthetic and superficially removing the lesion. Seldom does this require a large surgical excision, and cauterization on the skin following removal of a lesion usually will heal within 2 weeks. Basal and squamous cell carcinomas have been removed without incident when they were small, and healing has been successful. However, we have had several patients where amputation was necessary for lymphangioma, and these resulted in recurrence with subsequent lymphangiosarcoma and death. Here again, an accurate diagnosis is of utmost importance.
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. In some instances localized pressure from a poorly fitting prosthesis can produce erosion followed by ulceration ( Fig 26-4.). Continued edema of the distal stump skin must be corrected early in order to avoid ulceration. Malignant ulcers can develop within old, persistent stump ulcerations; therefore, every effort should be made to treat the process before it becomes chronic. With repeated infection and ulceration of the skin, the amputation scar may become adherent to the underlying subcutaneous tissues, a process that invites further erosion and ulceration ( Plate 19. ). 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.
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In every instance one must ascertain the cause of the stump ulceration and discuss corrective therapy with the amputation surgeon and prosthetist.
VERRUCOSE HYPERPLASIA
A warty or verrucose condition of the skin of the distal portion of the stump has been seen in many instances. The disorder has been described by some as the common wart virus invading the skin, while others have thought that the condition was associated with malignancy. In our experience, we have found only one such instance among numerous patients with verrucose hyperplasia; in all other cases the process has been entirely reversible. In our malignant instance, a 40-year-old physician had extensive ulceration and infection of the stump skin with verrucose hyperplasia of long standing ( Plate 20. ). A squamous cell carcinoma ultimately developed in the distal skin and extended into the bone. The patient subsequently died in a matter of months from metastases to the lungs. 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. and Plate 22. ). Patients with this condition have made the rounds of general practitioners, orthopaedists, dermatologists, prosthetists, therapists, and others dealing with amputees. Many have been treated with topical preparations and by other forms of therapy without effect. At the best, treatments had been of only temporary benefit. 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. In the transtibial amputees we have reviewed who had this process, the distal part of the stump was edematous and dangled without distal support in the socket. When support of the end was provided in the socket by means of a temporary platform built up with cushions or compression, the warty condition was slowly reduced. The greater the compression on the distal skin, the more immediate and lasting was the improvement. As a result of our investigation, the engineers and prosthetists then modified a prosthetic design to provide backpressure for the tissues at the end of the stump. After several weeks' use of the modified prosthesis, the verrucose condition disappeared and did not recur as long as the compression was continued. 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. This hyperplastic condition appears to be secondary to an underlying vascular disorder related to poor prosthetic fit and alignment and, possibly, bacterial infection. Although these factors may be present in combination, it is clear from our studies that the poor pressure gradient, which tends to drive fluids into the distal tissues, plays an especially important role. It occurs whenever there is an increase of proximal over distal pressure on the tissues. In an amputation stump with redundant, unsupported tissues, 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. A shrinker sock used continuously until prosthetic fitting and thereafter whenever a prosthesis is not employed is distinctly advantageous. If the amputee is then fitted with a prosthesis that distributes pressure properly, the edema will subside. However, if his prosthesis produces greater proximal than distal pressures, the edema will be increased.
SUMMARY
Amputation surgeons, prosthetists, and engineers are applied scientists from whom great technical assistance is expected. Through their efforts, we have made great strides in our knowledge and technical ability to produce the finest of prostheses, but their skills must be combined with the contributions of the dermatologist in the solution of the many skin problems of the amputee. The importance of early recognition and treatment of the common skin disorders of residual limbs, as described in this chapter, cannot be overemphasized. References: 1. Allende MF, Barnes GH, Levy SW, et al: The bacterial flora of the skin of amputation stumps. J Invest Dermatol 1961;36:165-166. 2. Allende MF, Levy SW, Barnes GH: Epidermoid cysts in amputees. Acta Derm Venereol (Stockh) 1963; 43:56-67. 3. Fisher AA: Contact Dermatitis. Philadelphia, Lea & Fe-biger, 1986.
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4. Gillis L: Amputations. London, Heinemann, 1954. 5. Golbranson FL, Asbelle C, Strand D: Immediate post surgical fitting and early ambulation: A new concept in amputee rehabilitation. Clin Orthop 1968; 56:119-131. 6. Jelinek JE: The Skin in Diabetes. Philadelphia, Lea & Fe-biger, 1986. 7. Levy SW: Skin Problems of the Amputee. St Louis, Warren H. Green Inc, 1983. 8. Wirta RW, Golbranson FL, et al: Analysis of below-knee suspension systems: Effect on gait. J Rehabil Res Dev 1990; 27:385-396.
Chapter 26 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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thermoreceptors have a distinct sensitivity to high and low skin temperatures but can be excited by firm pressure. On the other hand, nociceptors have a high threshold to an The two subclasses of appropriate stimulus and a relatively small field of reception. nociceptors are thermal nociceptors and mechanical nociceptors. These receptors are terminal endings of small myelinated and nonmyelinated fibers and are activated by intense mechanical stimulation and low (less than 15C) or high (above 50C) temperatures. There is considerable controversy regarding the existence of specific chemoreceptors. Although past studies have failed to substantiate unique chemoreceptors, there is abundant evidence from experimental work that extracellular chemical substances (such as bradykinin, histamine, and prostaglandins) released into extracellular fluid following tissue damage secondary to injury or disease act in some way to produce pain. Once depolarization is initiated, the generated action potential flows along sensory nerve fibers to superficial and deep cutaneous complexes and ultimately to the dorsal root ganglion, where cell bodies of the afferent neurons are located. 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.). The dorsal horn has been divided into six laminae on an anatomic and functional basis. Sensory input from the periphery is roughly distributed according to fiber size. The large myelinated fibers give off a collateral, which enters the dorsal horn and forms synaptic connections with cells and various laminae, especially laminae II and III. The small myelinated sensory afferent fibers proceed into the Lissauer 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.). The long ascending afferent pathways are formed by axons of neurons from laminae I, IV, V, and VI. The majority of these axons ascend in the contralateral spinothalamic tract. 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.). The spinothalamic system is composed of two divisions: the neospinothalamic tract and the paleo-spinothalamic tract. The neothalamic system is characterized by long fibers that make direct connections to the ventrolateral and posterior parts of the thalamus. The third relay of fibers at the thalamic level is relayed to the postcentral gyrus, which represents the primary somatosensory cortex of the brain. This system provides rapid transmission of somatosensory information regarding the location of peripheral stimulation in space, time, and intensity. Although it has only three neurons involved in its transmission, the system sends numerous collaterals to the paleospinothalamic system, which ascends medially to it. The paleospinothalamic system is associated with short fibers that project to the reticular formation, the pons, and the midbrain. It then connects with the medial intralaminar thalamic nuclei and from there to the limbic forebrain, hypothalamus, and other diffuse areas of the brain. This older system has frequent synapses and slow transmission. Functionally, it provokes a non-discrete, deep unpleasant sensation that motivates the individual into action. Also, it is involved with supra-segmental reflex responses that play a role in respiratory, circulatory, and endocrine functions of the organism. Another important projection system for transmission of pain is the lemniscal system. 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. Second-order neurons cross the medulla and ascend in the medial lemniscus to the ventral and medial thalamus. Finally, third-relay neurons project through the internal capsule and corona radiata to the sensory cortex. The large, fast-conducting fibers of this system carry information concerning touch, pressure, vibration, and proprioception. Moreover, the lemniscal system assists in central analysis, assessment, and localization of sensory messages and then modulates, through corticifugal impulses, the sensory input before the action system is activated. More recently other ascending pathways have been recognized as being important in the study of pain. The spinoreticular multisynaptic ascending system, the spinocervicothalamic system (SCT), the dorsal intra-cornu tract, and other propriospinal systems may play a role in the transmission of nociceptive impulses. Information regarding these alternate systems is sketchy, and their precise function in pain has not been described. During the past 20 years investigators have attempted to unravel the complexities of the poorly understood, although extremely important inhibitory and facilitory mechanisms of pain acting at all levels of the central nervous system. Dorsal horn cells are modulated by
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peripheral sensory input. Lamina I cells are inhibited by stimulation of the sensitive mechanoreceptors and high-threshold afferents near the excitatory receptive field but are In contrast, lamina V cells strongly excited by high-intensity thermal and mechanical stimuli. have a wide range of inputs from skin, subcutaneous tissue, muscle, viscera, and other deep Inhibition of structures and are quite responsive to noxious stimuli in their respective field. lamina V cells is produced by stimulation of low-threshold afferents at the periphery of the receptive field. In addition to local and segmental factors that participate in modulation of sensory information from the periphery to the brain, supraspinal descending neural systems strongly influence synaptic transmission in the dorsal horn and along the course of the ascending The pyramidal tract, rubrospinal tract, and reticulospinal tract have somatosensory tracts. been shown to inhibit firing of the cells in the dorsal horn and other parts of the spinal cord. The descending fibers from the cortex of the brain affect transmission in the thalamus, reticular formation, and dorsal-column relay station. Other fibers from each of these structures descend to lower relay stations and influence their transmission. Scientific data Psychological factors play an important role in the total pain experience. suggest that various emotional, motivational, cognitive, 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. Paradoxically, psychological factors can enhance the transmission of noxious impulses to the brain under certain conditions and consequently increase the severity of the pain problem. To summarize, 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. Rather, the situation is one of convergence, interaction, and control. The gate-control theory proposed by Melzack and Wall in 1965 ( Fig 27-4.) is one of the basic pain theories used to explain the complex anatomic and physiologic mechanisms that perform this integration process. 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. The somatic input is modulated by the gate mechanism before it promotes pain perception and response. The degree of modulation by the gate is determined by the relative activity in the large (A ) and small (A d and C) fibers and the descending influences from the brain. 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.
Phantom Sensation
In 1551, Ambroise Pare first described the phenomenon of phantom limb sensation. After wrote a classic essay on his experience with the Civil War (1871), Silas Weir Mitchell phantom sensation. His observations resulted from management of 90 amputees from the 15,000 individuals who were estimated to have lost limbs during the conflict. His work pointed out that phantom sensation, with its remarkably constant subjective pattern, is almost universally a sequela of a major amputation. 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. It is rarely unpleasant; in fact, the majority of amputees describe their phantom sensations as painless. The presence of this phenomenon is usually described in terms of numbness, pressure, position, temperature, or needles and pins. These sensations seem to vary in intensity in individual patients, and the type of sensation described differs with each. Since the phantom sensation is a painless image, no treatment is necessary. However, 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. The phantom limb may change in its position and character in response to an external stimulus such as wrapping the stump, use of a postoperative rigid dressing, or wearing a prosthetic device. 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. Most amputees are aware of the phantom limb immediately after surgery. The pattern of the phantom sensation is usually the most distal portion of the limb, namely, the hand or foot. The extent to which the more proximal segments of the ablated limb are present varies widely among individual amputees. In some patients the limb
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progressively shortens, with telescoping of the segments proximal to the hand or foot. The duration of the sensation is a matter of years, with only rare instances of complete disappearance of the phantom limb.
Phantom Pain
In contrast to phantom limb sensation, the patient with phantom pain tends to fall into certain broad categories. The three most commonly described painful sensations are (1) a postural type of cramping or squeezing sensation, (2) a burning pain, and (3) a sharp, shooting type of pain. Many patients may complain of a mixed type of pain, but often the major sensation falls into one of these categories. Variation in the degree of discomfort of the phantom sensation led Feinstein et al. to suggest "that the painful state may be an accentuation or exaggeration of the type of feeling ordinarily experienced in the painless phantom. Thus tingling or pins and needles may become a stabbing type of pain; temperature variations, a burning pain; and postural or positional abnormalities, a cramping pain." 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; (2) trigger zones may spread to healthy areas, and stimulation of these zones will produce pain; (3) phantom limb pain is more likely in patients who have suffered pain in the limb for some time; and (4) phantom pain may be abolished by changes in somatic input. Peripheral nerve irritation, The causal mechanism of phantom pain remains controversial. abnormal sympathetic function, and psychological factors all contribute to the pain in some manner, yet none of these mechanisms satisfactorily explains the phenomenon of phantom limb pain. 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. When amputation surgery destroys a large number of sensory fibers to the reticular formation, the inhibitory influence is diminished. This results in self-sustaining neural activity at all levels that can be initiated by the remaining fibers. If the self-sustaining activity reaches a critical level, pain results. In 5% to 10% of amputees, painful sensations may occur in the phantom limb from immediately after surgery to years later. They may be episodic or continuous and are variously described as shooting, burning, cramping, or crushing. 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, local heat, or dependent positioning of the stump. Yawning, micturition, defecation, or coughing may suddenly precipitate more severe pain. Emotional disturbances such as anxiety, depression, sleeplessness, and emotional stress can elicit painful attacks but are not the primary cause. In some patients pain can be stimulated by touch or pressing over sensitive areas of the stump called "trigger points." If phantom pain persists for long periods of time, the trigger zones may spread to other unrelated healthy areas of the body. Although the management of phantom pain is exceedingly frustrating, the task can be made less onerous by a systematic approach to evaluation and subsequent treatment. Initially, a thorough examination of the stump is mandatory to eliminate other causes of stump pain such as adherent scars, neuromas, bursitis, tendinitis, joint contractures, vascular insufficiency, vasomotor and sudomotor disturbances, soft-tissue infection, tumors, or pathologic conditions of underlying bone. A vascular etiology for certain patterns of phantom pain has long been recognized. A consistent inverse relationship has been demonstrated between stump temperature in a painful stump in comparison to the contralateral asymptomatic limb, thus suggesting some correlation with blood flow. Especially in dysvascular amputees with chronic stump pain, a vascular evaluation should be performed, including transcutaneous Po2 determinations or Doppler flow studies. Occasionally, short-term treatment of phantom pain may be successful with the usage of certain drugs that increase peripheral blood flow such as (-blockers (propranolol). In addition, sympathectomy, which increases blood flow to a limb, may also decrease the burning sensation of phantom pain. Simple treatment measures that create increased peripheral central input may provide at least temporary partial relief of the phantom pain. Certainly one of the more effective adjuncts to the treatment program is extensive use of the prosthesis. Other treatment modalities include gentle manipulation of the stump by massage or a vibrator, stump wrapping, baths, and application of heat with hot packs, microwaves, or ultrasound. Most of these noninvasive
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techniques are easily learned and can be carried out as a home treatment program without expensive equipment. No singular drug has been proved effective in long-term control of phantom pain. The use of other than mild analgesic drugs may lead to a serious drug addiction. Specific "trigger points" on or near the stump may be injected with local anesthetic agents in combination with aqueous steroid preparations. Occasionally, prolonged relief of phantom pain is obtained. However, all too frequently pain recurs at a later date, but repeat injections of the trigger point can be performed at will with little risk or morbidity to the patient. 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. Although the sympathetic nervous system seems to contribute to phantom pain in some way, the success of sympathetic blockade in relief of agonizing phantom pain is unpredictable. At times, abnormal sympathetic manifestations such as excessive sweating, vasoconstriction, decreased skin temperature, or hypersensitivity to light touch may be relieved for prolonged periods by anesthetic block of the sympathetic ganglia. Unfortunately, the phantom pain may not be affected. The greatest success with sympathetic blockade seems to occur when this type of therapy is instituted soon after the onset of pain. Since sympathetic activity is not a major cause of phantom limb pain, surgical removal of a segment of the sympathetic ganglia rarely produces lasting relief of this frustrating pain. Transcutaneous electrical nerve stimulation (TENS) has been reported as being successful in reducing phantom limb pain on a temporary basis. Even if this technique is only partially successful, it may reduce the patient's requirement for more potent analgesic drugs. This safe and simple technique of neuromodula-tion is designed to diminish chronic pain through lowlevel stimulation of large myelinated afferent fibers. Since the equipment is portable, patients are able to treat themselves at home. The intensity of stimulation and the length of each treatment session are individualized. The combined use of TENS and appropriate psychotherapy may represent one of the most realistic approaches to the management of phantom pain. However, 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. 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, respectively. these techniques have proved partially effective in the relief of chronic pain, they appear to be no more effective than TENS, which does not have the attendant potential surgical hazards. Interruption of the anatomic pathways of somatosensory input has led to a wide range of ineffective surgical intervention at all neuroanatomic levels. Surgical procedures for sensory interference range from neurectomies at the periphery, rhizotomies, cordotomies, tractotomies to thalamotomies, cortical ablation, and lo-botomies. In general, the long-term results of these surgical procedures have been disappointing, particularly in view of the associated complaints and risks. Dorsal root entry zone procedures have shown good results in treating isolated phantom pain but poor results in combined stump pain and phantom pain. Therefore, surgical intervention has a well-defined yet limited role in the treatment of chronic amputee pain. Phantom pain may be controlled or abolished by distraction conditioning, hypnosis, and other forms of psychotherapy. The Minnesota Multiphasic Personality Inventory is a useful means of evaluating the presence of depression, hypochondriasis, and other personality disorders that may be influencing the degree of phantom limb pain. When considering the multiple treatment modalities suggested for control of phantom pain, it is quite apparent that none of these methods is highly efficacious. Therefore the treatment of every amputee afflicted with this difficult problem must be approached on an individual basis. The ultimate treatment program should consist of carefully selected treatment techniques combined with ongoing psychotherapy and counseling.
Neuromas
The development of a neuroma is a natural repair phenomenon that occurs in any transection of a peripheral nerve. During the repair phase of the nerve the axons lose their architectural
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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. Surgeons have varied in their recommendations regarding the handling of peripheral nerves during the performance of an amputation. Some adhere strictly to gentle traction on the nerve, followed by its division with a sharp scalpel, allowing the nerve to retract several inches above the distal end 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. They believe that the ligature per se adds little to the degree of neuroma formation. Virtually no one now advocates injection of a nerve with noxious substances such as alcohol, phenol, or radioactive isotopes. The importance of neuroma formation lies in its size and location. If the neuroma is located well above the distal end of the stump and is buried in adequate soft tissue, pressure and traction will not be sufficient to produce any local symptoms. Moreover, large neuromas located superficially may not be symptomatic when covered by a carefully fitted prosthetic socket. 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. If the prosthesis does trigger discomfort by stimulation of the neuroma, relief of the socket will generally alleviate the pain. Injection of the neuroma site with local analgesics and steroids may alleviate the pain. Since pain relief may be only temporary, several injections may be necessary before a lasting remission is obtained. Large neuromas buried in a scar or located in an exposed position may be so symptomatic that the amputee is severely impaired. Although surgical excision is the treatment of choice, resection of neuromas has failed to yield uniform results. Commonly, relief of pain is quite transient due to the eventual development of a new neuroma. Some of these neuromas may be more easily handled by a proximal neurectomy rather than an extensive exploration of the stump. Encasement of the nerve stump in a microporous filter sheath (H.A. Millipore) occluded by a Silastic rod has been recommended. Not only has this technique been effective in preventing some cases of recurrent symptomatic neuromas, but it has also decreased phantom limb pain in some patients as well. Similar results have been achieved by producing slow atrophy of the intact nerve above the level of transection. Prolonged nerve compression is obtained by turning a Silastic rod around the nerve trunk 20 to 40 times.
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The early treatment is interruption of the abnormal sympathetic reflex. 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. Transcutaneous electrical nerve stimulation has afforded pain relief for patients who have not responded to nerve block. Stilz et al. have shown an increase in cutaneous blood flow with a 1.5 to 2.5C rise in skin temperature with this technique. Nerve stimulation should be strongly considered for those patients whose pain persists after a stellate ganglion block.
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Pressure on the biceps femoris and semitendinosus produces hyperemia of the skin in the area of the distal portion of these tendons. The involved skin and tendons are tender to palpation. If the pressure gradient increases, superficial skin ulceration may occur. 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. High floor reaction forces are generated between heel-off and toe-off, 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. 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.
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solution may be used. 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. If the patient is using a socket liner, exterior pads may be added at various locations on the liner to compensate for the stump volume loss. Again, 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. Unless the problem is easily resolved, in the long run it is preferable to fit the patient with a new socket. Uneven Skin Pressure. -A common problem produced by an ill-fitting socket is uneven distribution of skin pressure over bony prominences. Frequently, involved areas are the head of the fibula, tibial tuberosity, distal pole of the patella, and distal ends of the fibula and tibia. Occasionally, the condyles of the tibia may show evidence of increased soft-tissue pressure. Fluctuating stump volume is a major cause of unequal skin pressure distribution. With a reduction in stump size secondary to the loss of edema, muscle atrophy, or excessive weight loss, the intimate contact between the surface of the stump and the socket is altered. Thus the stump may shift slightly distally in the socket. Even minor distal displacement may apply forces of a higher magnitude over various surface contours. Other causes of uneven skin pressure include excessive use of stump socks, increased stump growth, and increased stump volume due to muscle hypertrophy, weight gain, or edema. On physical examination there is significant erythema of the skin overlying involved bony prominences. Although this skin has good capillary refill, the redness will persist for several minutes to several hours after removal of the socket. Even with minimal skin changes, the patient is usually very specific about areas of tenderness and can point directly to the involved area. With higher pressure gradients, the skin may have a deep violaceous color and be tender to palpation. With the use of multiple stump socks, ridges or indentations in the skin from the weave of the stump sock material may be present in areas of high pressure. In amputees who persist in walking despite considerable discomfort, superficial skin ulceration or blistering may occur. If the skin has resisted breakdown, the area of involvement may respond by formation of a callus or corn. The distal portion of the stump may have chronic lymphedema with associated generalized rubor, both of which are secondary to choking because of the tight fit at the inlet of the socket. When the patient dons the prosthesis, the stump may be in the socket to the proper depth, but the anteroposterior or mediolateral diameters may be very snug. Frequently, a large number of stump socks are being worn. 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. 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. If the patient is long on the prosthetic side, this may indicate that the stump is not in the socket to the proper depth. Removing a few of the stump socks might correct this misfit and substantially relieve the patient's discomfort during standing and walking. If the patient's socket is too tight as a result of increased stump volume or limb growth, skin redness, localized tenderness, and vivid stocking marks will be present. The use of a microcapsular stocking will dramatically outline the areas of increased pressure. Radiographic studies are seldom necessary in this situation, unless the examiner is concerned about the adequacy of total contact at the distal end of the stump. More precise information regarding areas of specific skin loading can be determined by use of a transparent check socket. An easy therapeutic as well as diagnostic tool is reduction of the thickness of the socket wall in areas of skin discoloration and pain. If the patient is comfortable in standing and walking after adjustment of the socket, the problem is both identified and resolved. If all conservative measures of socket readjustment fail, fabrication of a new total-contact socket may be the only solution. Frictional Skin Loss.-Superficial frictional blisters are a deterrent to prosthetic comfort and effective gait training. This phenomenon is predominantly seen in new amputees. Possible underlying pathomechanics include (1) highly localized shear forces to skin over bony prominences, (2) immature epithelium in areas of secondary healing of the surgical incision, (3) obstruction of venous and lymphatic outflow with vertical positioning of the limb and resultant localized edema blebs in regions of secondary healing, or (4) the presence of an extension contracture of the knee.
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Physical examination reveals a superficial blister or shallow ulcer with surrounding erythema. The skin appears thin, shiny, and immature. The lesion may be surprisingly devoid of significant tenderness. However, if the condition is not recognized and treated, the lesion will increase in size and be accompanied by progressive discomfort. Slight alteration of socket fit due to increased stump volume is a common cause of this type of skin breakdown. Among new amputees variability in stump volume from day to day is a constant hazard. Despite extensive efforts toward excellent stump compression and judicious inspection of the limb during gait training, development of a skin blister or small ulcer is likely to occur even under the supervision of an experienced prosthetic team. The transient change in socket fit is subtle, and it is sometimes difficult to detect. Consequently, 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. Improper socket fabrication can create skin breakdown. If the anteroposterior diameter of the socket is too large, 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. This error can be compounded by inaccurate placement of the pivotal axis for the suspension straps on the medio-lateral aspect of the socket. If the posterior trim line is too high or there is an extension contracture of the knee, the stump will be levered upward from the distal end of the socket, and again, the forces against the anterodistal stump surface are significantly increased. Provided that stump volume control is not a problem, 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. While the patient is seated, the anterior wall of the socket can be forced backward against the front of the stump. By placing a hand inside the posterior wall of the inlet, one can determine the tightness of the anteroposterior diameter. At the same time the location of the pivot point of the suspension system should also be checked. 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. a firm heel wedge is used, 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. 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), or moving the foot forward. The occurrence of a blister or ulcer should signal the discontinuance of the prosthesis until the lesion is healed. During this time proper stump wrapping must be done continuously. Range-of-motion and muscle strengthening exercises should be carried out at the knee and hip. Any design discrepancies of the socket should be corrected before the patient returns to walking. With closure of the lesion and gaining control of the stump volume, prosthetic training can be initiated with skin inspection at frequent intervals and graduated periods of stump loading until skin tolerance is achieved. Loss of Total Contact.-Satisfactory total contact over the distal portion of a stump is difficult to maintain when stump shrinkage or loss of weight occurs. 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. The patient may complain of excessive tightness about the knee while still feeling looseness in the distal portion of the socket. Subsequently, choking of the stump may occur with gradual development of lymphedema in the lower portion of the stump. Chronic edema encourages the development of stasis pigmentation and hemorrhagic papules and nodules of the distal portion of the stump. In some instances, the skin takes on a characteristic hypertrophic Assuring called verrucous hyperplasia. In individuals with vascular insufficiency, particularly those with diabetes mellitus, progressive lymphatic and venous outflow obstruction may produce a stasis ulcer at the distal end of the stump. Failure to recognize this condition and to take appropriate corrective steps will only lead to gradual worsening of the soft-tissue ulceration. 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. With reestablishment of proper limb volume and healing of the stasis ulcer, a new total-contact transtibial socket should be prescribed. Hammocking Phenomenon.-A somewhat uncommon, but frustrating problem is the
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development of localized skin abrasion or ulceration produced by the hammocking effect of a stump sock. This peculiar problem is the result of two major factors. First, there is a lack of total contact over the distoposterior aspect of the stump. Second, because of snug anteroposterior and mediolateral diameters at the midportion of the socket, the stump sock is suspended at this level as the prosthesis is donned. Consequently, the posterior side of the stump sock is drawn tightly against the distoposterior aspect of the stump. Edema gradually develops in the lower portion of the stump with use of the prosthesis. 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. The unusual location of this ulcer should be a clue to its possible cause. 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. A temporary solution to the problem may be obtained by altering the anteroposterior and mediolateral diameters of the socket, the use of a Daw nylon sheath, and Silastic foaming of the distal aspect of the socket. The definitive solution is refitting the amputee with a new total-contact socket with proper dimensions. Inlet Impingement. -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, discomfort may result from pressure being applied against the hamstring tendons or the skin of the popliteal area with increased flexion of the knee. The amputee complains of tenderness and chafing of the skin behind the knee and in the region of the biceps femoris or semitendinosus tendons. The discomfort is made worse by sitting or excessive bending of the knee. Physical examination reveals redness and chafing of the skin along the course of the involved tendon and associated point tenderness. The skin may have a superficial ulceration where the pressure is maximal. 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. Elimination of the source of the problem can be achieved by lowering the posterior trim line or deepening the channels for the hamstring tendons.
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socket fit, a horizontal bulge of soft tissue, or adductor roll, may develop high on the medial aspect of a transfemoral stump. The size of this roll may eventually prevent the amputee from donning the prosthesis properly. If the roll is excessive, 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. An adductor roll causes a relative lengthening of the prosthetic limb and a variety of gait deviations. When standing, the iliac crest on the involved side is higher than on the contralateral side. The patient may be forced to circumduct the prosthesis or vault on the opposite lower limb to clear the foot during swing phase. Or the patient may walk with the limb in abduction to reduce the medial wall pressure against the adductor roll. Palpation confirms the position of the ischial tuberosity well above the ischial seat. The adductor roll is easily felt on the inside of the stump above the brim of the medial wall. Examination following removal of the prosthesis reveals a somewhat firm, tender roll of soft tissue with a horizontal orientation in the adductor region of the thigh. Inspection of the inferior margin of the roll may reveal considerable erythema but rarely any evidence of superficial ulceration. 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. A combination of correct stump wrapping with modification of the prosthetic socket is quite likely to resolve the adductor roll problem. If the roll is small, 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. Subsequent atrophy of the roll provides an improved socket fit. When adductor roll is extensive, 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. Choking.-Constriction of the proximal portion of a transfemoral stump impedes venous and lymphatic outflow from the remainder of the stump. Excessive use of stump socks, weight gain, musculoskeletal growth, and limb swelling are some of the causes of stump choking. Resultant stump abnormalities include the absence of stump sock markings over the distal part of the stump, along with associated palpable edema, generalized skin redness, and a possible adductor roll. If severe, the skin may show typical stasis changes that eventually lead to verrucous hyperplasia. Stasis ulceration may be a late-stage sequela, but it is rather uncommon. Usually careful assessment of the amputee while wearing the prosthesis will suffice in elucidating the nature of the problem. Almost inevitably the stump is riding partially out of the socket. Therefore the ischial tuberosity is well above the ischial seat; the ipsilateral iliac crest is elevated, thus creating pelvic obliquity, and the patient walks with some type of gait deviation such as abduction of the hip, circumduction of the prosthesis, or vaulting on the intact limb. If confirmation of the loss of total contact is necessary, a clay ball compression test, radiographs through the socket, or a microcapsular stocking are helpful techniques. Seldom is a clear check socket necessary. The resolution of choking should be approached initially by improving the socket fit through removal of unnecessary stump socks, use of a pull-through sock, improved stump wrapping, socket relief, and foaming the lower end of the socket to regain total contact. If these measures are only partially effective, the definitive solution is fabrication of a new socket. Malalignment.-In the short transfemoral amputee, the degree of adduction of the lateral wall should be as much as conditions permit. Also, the lateral wall must be precisely contoured to evenly distribute the socket pressures over the largest possible surface area during midstance. Despite careful socket design, the patient may complain of progressive pain and soreness over the distolateral aspect of the stump. To alleviate the concentration of forces in this area during walking, he must incline the trunk laterally over the prosthesis to shift the weight line closer to the support line. His base of support may be widened by abduction of the hip as well. Examination of the stump reveals no striking features except for varying degrees of skin erythema and localized tenderness in the area of increased pressure. The socket fit is nearly always satisfactory. Use of a microcapsular stocking or thermography are the most practical means to verify the increased local pressure to the stump.
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Alignment adjustment through reducing the adduction of the socket and out-setting the prosthetic foot usually eliminates this problem. Inlet Impingement. -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. This occurs when the adductors are impinged by a narrow adductor channel of the socket. Physical examination rarely demonstrates any evidence of change in the stump except for point tenderness over the adductor longus and gracilis. This finding should suggest the cause of the patient's complaints. A diagnostic as well as treatment method consists of routing the adductor channel to increase its size. With this modification the patient is frequently relieved of his pain. Excessive End Bearing. -As in the transtibial amputee, the reduction of stump volume or a significant drop in body weight will change the socket fit dramatically. The stump is able to descend deeper into the socket since all total contact with the socket surfaces has been lost. 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 physical findings are comparable to those of a transtibial stump, namely, hyperemia of the skin with possible bursitis over the distal third of the femur, localized soft-tissue tenderness, callus formation, and occasional superficial ulceration. Positive physical findings include (1) relative shortening of the prosthetic limb, (2) displacement of the ischial tuberosity forward and distal to the seat, 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. Patients with minimal end bearing may be more accurately diagnosed by a trial of additional stump socks, a clay ball compression test, microcapsular stockings, socket radiographs, or a clear check socket. In suction sockets or sockets with openings for pull-through socks, the stump may be evaluated both visually and manually. The addition of more stump socks may be the only treatment required in amputees with mild end bearing. Relief of the distal end of the socket and lining the socket to decrease the anteroposterior and mediolateral diameters may suffice in moderate cases. In more advanced circumstances the best remedy is fabrication of a new total-contact socket. Any associated skin ulceration can be treated with appropriate topical care and stump wrapping. The underlying bursitis often responds to the relief of socket pressure and stump wrapping. 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. In the small number of amputees who are greatly disabled by chronic bursitis, surgical excision may be necessary. Pressure From a High Anterior Wall. -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 is accomplished by building the anterior brim 5 to 6.5 cm (2 to 2 in.) higher than the ischial seat, flaring the margin of the brim generously, and bulging the inner wall of the brim in the area of Scarpa's triangle. Ordinarily, the high front does not interfere with sitting or bending over, provided that there is no contact with bony prominences of the pelvis and a channel is provided for the rectus femoris muscle. However, 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. It is rare to have any difficulty with standing or walking. Customarily, the socket fits well otherwise. When the patient sits or leans forward, palpation demonstrates high compression against the lower abdominal tissues. With the prosthesis removed, the only localizing signs are erythema of the skin, varying degrees of tenderness in the areas of pressure, and occasional small hemorrhagic lesions secondary to contusion of the skin. Judicious lowering of the anterior wall and increasing the flare of the brim usually provide prompt relief. High Medial Wall. -In a properly fitted quadrilateral socket essentially no weight should be borne by the medial wall. The upper third of the medial wall should be flattened and the superior brim flared to prevent skin irritation. Although the medial wall should be as high as tolerated, it is usually 0.3 to 0.6 cm (1/8 to 1/4 in.) lower than the ischial seat. With pelvic tilt, excessive adduction of the socket, or too much length of the medial wall, 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 patient compensates for these changes while walking by
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maintaining a wide base of support by abduction of the hip during both stance and swing phase. Relief is provided by lowering the medial wall and flaring the superior brim.
Summary
The major prosthetic causes of pain in the lower limb are volumetric changes, malalignment, and inlet impingement. Comparison and contrast are best summarized in Table 27-1..
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. With any reduction of total contact in the region of the distal radioulnar joint, the distal end of the stump tends to rotate independently of the prosthetic wall during pronation
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and supination of the forearm. The torsion of the prosthesis creates a high shear force across the skin in the region of the radial and ulnar styloid processes. In addition to localized pain, repetition of these forces across the involved skin produces reactive hyperemia, localized soft-tissue tenderness, and possible skin ulceration. Detection of the source of pain and irritation is often a simple matter of careful inspection of the distal end of the amputation stump. If localizing signs are scant, the use of a microcapsular stocking may demonstrate increased localized pressure in the region of the ulnar and radial styloids. Seldom is it necessary to resort to radiographs through the socket, clear check sockets, or thermograms. Foaming of the distal end of the socket with Silastic to regain satisfactory total contact is usually adequate in relieving this problem. If the volumetric loss of the stump is high, it is preferable to fabricate a new wrist disarticulation socket. When the problem may be the result of increased soft-tissue edema or a tight distal socket, relief in the area of skin pressure provides an easy solution. In those few patients with chronic skin problems despite frequent adjustments and redesigning of the wrist disarticulation socket, surgical revision of the stump may be necessary. 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, which is critical to the preservation of forearm pronation and supination.
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stump sock indentations indicating increased skin pressures. With the prosthesis donned the olecranon lies above the trim line of the posterior aspect of the socket, and this indicates a loss of socket fit. Removal of some of the stump socks will often achieve an improved fit of the socket. If edema prevents continued use of the socket, it may be necessary to resort to continuous wrapping for a few days. With elimination of the edema of the stump, satisfactory total contact and stump protection can be obtained by foaming the socket with Silastic. If a tight inlet is responsible for choking the stump, routing the socket walls will aid in opening the inlet. 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. Since this type of socket must be designed with restriction of complete extension of the elbow to maintain adequate suspension, excessive traction in the extended position would be expected to produce some discomfort over the humeral condyles or olecranon with high axial loads. However, some amputees find that with active flexion of their elbow they feel pressure over these bony prominences. 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. Failure to diminish elbow impingement by means of socket adjustments dictates fabrication of a new socket in greater extension.
Shoulder Disarticulation
Achievement of proper prosthetic suspension and total-contact fit of the socket is difficult in the shoulder disarticulation amputee. The weight of the prosthesis tends to create a downward displacement and rotation over the acromion. Combined high compression and shear forces generated over the tip of the acromion cause localized pain and concomitant
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skin changes. Lining the involved portion of the socket wall with Plasta-zote, Pelite, or similar synthetic materials distributes the forces over a larger skin surface area, thus making the soft-tissue pressure more tolerable. Adjustment or redesigning the suspension system will also reduce the rotary action of the socket. Meticulous socket design usually minimizes soft-tissue pressure problems over the anteroposterior aspect of the shoulder girdle. Subsequent alterations of tissue forces as a result of soft-tissue shrinkage, edema, or musculoskeletal growth can be managed by socket relief, socket lining, or increased socket dimensions by routing the socket wall.
Forequarter Amputation
Most of the discomfort associated with fitting a fore-quarter prosthesis is caused by uneven distribution of soft-tissue pressure. Suspension problems with this type of prosthesis are immense, and contouring the socket wall to accommodate uneven bony prominences and bulky soft tissues is most difficult. The use of the lightest possible prosthetic components minimizes the downward displacement of the device. Lining the socket wall with compliant synthetic materials improves soft-tissue pressure distribution. Considerable prosthetic discomfort may usually be prevented by adjustments of the trim lines; periodic checking of socket contact with the thoracic wall, base of the neck, and opposite shoulder region; and alteration of the suspension system. References: 1. Blankenbaker WL: The care of patients with phantom limb pain in a pain clinic. Anesth Analg 1977; 56:842-846 2. Bonica JJ: Causalgia and other reflex sympathetic dystrophies. Postgrad Med J 1976; 53:143-148 3. Bonica JJ: Neurophysiologic and pathologic aspect of acute and chronic pain. Arch Surg 1977; 112:750-761 4. Brand PW, Ebner JD: Pressure sensitive devices for denervated hands and feet. J Bone Joint Surg [Am] 1969; 151:109-116 5. Carron H, Weller RM: Treatment of post traumatic sympathetic dystrophy, in Bonica JJ (ed): Advances in Neurology, vol 4, Pain. New York, Raven Press, 1974 6. Casey KL: Pain: A current view of neural mechanisms. Ami Sci 1973; 61:194-200 7. Ersek RA: Transcutaneous electrical neurostimulation: A new clinical modality for controlling pain. Clin Orthop 1977; 128:314-324 8. Feinstein B, Luce JC, Langton JNK: The influence of phantom limbs, in Klopsteg PE, Wilson PD (eds): Human Limbs and Their Substitutes. New York, McGraw-Hill, International Book Co, 1954, pp 79-138 9. Ferguson JP, et al: Neurosurgical management of intractable pain. NC Med J 1973; 34:707-710 10. Finsein V, Persen L, Lvlien M: Transcutaneous electrical nerve stimulation after major amputation. J Bone Joint Surg [Br] 1988; 70:109 11. Foort J: The patellar-tendon-bearing prosthesis for below knee amputees: A review of technique and criteria. Artif Limbs 1965;9:4-13 12. Frazier SH, et al: Psychiatric aspects of pain and the phantom limb. Orthop Clin North Am 1970; 1:481-495 13. Hampton FL: Prosthetic principles in the lower extremity amputee. Orthop Clin North Am 1972; 3:339-347 14. Henderson WR, Smyth GE: Phantom limbs. J Neurol Neurosurg Psychiatry 1948; 11:88-112 15. Iacono R, Linford J, Sandyk R: Pain management after lower extremity amputation. Neurosurgery 1987; 20:496 16. Iggo A: Pain receptors, in Bonica JJ, Procacci P, Pugni CA (eds): Recent Advances on Pain: Pathophysiology and Clinical Aspects. Springfield, Ill, Charles C Thomas Publishers, 1972 17. Iggo A: The case for "pain" receptors, in Tanzen R, Keide WD, Herz A, et al (eds): Pain. Baltimore, Williams & Wilkins, 1972, pp 60-61 18. Jensen T, Krebs B, Nielsen J, et al: Immediate and long term phantom limb pain in amputees: Incidence, clinical characteristics and relationship to preamputation limb pain. Pain 1985; 21:267 19. Kerr FWL: Segmental circuitry and spinal cord nociceptive mechanisms, in Bonica JJ, Albe-Fessard D (eds): Advances in Pain Research and Therapy, vol 1. New York, Raven Press, 1976, pp 75-89
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20. Lim RKS: Neuropharmacology of pain and analgesia, in Lim RKS, Armstrong D, Pardo EG (eds): Pharmacology of Pain, vol 9. New York, Pergamon Press Inc, 1968, pp 169217 21. Loeser JD: Neurosurgical relief of chronic pain. Post Grad Med J 1973; 53:115-119 22. Loeser JD, et al: Relief of pain by transcutaneous stimulation. J Neurosurg 1975; 43:308-314 23. Long DM: External electrical stimulation. Minn Med 1974;57:195-198 24. Melzack R: Central neural mechanisms in phantom limb pain, in Bonica JJ (ed): Advances in Neurology, vol 4, Pain. New York, Raven Press, 1974, pp 319-326 25. Melzack R: Phantom limb pain: Implications for treatment of pathologic pain. Anesthesiology 1971; 35:409-419 26. Melzack R: The Puzzle of Pain. New York, Basic Books Inc Publishers, 1973 27. Melzack R, Wall PD: Pain mechanism: A new theory. Science 1965; 150:971-979 28. Mitchell SW: Phantom limbs. Lippincott Mag 1871; 8:563 29. Nathan PW: Pain. Br Med Bull 1977; 33:149-155 30. Nielson KD, et al: Phantom limb pain. Treatment with dorsal column stimulation. J Neurosurg 1975; 43:301-307 31. Parkes CM: Factors determining the persistence of phantom pain in the amputee. J Psychosom Res 1973; 17:97-108 32. Radcliffe CW: Functional considerations in the fitting of above knee prostheses. Artif Limbs 1955; 2:35-60 33. Radcliffe CW, Foort J: The Patellar-Tendon Below Knee Prosthesis Manual. Berkley, Calif, University of California, Biomechanics Laboratory, Department of Engineering, 1961 34. Rexed B: The cytoarchitecture organization of the spinal cord of the cat. J Comp Neurol 1952; 96:415-496 35. Riding J: Phantom limb: Some theories. Anesthesia 1976; 31:102-106 36. Saris S, Iacono R, Nashold B: Dorsal root entry zone lesions for post-amputation pain. J Neurosurg 1985; 62:72 37. Saris S, Iacono R, Nashold B: Successful treatment of phantom pain with dorsal root entry zone coagulation. Appl Neurophysiol 1988; 51:188 38. Sherman R: Stump and phantom limb pain. Neurol Clin 1989; 7:249 39. Sherman R, Sherman C, Gall N: A survey of current phantom limb pain treatment in the United States. Pain 1980; 8:85 40. Sinclair WF: Below the knee and Syme's amputation prostheses. Orthop Clin North Am 1972; 3:349-357 41. Stilz RJ, Carron H, Sanders DB: Reflex sympathetic dystrophy in a 6-year-old: Successful treatment by transcutaneous nerve stimulation. Anesth Analg 56(3): 1977; 53:438-443 42. Sweet WH, et al: Stimulation of the posterior columns of the spinal cord for pain control: Indications, techniques and results. Clin Neurosurg 1974; 21:278-310 43. Wall PD: Physiological mechanisms involved in the production and relief of pain, in Bonica JJ, Procacci P, Pagni CA (eds): Recent Advances on Pain: Pathophysiology and Clinical Aspects. Springfield, Ill, Charles C Thomas Publishers, 1974, pp 36-63 44. Webster KE: Somesthetic pathways. Br Med Bull 1977; 33:113-120 45. Whidden A, Fiddler MR: Pathophysiology of pain, in Ja-cox AK (ed): Pain: A Source Book for Nurses and Other Health Professions. Boston, Little Brown & Co Inc, 1977, pp 27-56 46. Wilson ME: The neurological mechanisms of pain. A review. Anaesthesia 1974; 29:407-421
Chapter 27 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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Personality Style
Individuals who are narcissistically invested in their physical appearance and power tend to
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react negatively to the loss of the limb. They see it as a major assault upon their dignity and self-worth. Conversely, dependent individuals may cherish the sick role and find in it welcome relief from pressure and responsibility. Those with a premorbid history of depression are more susceptible to dysphoria following amputation. The loss serves to crystallize notions of a basic defect, sometimes expressed in self-punishing behaviors. 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. Unexpected reactions may arise from secondary gain. If disability results in improved financial or social status, psychological adjustment may be made easier, especially if those gains are not directly challenged. Should the amputation bring about the resolution of a psychological conflict, be it conscious or otherwise, the individual may indeed be happy that it occurred. Although Kolb and Brodie report that rigid personality style may predispose to a greater incidence of postoperative complications, including phantom pain, the recent literature review of Sherman et al. indicates no relationship between such a personality and phantom pain. Those tending toward a pessimistic or paranoid outlook are likely to find their worst expectations confirmed, and their rehabilitation may be colored by much bitterness and resentment.
Psychosocial Support
All human beings require a support system throughout life in order to maintain emotional health. However, not all are so blessed, and many find themselves transiently or permanently in a state of isolation. Single and widowed individuals suffer more psychological distress and difficulty in adapting to amputation than do those who are married and have a family. Particularly helpful in the adjustment of the adult amputee is the presence of a supportive partner who assumes a flexible approach, takes over functions when needed, cuts back when the amputee is able to manage, but at all times maintains the amputee's self-esteem. As might be predicted, parents are the major source of support for children and adolescent amputees. But peer acceptance beyond the family is critical in the successful adaptation of all amputees and, especially, as mentioned above, children and adolescents.
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attendant loss of energy, pessimism, and psychomotor retardation-may delay rehabilitation, a delay that in turn exerts a depressing effect on the individual. Furthermore, anger often underlies the depressive reaction described earlier. In a study of 46 amputees seen in London, Parkes found that Among the 38 amputees who were thought to have some overall limitation of function attributable to psychological origin, factors inculpated, in order of frequency, were depression, timidity, fear of further self-injury, selfconsciousness, low intelligence, senility, anger, resentment of the need to rely on others, and secondary gain.
Surgical Complications
Those individuals who suffer pain, infection, and residual-limb revision tend to develop greater degrees of despair and withdrawal than those who do not. This highlights the importance of surgical skill in the performance of the amputation. As noted in an earlier communication, "A poorly performed amputation almost guarantees poor rehabilitation. While a well-performed amputation does not guarantee a successful rehabilitation outcome, it certainly makes successful rehabilitation more possible."
Prosthetic Rehabilitation
The earlier a prosthesis is applied, the less the psychological distress observed after amputation. Conversely, if the prosthetic application is absent or delayed, greater degrees of anxiety, sadness, and self-consciousness are noted. 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.
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Extremes of age are by no means intrinsic contraindications for prostheses. However, among the elderly, pre-existing illness may compound the difficulties of adjusting to such devices. For example, elderly amputees with chronic obstructive pulmonary disease are already compromised with respect to strength and endurance. Nonetheless, they deserve a trial period of rehabilitation with a prosthesis, albeit under close supervision.
Vocational Rehabilitation
Restoration of the capability for gainful employment is an integral part of the patient's recovery. Kohl notes that amputees may regard unemployment as a "denial of their 'right' to participate in the family's decision making processes." It is her view that "the success of rehabilitation efforts should not only be measured by return to income-producing work, but rather the return to the person of his decision-making abilities to choose the lifestyle that would be most fulfilling to him."
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. It is useful and customary to think of the process of adaptation as occurring in four stages. With the exception of the clear demarcation between preoperative and postoperative stages, most of the adjustment occurs in a gradual and often invisible continuum. A division into four stages, however, allows for the highlighting of issues that arise most critically at each point in time.
Preoperative Stage
Among amputees for whom there is ample opportunity to be prepared for surgery, 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. Along with this acceptance, there may be varying degrees of anxiety and concern. Such concerns fall into two large groups. First and, perhaps for most persons, the more important are such practical issues as the loss of function, loss of income, pain, difficulty in adapting to a prosthesis, and cost of ongoing treatment. Second are more symbolic concerns such as changes in appearance, losses in sexual intimacy, perception by others, and disposal of the limb. Most individuals informed of the need for amputation go through the early stages of a grief reaction, which may not be completed until well after their discharge from the hospital. Dise-Lewis suggests that the death and dying paradigm may be usefully applied to the amputees impending loss of a body part, a loss that may threaten the amputee's core identity. The manner in which the surgery is presented by the surgeon can have much bearing on the magnitude and kind of affective response. Mendelson and coworkers recommend that the surgeon paint a realistic picture of the immediate and long-term goals for the patient and his family. 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. Furthermore, a hopeful attitude, 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, anger, and despair. Several members of the self-help group interviewed for this report eloquently described the consequences of failed communication. One who regarded her impending amputation as "losing a member of my family" felt scared "out of my wits" and was repeatedly "horrified." She reported that her surgeon had described her as his "failure" and told her very little about
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the details of the surgery and the process beyond. Another, when informed that she would lose her leg, reacted with the thought, "They might as well take off my head." 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. But the process took time and effort. One member of the group described her reaction as one of ambivalence and oscillation. She switched repeatedly from acknowledging that the amputation was to be expected, and even desirable, to great fear and dread. "Like a ghost in my closet," she said, "I took it out now and then to scare myself with it."
In-Hospital Rehabilitation
In-hospital rehabilitation, in many ways, is the most critical phase and presents the greatest challenges to the patient, the family, and the amputation team. It calls for a flexible approach addressed to the rapidly evolving needs of the individual. Initially, the patient is concerned about safety, pain, and disfigurement. Later on, the emphasis shifts to social reintegration and Some individuals in this phase experience and express various vocational adjustment. kinds of denial shown through bravado and competitiveness. A few resort to humor and minimization. Mild euphoric states may be reflected in increased motor activity, racing through the corridors in wheelchairs, and overtalkativeness. Others make wisecracks such as "You see more when you walk slowly." Eventually sadness sets in. The grief response to limb loss is probably universal and time He lists four limited. Parkes describes the response as similar to that seen in widows. phases: (1) "numbness," in which outside stimuli are shut out or denied; (2) "pining" for what is lost; (3) disorganization, in which all hope of recovering the lost part is given up; and (4) reorganization. The degree to which individuals go through these four phases varies from individual to individual, and indeed, the process often lasts well beyond the period of inhospital rehabilitation. It is also during this time that some experience phantom limb sensations and phantom pain (see the discussion that follows). Factors that are noted to facilitate adjustment and rehabilitation in this phase are early prosthetic fitting, acceptance of the amputation and the prosthesis by family and friends, and introduction of a successfully rehabilitated amputee to the recovering patient. Almost all the members of the group interviewed for this report agreed that early prosthetic introduction was of the highest importance. For two women who sustained below-knee (transtibial) amputations, awakening to find that they had two "legs" in bed was most reassuring. The 13-year-old delighted in throwing back the bedclothes and flaunting her artificial leg to her adolescent visitors. Those who did not, for one reason or another, obtain a prosthesis looked forward to it and often fantasized about it. One young man who lost the upper part of his arm as a result of an electrical injury dreamed of becoming a "bionic man." Sadness, although keenly felt, may be concealed. A young mother who lost her hand in a paper shredder tried to put on a happy face for her family. "Sometimes," she said, "we have to joke so that people around us can deal with it."
At-Home Rehabilitation
By all accounts, 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
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provided by the rehabilitation team. Hence, the attitude of the family becomes a major determinant of the amputee's adaptation. Family members should be involved in all phases of the rehabilitative process. It is during this phase that the full impact of the loss becomes evident. A number of individuals experience a "second realization," with attendant sadness and grief. Varying degrees of regressive behavior may be evident, such as a reluctance to give up the sick role, a tendency to lean on others beyond what is justified by the disability, and a retreat to "baby Some resent any pressure put upon them to resume normal functioning. Others may talk." go to the other extreme and vehemently reject any suggestion that they might be disabled or require help in any way. An excessive show of sympathy generally fosters the notion that one is to be pitied. In this phase, three areas of concern come to the fore: return to gainful employment, social acceptance, and sexual adjustment. 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. 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. He regressed to the point that she felt she "had another baby in the house." (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." 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. 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. She did so with tears running down her face and thoughts running through her mind of her husband as cruel and mean. 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. Equally helpful to her was her children's startled response on learning that their mother was receiving disability benefits. To them, she did not seem to be disabled at all and therefore did not need benefits. In fact, 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. The group members were unanimous in rejecting the "handicapped" label, and each thought that his affliction was lighter than those of the others. One of them said, "Most well-adjusted people prefer to accept what happened to them" and thus "would not trade with another amputee." All conceded that the adaptation would have been immensely more difficult without the active support of their families. A subtle but often overlooked issue is the ease with which the disability can be concealed in social settings. One group member, for example, remarked that one advantage of a leg amputation over an upper-limb loss was that it could escape detection in such settings. Not surprisingly, those amputees able to resume a full and productive life tend to fare best; this is much easier for those with marketable skills who sustain the amputation while still in vigorous health. For elderly amputees who have limited skills, particularly if they have other medical disorders, the probability of a full return to an active life is considerably diminished. This can be partially or fully balanced by a more philosophical acceptance of a new, more leisurely way of living and by reduced responsibility and pressure to produce.
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Phantom Pain
Pain experienced in the missing limb is a much more serious issue than phantom limb sensations. At the University of Arizona, phantom pain has been reported by fewer than 2% of amputees. 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 the series of 2,284 amputees studied by Ewalt and colleagues at the end of World War II, phantom pain was extremely rare and was noted in individuals who also showed psychopathology. The authors wrote that pain "tended to come and to go with psychopathological symptoms, irrespective of what type of external treatment was carried on." Parkes found that phantom pain could be predicted by certain immediate postoperative phenomena such as the presence of residual-limb pain, prior illness of more than 1 year, the development of residual-limb complications, and interestingly, other factors not related to surgery (e.g., continued unemployment and a rigid personality). Some amputees experience phantom pain in association with micturition, climatic changes, and emotionally disturbing events. Sherman et al. 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. Pinzur regards phantom pain as a variant of sympathetic dystrophy. There is general agreement that phantom pain and life stresses are related. In a study of 24 male amputees, Arena et al. found an isomorphic pain-stress relationship, namely, 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. differ from that of the general population of chronic pain sufferers. Thus, phantom pain, which can be serious and disabling, remains incompletely understood but approaches the model of a chronic pain syndrome with evidence of physiologic and psychological components. In the self-help group, only one member reported persistent phantom pain accompanied by residual-limb pain. He detailed long and complicated procedures after the initial amputation, all designed to relieve his phantom pain. These included nerve stimulation, acupuncture, residual-limb revision, and even spinal block. At the time of the interview, his only relief came from the use of oxycodone (Percodan) on a regular basis. 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. Other members experienced fleeting episodes of pain described as an electric shock sensation or, as one put it, "like putting your finger in a 220 [volt] outlet." A few described cramping sensations and feelings of constriction that diminished over time. Two mentioned aching when the weather changed and rain was approaching. 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.
Body Image
Amputation, of necessity, requires a revision of body image. This is reflected in dreams and in the draw-a-person test. It has been reported that amputees who adapt well draw a person with a foreshortened limb or without any limb at all, whereas those who adapt poorly draw the Similarly, dreams missing limb larger than the opposite limb or with increased markings. that incorporate the prosthesis or do not particularly dwell on the missing part are consistent with a more positive adaptation. 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, the frequency of such nightmares decreased significantly about 1 month postoperatively. It has been suggested that the amputee, in a sense, must contend with three body images: intact, amputated, and with prosthesis. 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. and acceptance by others. Even when considerable success is achieved in functional restoration, there often remains some shyness about revealing the amputated body to others. The members of the group confirmed these observations and saw a connection between accepting one's new bodily configuration and accepting a prosthesis. One viewed her body more positively after amputation because her prosthetic leg worked better than the leg that she had lost. Most had come to regard their prosthesis as part of themselves, at times
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revealed in dreams. Nonetheless, despite their successful adaptation and acceptance of the new body image, all of them continued to experience self-consciousness in social situations. For example, they tended to walk more clumsily when they felt observed by other people in public. They described a pool party to which they had invited their friends and relatives. Significantly, the only people who actually went into the pool were the nonampu-tees.
Sexuality
This is an area of some anxiety for most amputees, especially those who are young and in Concern arises from the following sources: (1) fear that the body would the prime of life. not be accepted by the partner, (2) the loss of a functioning body part such as the hand, and (3) the loss of an area of sensation. Whereas a prosthesis can provide functional restoration and some return to normal appearance in most situations, it is absolutely of no use in the sexual area. A comparison with the sexual experience of paraplegics is instructive. Those who suffer paralysis still enjoy sensation from the affected part and continue to see their body as intact. They may also entertain hope of a return of function in the affected part. The amputee enjoys none of these advantages. Among the members of the group, sexuality was an important issue that had to be faced by each of them. Most reported success in facing it, mainly attributed to the supportive response of the partner. Yet, despite verbal and behavioral reassurance of the partner, several spoke of lingering difficulty in seeing themselves as adequate sexual partners rather than as repulsive sexual "freaks." As one group member put it, "There is still a small part that doesn't accept." It would appear that the passage of time aids in this adjustment; one member stated that 15 years after the event, her missing limb was "a nonissue" in the sexual sense. This was not the case for the 13-year-old, who had expressed the concern that no boy would ever look at her. She lived for 2 years after her surgery but did not have occasion to go out on a date. She maintained the hope that one day she would do so and was greatly comforted by her brother-in-law, who told her that her amputation would "weed out the creeps."
MANAGEMENT
Six principles of psychological management of the amputee are implied in the foregoing discussion.
Preparation
Although it is hard to prove statistically that preparation has a bearing on ultimate outcome, common sense, clinical observation, and the reports of amputees all suggest that proper Such preparation must include a clear explanation of the preparation is highly desirable. reasons for the amputation; the viable alternatives, if any; the exact surgical procedure; and the rehabilitative process following it. Anticipating and dealing with the various issues that patients will face, even if these are not raised by the patients themselves, is of great help. Such issues include disposal of the limb, relationship with friends and family, degree of functional loss and return, work capability, costs of surgery and rehabilitation, sexual adjustment, and social impact. 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. 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, it has been suggested that the term with limb-sparing treatments. "reconstructive surgery" is preferable to "amputation" and can certainly be used along with it. It should go without saying that much of the preparation should be conducted by the operating surgeon; although the information is widely available and may be imparted by any member of the team, no other person can communicate the same degree of authority and confidence that patients need as they contemplate the imminent loss.
Surgical Technique
It should be obvious to the readers of this book that good technique is of the essence. 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. It is an error to relegate this procedure to inexperienced
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hands. As Bradway and associates wrote, "In our program, the senior surgical attending physician is directly involved in the performance of all amputations and supervises the entire process of amputation rehabilitation."
Vocational Rehabilitation
No approach to amputation can be considered successful without some resolution of the issue presented by the loss of skill, job, and livelihood. Even in the absence of pressing financial need, the loss of earning capacity may entail a profound loss of self-esteem, which brings with it a variety of adverse psychological phenomena. It is not essential that the person resume work, but it is essential that the person accept whatever new role and This is an issue to be approached with an open mind. capacity that can now be enjoyed. Some, for example, prefer returning to employment, with all the security, stimulation, and structure that it presents. Others may find that thanks to personal wealth or to disability and retirement benefits, they are in a position to stay away from work. As Kohl 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." success in the rehabilitation of amputees. 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. 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, any psychological for rehabilitation outcome. testing ought to be deferred until the patient is physically and emotionally prepared to withstand the stress of its administration.
Special Approaches
Increasingly, group support is part of the help being provided to amputees. One such modality is Schwartz's situation-transition (ST) group, which is different from other self-help groups for alcoholics, smokers, and overeaters in that "members are not required to espouse Whether a trained person leads the group a particular moral or behavioral value system."
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or it is conducted entirely by its own members, the group experience is likely to be of great value to both the participants and their families. 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. 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. 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. There are those individuals who may continue to mourn the loss of their limb for a long time or who, having shelved the issue, return to it at a much later date (delayed grief reaction). Vivid flashbacks have been reported as among the most common early reactions to amputation. Reclusiveness, hy-pervigilance, and delusions have also With the possible exception of been noted as manifestations of body image disturbances. the use of low-dose, low-potency neuroleptics to extinguish flashbacks, 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. Feelings of sorrow, anger, and anxiety must be expressed before further therapeutic work can be accomplished. Occasionally, 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. It is, of course, perfectly possible for psychological problems that have been avoided or disregarded in the past to surface after surgery and, indeed, to be blamed on it. This might be the case, for example, in longstanding marital discord, chronic depression, anxiety disorder, drug dependence, alcohol abuse, and antisocial behavior. These psychiatric challenges can be addressed therapeutically on their own merit, without the necessity of determining the degree to which they are related to the amputation. If and when such a determination becomes desirable, such as in complicated legal situations, the individual's previous history and former level of adjustment can be of great value in clarifying the issue. For most amputees, however, psychiatric consultation and therapy are not indicated. With respect to phantom pain, biofeedback and relaxation appear to be useful adjuncts to medical care of the stump and pain control measures. Neither psychotherapy nor Psychological psychoactive medicine appear to be of efficacy in treating phantom pain. sophistication and sensitivity on the part of members of the team, however, are indispensable. In the self-help group that was interviewed for this report, there was unanimous agreement with these principles of management. Furthermore, most individuals noted an improvement in the quality of their lives after surgery. As one member put it, "You become a more compassionate and less critical person towards others." Another, who had suffered greatly both before and after his amputation, said, "When you become an amputee, you become a better person because you have to work for everything."
Acknowledgement
This chapter was written with the assistance of Richard E. D'Alli. Many individuals have assisted materially in all aspects of preparing this report. I wish in particular to acknowledge my debt of gratitude to John Bradway, M.D., who, as a third-year clinical clerk in psychiatry, piqued my interest in this area by preparing a paper on psychological adaptation to amputation, which in turn formed the basis of a report written by him, myself, and a number of others ; to James Malone, M.D., for sharing his extensive knowledge and experience; to Joseph Leal, C.P., who put me in touch with the amputee selfhelp group in Tucson; to Sharon Stites, leader and organizer of the self-help group; to Diane Atkins, occupational therapist and coordinator for the Houston Center for Amputee Services, who shared a wealth of experience with hundreds of amputees at that center; to Sybil Kohl, social worker at the Houston Center for Amputee Services, for her profound observations and reflections on the lives of amputees; to Jan Pankey and Sandy Levitt, third-year clinical clerks, who assisted me greatly in my meeting with the self-help group in Tucson; and to the eight members of the group who, although unnamed, were the source of information, guidance, and inspiration to all who study amputation and those who must adapt to it. References: 1. Arena JG, Sherman RA, Bruno GM, et al: The relationship between situational stress
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2. 3. 4. 5. 6. 7. 8.
9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
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35. Osterman HM, Pinzur MS: Amputation: Last resort or beginning? Geriatr Nurs 1987; 8:246-248. 36. Parkes CM: Determinants of disablement after loss of a limb, in Krueger DW (ed): Emotional Rehabilitation of Physical Trauma and Disability. New York, SP Medical & Scientific Books, 1984, pp 105-111. 37. Parkes CM: Factors determining the persistence of phantom pain in the amputee. J Psychosom Res 1973; 17:97. 38. Parkes CM: Psychosocial transitions: Comparison between reactions to loss of a limb and loss of a spouse. Rr ] Psychiatry 1975; 127:204. 39. Parkes CM: The psychological reactions to loss of a limb: The first year after amputation, in Howells JG (ed): Modern Perspectives in the Psychiatric Aspects of Surgery. New York, Brunner-Mazel, 1976, pp 515-532. 40. Pinzur MS: Phantom pain: A lesson in necessity for careful clinical research on chronic pain problems (letter). J Rehabil Res Dev 1988; 25:83. 41. Pinzur MS, Graham G, Osterman H: Psychological testing in amputation rehabilitation. Clin Orthop 1988; 229:236-240. 42. Randall GC, Ewalt JR, Blair H: Psychiatric reaction to amputation. JAMA 1945; 128:645. 43. Reinstein L, Ashley J, Miller KH: Sexual adjustment after lower extremity amputation. Arch Phys Med Rehabil 1978; 59:504. 44. Sherman RA: Stump and phantom limb pain. Neurol Clin 1989; 7:249-262. 45. Sherman RA, Ernst JL, Barja RH, et al: Phantom pain: A lesson in necessity for careful clinical research on chronic pain problems. J Rehabil Res Dev 1988; 25:6-10. 46. Sherman RA, Sherman CJ, Bruno GM: Psychological factors influencing chronic phantom limb pain: An analysis of the literature. Pain 1987; 28:285-295. 47. Shukla ED, Sahu SC, Tripathi RP, et al: A psychiatric study of amputees. Rr J Psychiatry 1982; 141:50-53. 48. Sioson ER: The elderly amputee with severe chronic obstructive pulmonary disease. J Am Geriatr Soc 1990; 38:51-52. 49. Sturup J, Thyregod HC, Jensen JS, et al: Traumatic amputation of the upper limb: The use of body-powered prostheses and employment consequences. Prosthet Or-thot Int 1988; 12:50-52. 50. Sugarbaker PH, Barofsky I, Rosenberg SA, et al: Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery 1982; 91:17. 51. Tebbi CK, Mallon JC: Long-term psychosocial outcome among cancer amputees in adolescence and early adulthood. J Psychosoc Oncol 1987; 5:69-82. 52. Tebbi CK, Petrelli AS, Richards ME: Adjustment to amputation among adolescent oncology patients. Am J Pedi-atr Hematol Oncol 1989; 11:276-280. 53. Whylie B: Social and psychological problems of the adult amputee, in Kostuik JP (ed): Amputation Surgery and Rehabilitation: The Toronto Experience. New York, Churchill Livingstone Inc, 1981, pp 387-393.
Chapter 28 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library
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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. There are so many choices, in fact, that prescription becomes as much of an art as a science. This multiplication of options has resulted from a revolution in prosthetic design, manufacture, and fitting due to the introduction of new concepts in socket design as well as a wider array of components and new materials, including heat-mold-able plastics, lightweight metals, and carbon fiber-reinforced plastics. Before discussing factors involved in prescription, it is useful to review the reasons for not prescribing a prosthesis. 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, it is useless to prescribe one. The mental status of the patient must be such that he can learn its use and limitations. At the highest levels of amputation in both the upper and lower limbs, useful function decreases directly in relation to progressive loss of limb length. In addition, in lower-limb amputation, energy requirements for ambulation increase sharply with each more proximal anatomic level (see Chapter 15). A large number of factors affect the prescription, not all of which readily come to mind until one examines all the parameters of a given patients life. First and foremost, the prosthesis should meet the needs and desires of the patient, both vocationally and avocationally, insofar as possible. Prosthetic services should be readily available, not only for the provision of the initial prosthesis but also for its maintenance, repair, and replacement at suitable intervals. Since prostheses vary considerably in their complexity, 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. Geographic remoteness without ready access to a prosthe-tist for maintenance, repair, and replacement of a limb may dictate simplicity of design related to the need for self-repair of the device. Climate can also play an important role. In areas of excessive humidity, metal parts will tend to corrode and wood to rot. In areas of extreme aridity such as the desert regions of the world, fine sand particles will quickly wear out the joints of prostheses because of their close tolerances. The cost of a given prosthesis, both initial and ongoing, can be a limiting factor in determining the prescription. For example, some insurance companies will provide only one prosthesis for the life of the patient. Fiscal limitations at the local and state levels may mandate only a very simple prosthesis for indigent amputees, similar to those prescribed for amputees in the developing world. Local custom and knowledge are also powerful forces in determining prosthetic prescription in that they tend to limit the prescription options considered. The prescription of the most suitable prosthesis, taking into account the above factors, is most effectively done by a team. The team should consist of the patient/ family, the amputation surgeon, the prosthetist who will be making the limb, the therapist who will be providing the training in its use, a psychologist and/or social worker who will help the patient through his period of adjustment, and the insurance nurse, especially in workmen's compensation cases. There is a widely held misconception that this sort of team is available only in large medical centers. On the contrary, a very effective miniteam can be assembled in most small to medium-sized cities. It takes only an interested surgeon, the local prosthetist, a therapist, a psychologist/social worker, an insurance nurse, and amputees. If the surgeon
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.
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expresses an interest in this work, other local surgeons are very likely to refer patients for this purpose. By meeting once or twice a month at the physician's office or other designated location, team members can work far more effectively than by individually seeing the patient in isolation with no cross-fertilization of ideas. This approach also helps to upgrade prescription practices and tends to move the participants into a position of leadership in this field. While it is obvious that an amputation affects the amputee for the rest of his life, the need for regular lifelong prosthetic preventive maintenance is often forgotten. Even though there may be frequent follow-up visits immediately after the fitting is carried out, the amputee still needs to be seen at 6- to 12-month intervals for the rest of his life. Not only do residual limbs change in volume with muscle atrophy and weight gain or loss, prostheses also require maintenance, repair, and periodic replacement. Replacement may also be indicated as improved designs appear from time to time.
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prevent stress to the remaining foot is not recommended. This approach will result in months of avoidable deconditioning and tend to inure the patient to alternative modes of mobility. If the second foot is then amputated, 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 dysvascular amputee who loses one foot should therefore be made ambulatory with a prosthesis as rapidly as possible. If and when the second foot is lost, 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. Many younger lower-limb amputees, especially at the transtibial level, will wish to participate again in their previous sports activities. If the amputee is interested in returning to any sport based on running, 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. On the other hand, some amputees will benefit from prostheses specifically designed for given sports. These would include prostheses specifically made for skiing and swimming activities (see Chapter 24B). Because of these complexities, effective management is best achieved by a team as described above. Additional factors that may enter into the fitting of lower-limb amputees, especially in diabetes mellitus, are blindness and hemiplegia. Once properly trained, 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. The fitting of blind unilateral or bilateral transfemoral amputees should be approached with caution because of the loss of proprioceptive knee function. 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.
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prostheses, 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. Cosmesis is also of concern, especially to women and to all who must meet the public in their daily work. 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, nonfunctional device so long as it is cosmetically acceptable. The patient should meet as often as is necessary with team members, collectively or individually, to get desired information regarding the prosthesis and use training. The entire team should then meet again with the patient before actually ordering the prosthesis. In high bilateral cases, consideration should be given to modifying the amputee's environment as much as possible for more effective function. Blindness presents especially difficult problems for the upper-limb amputee since the use of a terminal device is almost entirely dependent on visual control. A blind bilateral upper-limb amputee will have no use for prostheses except perhaps as cosmesis. In this situation, consideration should be given to a Krukenberg procedure on one or both sides (see Chapter 36A). When these modified forearms are not in use, they can be covered with cosmetic prostheses. A blind unilateral upper-limb amputee may find a prosthesis useful for holding a coat or carrying objects in a gross manner. Questions are often raised, especially by third-party payors, as to what constitutes successful use of a prosthesis for the upper limb. 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. Nonetheless, it has served an extremely useful purpose at the workplace. Other amputees may wear the more cosmetic device at work and switch to a body-powered prosthesis for working in the garden after hours. Conversely, 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. Even part-time use of an upper-limb prosthesis for specific vocational, avocational, or purely social purposes is a sign of acceptance of the prosthesis. As in the case of lower-limb amputation, many upper-limb amputees will want to return to the sports and recreation activities in which they previously engaged. They have the option of myoelectrically controlled hands or body-powered terminal devices that feature either passive or active prehension. Again, the terminal device for sports and recreational activities should be carefully matched to the patient's needs and desires (see Chapter 12C). Follow-up with the team, after the initial intensive effort involved in fitting and training has been completed, should be on a lifetime basis, with at least yearly evaluations. Not only do prostheses wear out and sometimes break, but improved designs that might be a real advantage to individual amputees also appear from time to time.
Chapter 29 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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and then leans against the wall to hold that side while putting the other leg into the garment. Shirts are donned by first inserting the amputated limb in its sleeve and then the sound limb into the other. A buttoned cuff should be fastened before donning the shirt; securing the cuff button with elastic thread may be needed to allow the hand to slide easily through the cuff. A necktie can be knotted one-handed, particularly if the narrow end of the tie is held To don a glove, rub to the shirt with a tie clasp. A pretied, clip-on necktie is another option. it against the hip in the same direction as the hand is inserted. Once the hand is part way into the glove, one can use the back of a chair to work the fingers into place. A mitten, however, is simpler to manage. A watch with an expandable bracelet goes on more quickly than one with a buckled strap. To put the watch on the sound wrist, the individual lays the watch on a table and cups the fingers inside the band, then uses the table edge to slide the watch onto the wrist.
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. The antecubital fossae and, to a lesser extent, the axillae are useful to hold items. Objects may be stabilized in the teeth and between the thighs. Some adults are limber enough to be able to grasp with the feet. The child with congenital bilateral limb deficiencies should be encouraged to manipulate with the feet. They provide the individual with tactile sensation and considerable prehensile skill, thus reducing reliance on adaptive equipment and help from others. 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. For people of all ages, selection and modification of undergarments are especially important to foster independence. Underpants may have two tape loops sewn to the waistband. The client can then hang the pants on two wall hooks installed at a height suitable for stepping into the pants. Once they are on, the client rises on the forefeet to release the loops. A single padded hook or wooden knob on the wall can be used to aid dressing. One section of the trousers, skirt, 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 floor, then inserting the feet into the pants legs, and then raising one's legs. Shaking the torso and legs causes the pants to slide upward. When they are at the buttocks, the individual utilizes friction between the floor and trousers to work the garment into place. Children with a phocomelic hand can manage underpants to which a tape has been sewn from the midfront waistband to the midback waistband; the tape drapes over the front and With a reacher, a stick with a hook at one end, the continues to the back of the garment. Some girls and women find that underpants modified client can lower and raise the pants. Undergarments designed for incontinence are with a split crotch facilitate toilet activity. another option to augment security.
Bilateral Amputation
Clients with bilateral below-elbow (transradial) amputation can use a sponge mitt over one forearm for soaping and scrubbing. Alternatively, a terry cloth mitt can hold a bar of soap. For cleansing while in the shower, the patient can loop one end of a strip of toweling over the shower head by maneuvering with both amputation limbs. The other end of the strip adheres to the tub floor by means of suction cups. Most individuals can operate faucets with the feet, particularly if the faucet has a flange rather than a knob handle. Similarly, flanged faucet handles at the wash basin are convenient. A terry cloth bathrobe simplifies drying oneself.
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Before toileting, outer and undergarments must be loosened or removed. For men and boys, the trouser zipper may be left partially open, covered by the hem of an overshirt. The individual can urinate independently, particularly if he does not wear undershorts. 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. Some individuals regulate the diet in order to defecate at home in the morning or at night. Perineal cleansing can be accomplished by foot and trunk motion. Paper is held in the toes or Others drape paper over the rim placed over the heel; the patient then rocks over the foot. A bidet or special toilet seat of the toilet and straddle the bowl to wipe themselves. equipped with a water spigot and warm airflow is suitable for the home. Kuhn described a vaginal tampon applicator for women with bilateral amputation. hygienic aids can be constructed easily. Other
The individual with phocomelia can use a reacher stick with a padded hook or wire coil at one end to secure toilet paper. Various grooming aids may be attached to a similar stick, such as a comb, hairbrush, and toothbrush. An electric floor model shoe buffer enhances one's appearance.
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. The holder accommodates a spoon or If the amputation limbs are long enough, the patient does not need any device to hold fork. eating utensils; he or she merely stabilizes the fork or spoon with both limbs.
Bilateral Amputation
When writing, the client can secure the paper in a clipboard and use the transradial amputation limb or the chin to nudge the paper into position. 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 pen can be held in a forearm cuff, the teeth, or if one is limber, the toes. The client with bilateral transradial or elbow disarticulation amputations can The beginner use both limbs to stabilize a pencil, pen, or crayon for writing and drawing. will find that a felt-tipped pen makes writing easier.
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Bilateral Amputation
A reacher stick can help the client engage in light household tasks. Those with bilateral transradial amputations may make considerable use of the antecubital fossae for holding packages, which can then be opened with the teeth.
Bilateral Amputation
Book holders are offered by many special equipment manufacturers. The reader turns pages with the bare amputation limb or a mouth stick; commercial page turners are an expensive alternative. A leather mitt riveted to the side of each aluminum ski pole accommodates the skier with transradial amputations. A champion tennis player has bilateral longitudinal deficiencies.
Recreation: Music
Among the recreational options for patients with upper-limb amputation is musical participation. Children and adults play many instruments, sometimes aided by simple modifications or variation from customary performance practice.
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Unilateral Amputation
The individual with transradial amputation can support the trumpet on the amputation limb, with an adapted neck strap, or on a custom-made stand. Although valves are designed for the right hand, they can be depressed with either hand. The French horn is particularly suitable for those with amputation. Conventional performance assumes valve control with the left hand; thus the musician with right transradial amputation places the bare amputation limb in the bell. A cupped cardboard or plastic fixture mounted in the bell facilitates pitch regulation. A person with left amputation can play in reverse, although balancing the horn will be cumbersome. If the player develops a serious interest, an instrument with tubing coiled in reverse can be ordered from the manufacturer. 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. Numerous ways of striking percussion instruments such as drums and xylophones make them accessible to virtually all individuals with amputation. 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. A double-headed drum stick enables the bass drummer to play while marching. 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. Some musicians with transcarpal amputation who retain wrist motion hold the pick in the wrist. Those with left amputation reverse the strings and bridge and, for the steel-stringed guitar, the pick guard also. Commercial left-hand guitars are another option. The conventional strap aids in supporting the guitar, as does the footrest ordinarily used on the right side. The banjo and ukulele can be played in a similar manner. The piano and other keyboard instruments can be played one-handed, with music chosen from the large literature ranging from elementary to virtuoso pieces. Electronic keyboard instruments are another option for unimanual playing.
Bilateral Amputation
The musician with bilateral transradial amputation can sit and support the bell of a trumpet on the leg; valves are pushed with either or both amputation limbs, depending on the note. The bugle can be held and played by anyone with unilateral or bilateral transradial or above-elbow (transhumeral) amputations without prostheses. It can be held by either intact limb or by a neck strap or floor stand; because it has no valves, pitch is determined by the musicians mouth. Assembling the instrument is accomplished by asking a friend to assist, or the player can use the broad, resilient surfaces of the transradial limbs to stabilize the brass segments. Borrowing from the one-man-band tradition, 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. One or a pair of leather cuffs worn by a percussionist with bilateral transradial amputations enables playing the triangle, chimes, and gong suspended from a stand. Shaken instruments such as mara-cas can be secured with the cuffs, particularly if the handle is covered with friction tape to increase stability in the cuff. A snugly fitting sandal modified to hold a plastic pick enables one to play stringed instruments with the foot. One guitarist simply strums with the pick held in the toes. 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.
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more daunting for the client with bilateral upper-limb amputation. In contrast, the individual with amputation of one or both legs who does not wear prostheses is likely to experience considerably more difficulty during certain tasks, especially locomotion, than those who are able to use prostheses.
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Patients whose balance is poor or whose arms are not strong require the added support of axillary crutches. 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, although the pulse rate averaged 39% higher with the crutches. Six of the subjects were younger than 40 years of age. 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. Stair ascent on crutches is somewhat less intimidating than descent. 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. Evaluation of ten young adults demonstrated that they consumed 49% more Ten energy on stair ascent with axillary crutches than did nondisabled control subjects. patients with below-knee (transtibial) amputations performed more poorly with crutches than when wearing prostheses. Crutch use was associated with greater energy cost and slower speed; subjects had to lead with the intact leg and then raise the crutches. With the Young adults with transtibial amputation were prosthesis, they could climb step over step. 48% less efficient with crutches but only 29% less efficient with prostheses as compared with nondisabled adults. Hopping is another means that patients in good physical condition use to move over relatively short distances. Even those individuals who use a prosthesis may hop to get to the swimming pool from the locker room. The patient should endeavor to land lightly with a springy step on each hop to prevent spraining or fracturing the foot. The trunk should incline slightly forward, and the individual should lift the foot from the ground as short a distance as possible. To traverse very brief distances, the patient may prefer to pivot on the foot, alternately on heel and forefoot. The maneuver is less stressful than hopping. To operate an automobile, the driver with a right amputation should have a car equipped with a hand parking brake, hand dimmer switch, and left foot accelerator pedal.
Bilateral Amputation
Many people with bilateral amputation require a wheelchair. The chair should have its rear wheels set back to compensate for the posterior shift of the user's center of gravity. While swing-out footrests are appropriate for those who wear cosmetic or functional prostheses, those who do not wear prostheses can transfer to and from the chair more easily if there are no foot-rests. A reclining wheelchair relieves the discomfort of prolonged sitting. An overhead trapeze bar facilitates moving from the bed to the wheelchair, particularly when elbow extensors are not strong enough to lift the body weight. For other transfers, a wood or plastic sliding board may be used. The board bridges the gap between the wheelchair and the transfer goal, such as the bed. With the board in place, the individual can shift weight from one buttock to the other in a diagonal manner to maneuver from one surface to the next. Another option is a series of sturdy boxes of graduated height leading from the floor to the wheelchair seat. The patient shifts from one box to the next with support by the buttocks and hands. Some individuals who can tolerate weight bearing through the ends of the amputation limbs, such as a person with bilateral knee disarticulations, can walk either unassisted or with the support of short canes or crutches. Others may find a cart or a low platform on casters suitable for scooting about the home, with the hands used for propulsion. Such a vehicle can be used in areas too narrow for a wheelchair. In an emergency, the patient can negotiate stairs by sitting on the top stair and lowering the trunk. Descent is controlled with the hands, which are placed on the tread or bannister posts. Climbing stairs in this fashion is more difficult but is less likely to be required. The automobile should be equipped with hand controls for safe operation. The controls, however, should augment rather than replace conventional foot controls so that the car can be driven by other family members or a mechanic.
Recreation
Numerous adaptations, described elsewhere in this book, enable many individuals with unilateral and bilateral leg amputations to engage in a wide variety of sports and other
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pastimes.
Unilateral Amputation
While many clients choose to swim and scuba dive without a prosthesis, they must have a means of moving from the dressing room to the water's edge, such as by hopping or using Agile individuals crutches. Swimming provides superb recreation as well as good exercise. can play several sports while balancing on crutches, for example, kick ball and soccer. Other sports that do not require the use of a prosthesis include mountain climbing, skiing, and sky diving.
Bilateral Amputation
Swimming is popular with some people having bilateral amputation, for they can use their upper limbs as the power source. The water enthusiast can obtain a wet suit or swim fins to fit the amputation limbs. A plastic wheelchair is ideal for beach use. Activities popular with paralyzed wheelchair users also suit individuals with leg amputation. Tennis, basketball, bowling, hockey, and dancing can be enjoyed by the seated individual. Other recreational pursuits enjoyed by those with bilateral leg amputation include horseback riding, motorcycling, skateboard stunts, mountain climbing, and weight lifting.
SUMMARY
Individuals with amputation, whether upper or lower limb, accomplish many personal activities without prostheses. Occasionally, 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, mechanically, or cosmetically acceptable options. Patients with unilateral or bilateral upper-limb absence can be guided to select clothing that is easy to don, with or without prostheses. 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, feeding, and other skills. At all ages, the teeth are useful for grasping. Many nonprosthetic techniques enable adults and children to complete grooming and hygienic care and eat a varied diet gracefully. Writing and keyboard usage, important for school and vocation, can be done with simple adaptation of basic implements and thoughtful selection of typewriters, computers, and other equipment. Virtually all homemaking duties can be managed without prostheses, sometimes borrowing techniques developed for persons with hemiplegia. A wide range of games, sports, and other recreational pursuits are within the compass of those who do not wear prostheses. Similarly, children and adults who do not wear lower-limb prostheses can learn suitable clothing styles and safe bathing procedures. Alternatives to prosthetic locomotion include crutches, hopping and pivoting, and operation of a wheelchair and automobile. Recreational endeavors with and without prostheses and with or without special equipment are burgeoning. Rehabilitation of the client with amputation is not synonymous with prosthetic fitting and use. Rather, the individual should be assisted to maximize personal, vocational, and recreational function whether or not prostheses are worn. Then can the goal of community entry, or reentry, be achieved. References: 1. Adaptability, catalogue. Post Office Box 515, Colchester, CT 06415. 2. Applied Technology for Independent Living, catalogue. 4732 Nevada Ave North, Crystal, MN 55428. 3. Bender LF: Prostheses and Rehabilitation After Arm Amputation. Springfield, Ill, Charles C Thomas, Publishers, 1974. 4. Breaking New Ground: Agricultural Tools, Equipment, Machinery, and Buildings. West Lafayette, Ind, Department of Agricultural Engineering, Purdue University. 5. Cleo Living Aids, catalogue. 3957 Mayfield Rd, Cleveland, OH 44121. 6. Cope PC, Hile J: A bathing assist. Inter-Clin Info Bull 1970; 10:6-8. 7. Crawford R, Bowker M: Flaying from the Heart. Rocklin, Calif, Prima Publishing & Communications, 1989.
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8. Danzig AL: Handbook for One-Handers. New York, Federation of the Handicapped. 9. Datta SR, Chatterjee BB, Roy BN, et al: Mechanical efficiencies of lower-limb amputees rehabilitated with crutches and prostheses. Med Biol Eng 1974; 12:519-523. 10. Edelstein JE: Musical options for upper-limb amputees, in Lee MHM (ed): Rehabilitation, Music and Human Well-Being. St Louis, MMB Music Inc, 1989. 11. Engstrom B, Van de Ven C: Physiotherapy for Amputees: The Roehampton Approach. New York, Churchill Livingstone Inc, 1985. 12. Erdman WJ, Hettinger T, Saez F: Comparative work stress for above-knee amputees using artificial legs or crutches. Am J Phys Med 1960; 39:225-232. 13. Everest & Jennings Avenues, catalogue. 3233 East Mission Oaks Blvd, Camarillo, CA 930112. 14. Fashion Able for Better Living, catalogue. 5 Crescent Ave, Rocky Hill, NJ 08553. 15. Fisher SV, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehabil 1978; 59:124-133. 16. Friedmann L: Functional skills in multiple limb anomalies, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1988, pp 150-164. 17. Friedmann L: Special equipment and aids for the young bilateral upper-extremity amputee. Artif Limbs 1965; 9:26-33. 18. Friedmann L: Toileting self-care methods for bilateral high level upper limb amputees, Prosthet Orthot Int 1980; 4:29-36. 19. Ganguli S: Analysis and evaluation of the functional status of lower extremity amputeeappliance systems: An integrated approach. Biomed Eng 1976; 11:380-382. 20. Ganguli S, Bose KS, Datta SR, et al: Biomechanical approach to functional assessment for use of crutches for ambulation. Ergonomics 1974; 17:365-374. 21. Gardner WH: Left Handed Writing Instruction Manual. Danville, Ill, The Interstate Special Education Series, 1958. 22. Garee B (ed): Single-Handed: Devices and Aids for One Handers and Sources of These Devices. Bloomington, Ill, Accent Special Publications, 1978. 23. Heger H: Adaptive devices for amputees and training of upper extremity amputees. A. Training of upper extremity amputees, in Banerjee SN (ed): Rehabilitation Management of Amputees. Baltimore, Williams & Wilkins, 1982, p 263. 24. Heinze A: Use of Upper Extremity Prostheses (video). Thief River Falls, MN 56701. 25. Holliday PJ: Nonprosthetic care, in Kostuik JP (ed): Amputation Surgery and Rehabilitation: The Toronto Experience. New York, Churchill Livingstone Inc, 1981, pp 248-252. 26. Karacoloff LA: Lower extremity amputation: A Guide to Functional Outcomes in Physical Therapy Management. Rockville, Md, Aspen Systems Corp, 1986. 27. Kegel B: Physical fitness: Sports and recreation for those with lower limb amputation or impairment. J Rehabil Res Dev 1985, suppl 1. 28. Kegel B: Sports for the Leg Amputee. Redmond, Wash, Medic Publishing Co, 1986. 29. Kerr D, Brunnstrom S: Training of the Lower Extremity Amputee. Springfield, Ill, Charles C Thomas Publishers, 1956. 30. Kessler HH: Three cases of severe congenital limb deficiencies: Twenty-year followup. Inter-Clin Info Bull 1971; 10:1-9. 31. Kuhn GG: Vaginal tampon applicator. Inter-Clin Info Bull 1977; 16:13-15. 32. Macnaughtan AKM: Clothing for the Limb Deficient Child. Edinburgh, Princess Margaret Rose Orthopaedic Hospital, 1968. 33. Maddak Inc, catalogue, Pequannock, NJ 07440. 34. May EE, Waggoner NR, Hotte EB: Independent Living for the Handicapped and the Elderly. Boston, Houghton Mifflin Co, 1974. 35. Melendez D, LeBlanc M: Survey of arm amputees not wearing prostheses: Implications for research and service. J Assoc Child Prosthet Orthot Clin 1988; 23:62-69. 36. Melendez T, White M: A Gift of Hope: The Tony Melendez Story. San Francisco, Harper & Row Publishers Inc, 1989. 37. Narang IC, Mathur BP, Singh P, et al: Functional capabilities of lower limb amputees. Prosthet Orthot Int 1984; 8:43-51. 38. Nesbitt JA: The International Directory of Recreation-Oriented Assistive Device Sources. Marina Del Rey, Calif, Lifeboat Press, 1986. 39. Patton JG: Developmental approach to pediatric prosthetic evaluation and training, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1988, pp 137-149. 40. Phippen W, Hunter JM, Barakat AR: The habilitation of a child with multiple congenital skeletal limb deficiencies. Inter-Clin Info Bull 1971; 10:11-17. 41. Ring ND: Miscellaneous aids for physically handicapped children. Inter-Clin Info Bull
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1972; 12:1-12. 42. Robinault IP (ed): Functional Aids for the Multiply Handicapped. New York, Harper & Row Publishers Inc, 1973. 43. Smith LA: A method of typing for the handicapped: One-hand touch typing. Cerebral Palsy Rev 1960, pp 11-12. 44. Typewriting Institute for the Handicapped, 3102 West Augusta Ave, Phoenix, AZ 85021. 45. Washam V: The One-Handers Book: A Basic Guide to Activities of Daily Living. New York, Harper & Row Publishers Inc, 1973. 46. Waters RL, Perry J, Chambers R: Energy expenditure of amputee gait, in Moore WS, Malone JM (eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989, pp 250-260. 47. Wellerson TL: A Manual for Occupational Therapists on the Rehabilitation of Upper Extremity Amputees. Dubuque, Iowa, Wm C Brown Book Co, 1958. 48. White EE: Jim Abbott: Against All Odds. New York, Scholastic Inc, 1990. 49. Wright B: Independence in toileting for a patient having bilateral upper-limb hemimelia. Inter-Clin Info Bull 1976; 15:21-24. 50. Youll WJ: Toilet aid for people with lower limb disabilities. Techn Aid Disabled J 1983, pp 13-15.
Chapter 30 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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necessary when it is time to pull to stand. Develop-mentally oriented physical and occupational therapists are an invaluable part of the clinic team. 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. There is, however, a difference in acceptance of upper vs. lower prosthetic limbs. Legs are required for mobility, and as soon as the child appreciates this, the prosthesis rarely comes off. Upper-limb prostheses, on the other hand, have varying degrees of acceptance. The upper-limb prosthesis is not able to replace a missing part to the same degree that a prosthetic leg can. At best it is a tool, and if it doesn't enhance function, it will be rejected. Few There have been several studies of rejection of upper-limb prostheses by children. sound conclusions have been reached. Clearly, cosmesis and function are two major concerns. A third factor, acceptance by the parents of the child's disability, may be more important. 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. Also, prosthetic wearing practices by the child are used as a behavior to influence their relationship with their parents. When pediatric amputees reach adolescence, they undergo the same intellectual and emotional changes that other adolescents face. The limb deficiency makes this adjustment that much more difficult. Frequently a limb is rejected as the child is confronted with a new group of peers. They don't want to be "different.'' As, it is hoped, acceptance into the group occurs, the limb goes back on to aid with function. This concern can pertain to lower-limb prostheses but applies much more so to upper-limb prostheses. Lower-limb prostheses may be worn because they are needed for ambulation, but the wearer may go to extremes to hide them. They may avoid swimming and clothing that fails to mask the limb loss such as shorts or dresses. These actions reflect the acceptance by the child of his own body image to a greater or lesser degree. Upper-limb prostheses tend to be rejected outright when there is frustration with self. In considering all of these growth and adjustment issues, there is little question that the child is not just a small adult. The clinic team is necessary to bring together professionals with expertise in addressing these many adjustment issues. In 1954, the need for an organized approach to the management of juvenile amputees across the country was discussed at a meeting in Grand Rapids, Michigan. Subsequently, Gerald F.S. Strong, Chairman of the Prosthetics Research Board, appointed an interim committee of ten members to pursue the issue. Dr. Charles H. Frantz chaired the first meeting at UCLA in 1956. The group officially became the subcommittee on Child Prosthetic Programs within the National Academy of Sciences Prosthetics Research and Development Committee in 1959. The goal of the subcommittee was to raise the standards of prosthetic care for children in the United States. Prior to this time prosthetic components were oftentimes not available in pediatric sizes. Prescriptions were withheld until the child started school and was therefore deemed to need a limb. To begin the dissemination of information and the establishment of clinic criteria, four major symposia were sponsored by the subcommittee to reflect the state-of-clinic expertise during the 1960s. By 1970, the subcommittee was charged to enlarge its sphere of activity to include children's orthoses and mobility aids. Under the guidance of Hector Kay, Assistant Executive Director of the Committee for Prosthetic Research and Development, the annual conferences were expanded to include cooperating clinic chiefs and their team members. The Association of Children's Prosthetic/Orthotic Clinics has held an annual interdisciplinary conference since 1972. It is now the primary forum for the exchange of information on the limb-deficient child in North America. Members include not only individuals but also the clinic teams as a unit. This recognizes the importance of the team approach. As stated earlier, the limb-deficient child has multiple needs that can only be addressed by the team. Children have many unique prosthetic needs. As their minds and bodies are growing, so are their residual limbs. Frequent socket revisions or replacements are necessary to accommodate this growth. 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, biannually from 5 to 12 years, and then one every 3 or 4 years until 21 years of age. The need for frequent and regular checkups by the clinic team is obvious.
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The durability of the young healthy tissue on the residual limb of a child is quite different from that of the dysvascular adult amputee. Consequently, alterations in fit are much better tolerated. Nevertheless, the frequent changes necessary present an economic concern. To lengthen the useful life of a prosthesis, materials that are easily modified and lengthened should be used. In addition, it should be noted that durability of children's prostheses is more important than cosmesis. In that regard, soft covers, while cosmetically desirable, are easily destroyed by the abuse children give them. Above all, prostheses must facilitate function. Those that the child must be careful of should be avoided. Healing in a child is much different than in the adult. Skin is much more elastic and will better tolerate stretching to cover the end of the residual limb. Skin grafts will frequently mature sufficiently to tolerate direct weight bearing as well as the shear forces experienced with socket wearing. The skeletally immature child relies on growth of the residual limb to maintain sufficient length for good biomechanical strength later on. This is generally not a concern with the congenital amputee. As a rule, the relative length discrepancy experienced in a congenital limb deficiency is maintained. One must, however, not leave this to chance. When planning the proper time for surgical intervention on a proximal femoral focal deficiency (PFFD), for instance, proper use of serial scan-o-grams is necessary. With the advent of newer techniques of limb lengthening and deformity corrections, proper documentation of growth potential is increasingly important. Residual-limb length is of vital concern for the acquired amputee. The concept of preserving as much length as possible should be considered, especially by the use of disarticulation rather than transosseous ablation. For example, since 70% of the growth of the femur comes from the distal femoral physis, a long trans-femoral amputation in a 2-year-old becomes very short by the time that child becomes an adult. A knee disarticulation will avoid this problem. If a knee disarticulation is done too close to the time of physeal closure, on the other hand, the relative retardation of physeal growth on that side may not be sufficient to avoid an overly long, uncosmetic thigh. The solution to this is a distal femoral epiphysiodesis. This provides end-bearing ambulation with shorter length that will allow trans-femoral knee components, with resultant good sitting and standing cosmesis. There is another reason to perform joint disarticulations rather than diaphyseal transections in children whenever possible. This is because the major complication of amputation surgery in children is bony overgrowth. It does not occur with disarticulations but frequently follows metaphysealor diaphyseal-level amputations. The incidence of this complication is variously reported in the range of 10% to 30%. Histologically, this is appositional bone growth of the remaining diaphysis. It is clearly not growth from the remaining proximal physis. Various techniques of handling the bone and periosteum during amputation have failed to decrease the incidence of this complication. Silastic caps or plugs have been tried, but the results Marquardt in Germany suggests transplanting a cartilaginous apophysis are disappointing. Usually from the ilium or preserving an epiphysis from the amputated portion of the limb. there is bursal formation over the end of the bone that can become exquisitely tender. Occasionally, skin breakdown occurs, and the bone may penetrate. Socket modification can delay revision, but once the residual limb becomes pencil shaped, revision is necessary. This is often required more than once until skeletal growth ceases. The residual limb does not need to be appreciably shortened overall since the appositional growth effectively adds length to the bone. There is one area where the option of preserving length at all costs must be carefully exercised. This is the post-traumatic partial-foot amputation. For example, forefoot amputation due to lawn mower injuries frequently leaves an infected residuum with plantar scarring. While it is advantageous to be able to walk barefoot without a prosthesis, making a functional partial-foot prosthesis, especially for a less-than-optimal partial-foot amputation, is technically challenging. Concerns related to cosmesis, comfort, and function are very difficult to satisfy. Frequently a Syme ankle disarticulation fitted with a prosthesis is the best option. It is very cosmetically pleasing in a child, where malleolar size is not a problem. Nevertheless, after investing a lot of time and emotional effort in preserving length at all costs, the family is often unwilling to consider a revision as an alternative to a very clumsy partial-foot prosthesis. This problem should therefore be carefully considered in the initial treatment of each partial-foot
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amputation. In the past, age appropriateness for prosthetic prescription was related to the purported ideal age at which a child could use an upperor lower-limb prosthesis. Now it pertains to appropriate ages for specific terminal devices and feet. There has also been an effort to develop criteria for the prescription of costly myoelectric limbs for very young children. Some clinics are claiming functional capabilities occurring earlier than we know them to happen in sound limbs. What is needed are controlled studies to evaluate the functional appropriateness of prescription ages. 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. Lower-limb components are being proposed for the pediatric population based on successes with adults. It is often asked whether dynamic-response feet for children should be prescribed. Due to the small body mass of the child and the frequent need for new limbs due to growth, their efficacy needs to be demonstrated. In the chapters that follow, a number of topics unique to the limb-deficient child will be addressed, including acquired amputations (Chapter 32). The epidemiology of injuries causing traumatic amputations must be studied to learn how to provide a safer environment for our young. Lawn mowers, farm instruments, and recreational vehicles are all hazardous to the inexperienced. The International Standards Organization (ISO) has recently adopted a definitive classification system for congenital limb deficiencies (Chapter 33). No longer is it necessary to learn a series of ancient language roots to describe our patients. This new system, utilizing just four words-longitudinal, transverse, partial, and total-has been accepted by the International Society for Prosthetics and Orthotics and the Association of Children's Prosthetic/Orthotic Clinics. It will allow for a more concise data base and communication of statistics on an international basis. Other areas of interest are the surgical and pros-thetic/orthotic management of upper-limb deficiencies (Chapter 34A and Chapter 34B). Reluctance has been expressed in the past for doing revision surgery on upper-limb amputees. It is time for this issue to be reconsidered. Prosthetic prescription, i.e., body vs. myoelectric power and tool vs. cosmetic hand terminal devices, should be addressed. There is good evidence that very young children are able to use myoelectric limbs. Is it necessary, advantageous, and cost-effective? More studies are needed to answer all of these questions. The developmental approach to upper-limb prosthetic training is discussed in detail (see Chapter 34D). As children grow and develop, especially in their early years, their motor skill capabilities change rapidly. Prosthetic components and training must change along with them. 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). To conclude the discussion of the child amputee with a chapter entitled Special Considerations is most appropriate (Chapter 36). The needs of the limb-deficient child are indeed special as this introductory chapter has sought to point out. The sections on the multiple amputee, tumor salvage procedures, and recreational concerns address the new frontiers being developed in the field of juvenile amputee management. References: 1. Aitken GT: Osseous overgrowth in amputations in children, in Swinyard CW (ed): Limb Development and Deformity; Problems of Evaluation and Rehabilitation. Springfield, Ill, Charles C Thomas Publishers, 1969. 2. Bunch WH, Deck JD, Ronner J: The effect of denervation on bony overgrowth after below knee amputations in rats. Clin Orthop 1977; 122:333-339. 3. Kruger L: Unpublished data. 4. Kubler-Ross E: On Death and Dying. New York, Mac-millan Publishing Co Inc, 1969. 5. Lambert C: Amputation surgery in the child. Orthop Clin North Am 1972; 3:473-482. 6. MacDonnell JA: Age of fitting upper extremity prostheses in children. J Bone Joint Surg [Am] 1958; 40:655-662. 7. Meyer LC, Sauer BW: The use of porous, high-density polyethylene caps in the prevention of appositional bone growth in the juvenile amputee: A preliminary report.
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Inter-Clin Info Bull 1975; 14:9-10. 8. Patterson DB, et al: Acceptance rate of myoelectric prosthesis. J Assoc Child Prosthet Orthot Clin 1990; 25:73-76. 9. Swanson AB: Bony overgrowth in the juvenile amputee and its control by the use of silicone rubber implants. Inter-Clin Info Bull 1969; 8:9-18. 10. Wang GW, Baugher WH, Stamp WG: Epiphyseal transplants in amputations. Clin Orthop 1978; 130:285-288. 11. Weaver SA, et al: Comparison of myoelectric and conventional prostheses for adolescent amputees. Am J Oc-cup Ther 1988; 42:78-91. 12. Wilke H: Presidential Guest Speech. 1989 Annual meeting of the Association of Children's Prosthetic/Orthotic Clinics.
Chapter 31 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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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
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. conserve all limb length possible, consistent with appropriate treatment for the condition that requires the amputation. Trauma is the proximate cause of most acquired amputations in children. In attempting to conserve length in the severely traumatized limb, adequate tissue vascularity of the growing child may allow the surgeon to use surgical techniques that are not successful in the adult. Skin grafts, firm traction, and wound closure under tension may be judiciously used in the child to conserve limb length without compromising wound healing or subsequent prosthetic use. Split-thickness skin grafts, even over large areas of the stump, may tolerate prosthetic use quite well in the child. 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. For the same reasons, open wounds may successfully be closed under slightly more tension in the child than would be permissible in similar adult patients. In each instance, however, good surgical judgment must be used since even the tissue tolerance of the child has its limitations. A second surgical dictum is, whenever possible, to perform a disarticulation rather than a transdiaphyseal amputation in a growing child. Disarticulation preserves the epiphyseal growth plate and thereby ensures longitudinal growth of the bone. Loss of stump length due to epiphyseal loss is most readily apparent in trans-femoral amputations in young
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children. In amputations at this level, the distal femoral epiphysis, which accounts for approximately 70% of the longitudinal growth of the femur, is sacrificed. When a midthigh amputation is performed in a young child, 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.). 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. The prominent condyles or malleoli resulting from disarticulation usually undergo atrophy with further growth of the child, thereby eliminating the cosmetic objection to this type of surgery when it is performed in the adult.
COMPLICATIONS
Terminal overgrowth is the most common complication of amputation surgery in the skeletally immature individual. This is an appositional overgrowth of new bone at the transected end of a long bone. 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. occurs most often in the humerus, fibula, tibia, and femur, in that order. In this condition, 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.). Many surgical techniques have been devised to prevent terminal overgrowth from developing. These include using intramedullary implants of silicone rubber or porous polyethylene to cap the resected bone end and prevent terminal overgrowth. This approach may eventually prove to be effective. However, the best treatment method remains stump revision with appropriate resection of the bony overgrowth. This has been necessary in 8% to 12% of several Once surgery becomes reported large series of acquired amputations in children. necessary to correct the problem, recurrences are common and may necessitate repeated stump revision at 2- to 3-year intervals until skeletal maturity. Adventitious bursae frequently develop in the soft tissues overlying an area of terminal overgrowth. Conservative treatment of such symptomatic bursae by aspiration, corticosteroid injection, and stump wrapping is seldom more than temporarily effective. Bursae that form over bony prominences subjected to recurrent pressure from a prosthetic socket are effectively managed by appropriate socket modifications. 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.). Bone spurs often form at the periphery of transected bone ends as a response to periosteal stimulation at the time of surgery. Such bone spurs rarely necessitate stump revision and should be easily distinguished from terminal overgrowth. Extensive stump scarring from trauma, previous surgery, or skin grafting is usually well tolerated by the child amputee. Stump revision is seldom necessitated by scarring alone, 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. usually relieve symptomatic pressure that is concentrated over small areas of scarring in relatively non-weight-bearing areas of the amputation 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. More extensive prosthetic modifications may be necessary when the scarred area is larger or is over weightbearing areas of the stumps. 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. For the severely scarred transtibial stump, 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. Other successful techniques include the use of an air cushion socket or a Silastic gel socket insert with a rubber sleeve for suspension. 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. Suspension is by means of a supracondylar strap or, if necessary, with outside knee joints and a thigh corset. When upper-limb amputations are complicated by extensive trunk scarring, harnessing techniques alternative to the figure-of-8 harness may be necessary. The shoulder saddle with chest strap is an excellent solution in such cases ( Fig 32-6.).
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Neuroma formation in amputation stumps of children is seldom symptomatic enough to warrant surgical treatment. In reviewing a large series of acquired childhood amputations, found that only 4% required surgical treatment for neuromas, most being Aitken satisfactorily managed by socket adjustment. The phantom limb phenomenon always occurs in children following acquired amputations. If the amputation is performed on a child under the age of 10 years, the phantom sensation is rapidly lost. Painful phantom limb sensation does not occur in growing children, but has been reported in the teenager.
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, surgical techniques in the child do not differ significantly from those used for the adult. Therefore specific surgical procedures will not be outlined for any of the major levels of amputation in the upper or lower limb. However, several specialized surgical procedures do deserve mention. The Krukenberg, or "lobster-claw," operation, may well deserve consideration in the child with a long transradial (below-elbow) amputation. 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. The forearm muscles that attach to the two rays provide voluntary opening and closing of these rays. 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. The procedure has its greatest application in bilateral upper-limb amputees, especially in the blind. Syme ankle disarticulation is a frequently indicated level of amputation in the growing child. 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. 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. As in other traumatic incidents, preservation of limb length is of major concern in both of these injuries. The physiologic tolerance of growing children fortunately allows the surgeon to preserve limb length by using skin grafts, traction, and soft-tissue-shifting plastic surgery procedures. Most lawn mower injuries sustained by children result in partial-foot amputations. Some of these injuries involve only the digits or the distal metatarsal area and present no great treatment problems. Others are quite extensive and involve most of the foot with multiple deep and extensively contaminated wounds. In these latter instances, 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. This decision is seldom obvious, and when doubt exists, it is better to err on the side of conservatism. The initial debridement of such injuries should be limited to excision of only that tissue that is absolutely nonviable, with any tissue of questionable viability being preserved. 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. Following thorough irrigation and debridement, the wound is lightly packed open. Five to 7 days later the wound is examined with the patient under anesthesia. After further debridement of any nonviable tissue, a decision may be made to revise the amputation to a higher level or to continue with a more conservative approach. For example, 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 revision to a higher level (Syme ankle disarticulation or transtibial amputation) is indicated at the time of the first wound dressing, an open amputation is preferable, followed by skin traction until secondary closure is performed 5 to 7 days later. If continued conservatism seems appropriate, it may be possible to partially close the wound at this time with minimal additional bone resection. If extensive skin grafting or tissue-shifting plastic surgery procedures such as a Z-plasty are needed, these are more safely done at the time of a second wound dressing 5 to 7 days later, when
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granulation tissue begins to cover open areas and the danger of infection is less. Thermal or electrical burns may cause such widespread tissue destruction that amputation of a major portion of the limb may become necessary. In such circumstances, conservative treatment should be pursued until there is adequate demarcation of nonviable tissue to allow open amputation at the lowest possible level. During this time, appropriate splinting of proximal joints is essential to minimize the development of joint contractures in nonfunctional positions. Despite splinting, late soft-tissue releases may be needed to improve joint motion. Extensive skin grafting is usually necessary in children with severe burns, and the resultant scarred stumps may present very difficult problems in prosthetic fitting. The use of pressure dressings over scarred and grafted areas helps to decrease scar hypertrophy. When healing has occurred, gentle massage is often beneficial in mobilizing scar tissue that is adherent to bone. Successful prosthetic use usually necessitates modification of prosthetic sockets and suspension systems as noted previously. References: 1. Aitken GT: Overgrowth of the amputation stump. Inter-Clin Info Bull 1962; 1:1-8. 2. Aitken GT: Surgical amputation in children. J Bone Joint Surg [Am] 1963; 45:17351741. 3. Aitken GT: The child with an acquired amputation. Inter-Clin Info Bull 1968; 7:1-15. 4. Aitken GT, Frantz CH: Management of the child amputee. Instr Course Lect 1960; 17:246-298. 5. Aitken GT, Frantz CH: The juvenile amputee. J Bone Joint Surg [Am] 1953; 25:659664. 6. Brand PW, Ebner JD: Pressure sensitive devices for de-nervated hands and feet. J Bone Joint Surg [Am] 1969; 51:109-116. 7. Cary JM: Traumatic amputation in childhood-primary management. Inter-Clin Info Bull 1975; 14:1-10. 8. Davies EJ, Friz BR, Clippinger FW Jr: Children with amputations. Inter-Clin Info Bull 1969; 9:6-19. 9. Frantz CH, Aitken GT: Management of the juvenile amputee. Clin Orthop 1959; 9:3047. 10. Hall CB, Rosenfelder R, Tabloda C: The juvenile amputee with a scarred stump, in Aitken G (ed): The Child With an Acquired Amputation. Washington, DC, National Academy of Sciences, 1972. 11. Herndon JH, LaNone AM: Salvage of a short below-el-bow amputation with pedicle flap coverage. Inter-Clin Info Bull 1973; 12:5-9. 12. Kay HW, Fishman S: 1018 Children With Skeletal Limb Deficiencies. New York, New York University Post-Graduate Medical School, Prosthetic and Orthotics, 1967. 13. Koepke GH, Giacinto JP, McUmber RA: Silicone gel be-low-knee amputation prostheses. Univ Mich Med Center J 1970;36:188-189. 14. Lambert CN: Etiology, in Aitken G (ed): The Child With an Acquired Amputation. Washington, DC, National Academy of Sciences, 1972. 15. Meyer LC, 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 1975; 14:1-4. 16. Romano RL, Burgess EM: Extremity growth and overgrowth following amputation in children. Inter-Clin Info Bull 1966; 5:11-12. 17. Snelson R: Use of transparent sockets in limb prosthetics. Orthot Prosthet 1973; 27:3. 18. Swanson AB: Bone overgrowth in the juvenile amputee and its control by the use of silicone rubber implants. Inter-Clin Info Bull 1969; 8:9-16. 19. Swanson AB: Silicone-rubber implants to control the overgrowth phenomenon in the juvenile amputee. Inter-Clin Info Bull 1972; 11:5-8. 20. Swanson AB: The Krukenberg procedure in the juvenile amputee. J Bone Joint Surg [Am] 1962; 46:1540-1548. 21. Von Soal G: Epiphysiodesis combined with amputation. J Bone Joint Surg 1939; 21:442-443. 22. Wilson LA, Lyquist E, Radcliffe CW: Air-cushion socket for patellar-tendon-bearing below-knee prostheses. Bull Prosthet Res 1968; 10:5-34.
Chapter 32 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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33: The ISO/ISPO Classification of Congenital Limb Deficiency | O&P Virtual Library
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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.
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METHOD OF DESCRIPTION
Transverse
The limb has developed normally to a particular level beyond which no skeletal elements exist, although there may be digital buds. 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.). It is possible to use another descriptor in the phalangeal case to indicate a precise level of loss within the fingers.
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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, and in this case there may be normal skeletal elements distal to the affected bone or bones. The following procedure should be followed to describe such a deficiency (see Fig 33-2. and Fig 33-3.): 1. Name the bones affected in a proximodistal sequence by using the name as a noun. Any bone not named is present and of normal form. 2. State whether each affected bone is totally or partially absent. 3. In the case of partial deficiencies the approximate fraction and the position of the absent part may be stated. 4. The number of the digit should be stated in relation to a metacarpal, metatarsal, and phalanges, the numbering starting from the preaxial, radial, or tibial side. 5. The term "ray" may be used to refer to a metacarpal or metatarsal and its corresponding phalanges. Examples of transverse and longitudinal deficiencies are shown in Fig 33-4. and Fig 33-5., 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, but the author has found it to be the most useful way of illustrating deficiencies in clinical notes, and it can be used to indicate some treatment as well as the deficiency.
BIBLIOGRAPHY
Burtch RL: Nomenclature for congenital skeletal limb deficiencies, a revision of the Frantz and O'Rahilly classification. Artif Limbs 1966; 10:24-25. Day HJB: Nomenclature and classification in congenital limb deficiency, in Murdoch G (ed): Amputation Surgery and Lower Limb Prosthetics. Edinburgh, Blackwell Scientific Publications Inc, 1988, pp 271-278. Frantz CH, O'Rahilly R: Congenital skeletal limb deficiencies. J Bone Joint Surg [Am] 1961; 43:1202-1204. Henkel HL, Willert HG: Dysmelia, a classification and a pattern of malformation of congenital limb deficiencies. J Bone Joint Surg [Br] 1969; 51:399-414. Kay HW: A proposed international terminology for the classification of congenital limb deficiencies. Inter-Clin Info Bull 1974; 13:1-16. Kay HW: The Proposed International Terminology for the Classification of Congenital Limb Deficiencies, the Recommendations of a Working Group of ISPO. Spastics International Medical Publications, W. Heinemann Medical books Ltd, and JB Lippincott, 1975. Swanson AB: A classification for congenital limb malformations. J Hand Surg 1976; 1:8-22. Swanson AB: A classification for congenital malformations of the hand. N J Bull Acad Med 1964; 10:166-169.
Chapter 33 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 34A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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flexing fingers, the palm of the hand, and the thumb metacarpal or proximal phalanx. Although the distal phalanx of the thumb may wrap around the object, the majority of the thumb power is contributed by the stabilizing effect of the adductor pollicis, which resists the pressure transmitted from the fingers through the object. The hand also has an important role in nonprehensile activities. These activities usually involve the transmission of force through the terminal portion of the limb to another object. Nonprehensile activities include typing or button pushing. Other nonprehensile activities include the punch thrown by a boxer or pushing open a swinging door.
SURGICAL TREATMENT
As one considers the treatment of an anomalous hand, it is well to contrast the effectiveness of surgical reconstructions with or without prosthetic management as opposed to doing neither. Nonprehensile activities are usually unaffected by surgical reconstruction. If a hand lacks a thumb (e.g., radial aplasia) and digital motion is good, side-to-side pinch will allow the child to perform most precision activities with reasonable facility. Without the buttressing effect of a thumb, however, power activities cannot be readily accomplished. Compensation may be achieved by flexing the fingers and wrist and securing a large object against the distal portion of the forearm. When the thumb is absent, shifting the index finger to the thumb position by polli-cization will improve power grasp as well as facilitate precision activity. 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. Construction of an ulnar-buttressing digit by either distraction lengthening, toe-phalanx transfer, or free-toe-transfer may allow the hand to achieve meaningful prehension. This may also be achieved by a prosthesis that provides a passive buttress. The infant is unaffected by his abnormality. As the baby begins to explore its environment, it learns to use its unique physical capabilities to best advantage. The young child's goal is to reach the cookie, grasp it, and bring it to its mouth. If this is most easily accomplished by one hand, the closest or most efficient hand will be employed. If the object is large or if singlehand prehension is not possible, then both hands will act together. The object may be secured against the chest. When upper-limb prehension is severely compromised, a child may develop the capacity for foot prehension. The child's growing awareness of his abnormality is usually the result of comments from playmates, siblings, or well-meaning adults. The child usually does not become selfconscious until about the age of 6 or 7 years. 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. Other points of psychological stress occur during adolescence as dating begins and concerns arise over attractiveness to the opposite sex. Feelings may be further complicated by impending marriage and the prospect of offspring with similar abnormalities. Access to knowledgeable genetic counseling is essential, particularly at that time. Aesthetic considerations are important when weighing different therapeutic alternatives in the management of congenital hand abnormalities. The hand and the face are the unclothed areas of skin most often exposed to scrutiny. When anomalous parts have an abnormal appearance and function is not compromised by their deletion, they should be removed. In this case, conversion of a malformed part to an amputation may result in an aesthetic improvement. On occasion, the removal of a functionless part may facilitate the fitting of a prosthesis. While approximately half of lower-limb congenital amputees require surgical revision prior to prosthetic fitting, only about 10% of congenital anomalous upper limbs fit for prostheses Consultation between the surgeon and prosthetist allows the require surgical revision. surgeon to understand which anomalies will obstruct prosthetic donning and wear. Portions of the affected limb that are useful for prehension without a prosthesis should never be amputated. It is possible to fit a prosthesis around a short phocomelic limb. This will allow the child to also develop functional capabilities out of the prosthesis. In some instances, the prosthesis may allow digits to function while the prosthesis is worn.
TIMING
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It is usually preferable to begin surgical reconstruction of the anomolous hand prior to or about the first birthday. Anesthesia can usually be safely accomplished by 6 months of age. For children under 18 months of age, it is possible to operate on both hands during the same surgical anesthetic. As the child ages, their frustration when both hands are immobilized increases. In addition, 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. Children undergoing digit-shifting procedures such as pollicization may benefit from early integration of the pollicized digit into evolving patterns of grasp. In some instances, it is wise to delay surgery until children are older because of systemic considerations. In children with TAR syndrome (thrombocytopenia with absent radius), in whom low platelet counts at birth gradually increase with age, it is usually wise to wait until before considering elective the child's platelet count has increased to at least 60,000/mm surgical reconstruction. In such cases, centralization of the wrist may sometimes be delayed until the child is 3 or 4 years of age. It is best to make major decisions regarding the reconstruction or deletion of digits when children are young. It is inappropriate to place the burden for deciding whether a digit is to be deleted or pollicized upon an adolescent. 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.
WRIST DISARTICULATION
The Krukenberg procedure has been suggested as a reconstructive alternative for children with congenital absence of the hand, particularly with profound contralateral abnormalities, associated blindness, or a lack of access to prosthetic care. The radius and ulna are separated from one another by the Krukenberg procedure. This creates a prehensile limb that will also allow prosthetic fitting. Because the cosmetic disadvantage of this procedure is substantial, it is rarely appropriate for the unilateral case (see Chapter 36A).
SYNDACTYLY
Syndactyly, the joining together of digits, may be categorized as complete or incomplete, with subcategories of simple or complex. When syndactylization extends the entire length of the digit, the condition is termed complete syndactyly. In cases in which the web involves only a portion of the length of the digits, it is termed an incomplete syndactyly. When skeletal and nail elements of the syndactylized digits are separate, the syndactyly is said to be simple. When there is joining of digital skeletal and/or nail elements, the syndactyly is termed complex. Acrosyndactyly refers to syndactyly in which the ends of the fingers are joined, often as a result of congenital constriction band syndrome. Dobyns et al. have further suggested that syndactyly of digits containing angulated phalanges be termed complicated syndactyly. Surgical release of syndactylized digits is usually indicated to enhance digital independence. Even short digits consisting of only a proximal phalanx may benefit from separation. Index finger radial abduction may be increased and pinch improved when a short index finger is untethered from the middle finger. Syndactyly release must provide skin coverage of the adjacent lateral surfaces of the released digits and also create a proper web space floor. 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. Many skin flap techniques have been advocated for the separation of syndactylized digits. Successful surgical procedures surface both digits with durable skin, create an appropriate web space floor, and accommodate growth of the digit without secondary contracture ( Fig 34A-1.,A and B). Effective techniques employ skin flap tissue to create a sloping web space
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floor of true anatomic proportions, both in width and depth. This flap tissue may be derived either from the dorsum of the hand, from the palmar aspect of the hand, or from a combination of both palmar and dorsal tissue. 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. A palmar flap provides a better commissure contour but results in the shifting of pink palmar skin into the web space. Since the web space is usually viewed from the dorsum, the difference in color is particularly noticeable in darkskinned individuals. 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. The web palmar commissure is supple enough to allow interdigital abduction of up to 45 degrees. 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. 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. After the web space floor has been closed and digital flaps rotated into place, templates are made of the residual defects. Templates are used to harvest full-thickness skin grafts from the groin crease. Skin grafts are sutured in place. Interdigital dressings are maintained until all wounds have healed. When multiple digits are syndactylized, it is usually wise to avoid releasing both sides of a digit during the same procedure.
POLYDACTYLY
Polydactyly takes many forms. In black children, post-axial (ulnar) Polydactyly is the most common form, while in white children preaxial (radial) Polydactyly is more frequent. Central Polydactylous Polydactyly is less common than either preaxial or postaxial Polydactyly. digits are rarely supernumerary, that is, they rarely represent parts additional to a normal hand. Most often polydactylous digits are abnormal and suggest an abnormal segmentation or separation of digital ray condensations, as though one or more of the five mesenchymal condensations was inappropriately longitudinally split. The challenge of surgery is not simply to remove sufficient tissue but rather to retain tissue sufficient to optimally reconstruct the retained digits. 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. This effect can be lessened by soft-tissue coaptation ( Fig 34A-2.,A and B). Incisions are planned to facilitate the coapting of soft tissues from both digits to provide optimal soft-tissue bulk. Angular deformity in either phalanx or metacarpal should be corrected by osteotomy. Surgical reconstruction aims to achieve a digit in which the carpometacarpal, metacarpophalangeal and inter-phalangeal joints are parallel. The longitudinal axis of the metacarpal and phalanges should be perpendicular to the three joints. Correction of angulation is usually achieved by a closing wedge osteotomy and secured by Kirschner wires. An opening wedge osteotomy using a segment of excised bone as intercalated graft is occasionally indicated. Preaxial Polydactyly takes many forms. Wassel has separated these abnormalities into seven categories, six of which involve biphalangeal thumbs ( Fig 34A-3.). Type I deformities may present as simply a wide distal phalanx and nail, in which case no treatment is indicated. If two nails are present, two alternative treatments may be considered. The first option is excision of one nail with the underlying bone, while the second involves a central resection of adjacent nail borders and underlying bone, combined with longitudinal phalangeal osteotomies to narrow the distal phalanx. When the latter technique, known as the BilhoutCloquet procedure, is attempted, care must be exercised in matching the nail matrix to avoid an unsightly longitudinal nail ridge. Osteotomies should be carried out distal to the physis to avoid growth disturbance. Type II duplications consist of two undersized (in comparison to normal) distal phalanges seated atop a somewhat widened proximal phalangeal distal articular surface. The radialmost digit possesses a collateral ligament along its radial border, while the ulnar digit possesses a collateral ligament along its ulnar border. The two digits abut with adjacent articular facets and are bound together by pericapsular tissue. It is preferable in most instances to excise the
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more radial digit because it is usually less well developed. The broad distal articular surface of the proximal phalanx may need to be tapered to a size appropriate to the distal phalanx. 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. Retained flexor and extensor tendons must be examined to ensure that the course and insertion of residual tendons are centered. Type III abnormalities are usually dealt with by deleting the radial digit. Type IV abnormalities usually require deletion of the radial digit, narrowing of the metacarpal head, and collateral ligament reconstruction. The intrinsic muscles that originally inserted into the more radial thumb are reinserted into the hood of the residual ulnar thumb component. Type V abnormalities usually require deletion of the more radial digit and reinsertion of the intrinsic muscle insertion into the residual ulnar 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. 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. In such instances the skeletal elements of the unsupported digit are excised, and skin flaps are designed to preserve or reconstruct normal web space contour and digital bulk. When formal ray resection is required, web space-preserving incisions should be selected. Postaxial Polydactyly of the digit joined only by soft tissue may be treated by simple excision. When the most ulnar digit articulates with the metacarpal head in a fashion similar to that in the Wassel type IV thumb duplication, simple digital excision will result in an inadequate residual digit. It may be necessary to narrow the metacarpal head, but it should be recognized that the little-finger metacarpal head, unlike the thumb metacarpal head, contains a physis and that care must be taken to preserve physeal growth. If the hypothenar musculature inserts into the more ulnar little finger, its insertion must be detached from the skeletal elements being resected and reinserted into the retained radial little finger. Similarly, 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. 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. radius is present. Surgery is useful in expanding the arc of elbow flexion and extension but does not gain forearm rotation. Because there is an overabundance of flexor musculature and relative paucity of extensor musculature, wrist flexion release may be necessary. 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.
RADIAL DEFICIENCY
The radial-deficient upper limb demonstrates a variable extent of radial absence, aplasia, or dysplasia of the soft-tissue and skeletal elements along the radial (preaxial) border of the When the radius is absent or severely dysplastic, the unsupported carpus will rest limb. against the radial border of the ulna and cause the hand to assume a posture at a right angle to the ulna. The thumb is frequently absent or, if present, is dysplastic. The more radial digits are often stiff with limited active flexion. Because the ring and little fingers are the most supple digits, they are frequently used for side-to-side prehension. 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. Beginning shortly after birth, the hand is splinted in an effort to stretch radial soft tissues. 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.,A-D). Centralization allows the hand to reach out away from the body, more effectively placing the radial digits in front of the body. 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. Although centralization does improve function in front of the body, it is not always indicated. If active elbow flexion is lacking, the abnormal radial deviation at the ulnocarpal level provides the child with the ability to bring the hand to the face. Because centralization frustrates this
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function, it is contraindicated if elbow flexion is lacking. The normal thumb participates in a wide variety of both precision and power prehensile activities. The hand without a thumb is nonetheless capable of great dexterity. Side-to-side pinch between fingers allows precision activity to be accomplished with relative facility. Normally, when an object is grasped in power prehension, the object is forced against the palm by the flexed fingers and buttressed by the stability of the thumb metacarpal. The ability of the individual without a thumb to hold large objects securely is thus markedly compromised. 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. 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. This shifted digit, however, is not a normal thumb. If the index and middle fingers were used for precision pinch prior to surgery, it is likely the pollicized index finger will continue to participate in precision activity against the middle finger. If the predominant pattern of precision prehension was between the middle and ring fingers or between the ring and little fingers, it is likely that this pattern will persist after polli-cization. In such situations the functional advantage of pollicization is realized only with power activity. Pollicization consists of four major elements, the skin incision, neurovascular dissection, skeletal adjustment, and musculotendinous rebalancing. 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.). 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. Care must be taken to preserve dorsal venous drainage of the digit. By resecting a major portion of the metacarpal, including the physis of the metacarpal head, the resultant digit will be of a length similar to that of a thumb. The metacarpophalangeal joint of the index finger is hyperextended and secured to the residual proximal 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. Shortening of the flexor tendons is not required. Spontaneous use of the digit is usually noted within a few months and continues to improve as the child ages.
ULNAR DEFICIENCY
The ulnar-deficient hand is characterized by an absence or hypoplasia of the ulna. Ectrodactyly is usually present and may be manifested in the absence of any of the fingers, including the thumb. Syndactyly is common, particularly between the ring and little fingers, and should be treated in the fashion described earlier in this chapter. The wrist is usually stable and rarely requires surgical intervention. The elbow may be stiff due to radiohumeral synostosis. In some instances, if the hand is positioned behind the body, osteotomy of the radius is indicated to bring it into flexion ( Fig 34A-6.). Another problem is the presence of severe flexion contracture of the elbow. Because surgical releases are usually limited by tight neurovascular structures, serial splinting or Ilizarov joint stretching have been employed to improve joint motion.
CLEFT HAND
Confusion exists regarding the appropriate classification of children with a normal-length radius and ulna and absence of the central (index, middle, and/or ring) fingers. 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. Morphologic variation is common. Digital absence, digital fusion, cross bones, syndactyly, and distal Polydactyly may all be evident within affected hands. Because the morphology of this condition may vary considerably from the right to the left side and from one generation to another, cases in which a true cleft is not evident are often overlooked. 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. The index metacarpal is often deviated toward the thumb metacarpal, thus creating a narrow first web space. Syndactyly is frequently encountered, particularly between the ring and little finger. Syndactyly should be released as previously described. Metacarpal osteotomies may be necessary to
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gain parallel alignment of metacarpals at the time of web space closure ( Fig 34A-7.,A and B). In many instances, 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.
BRACHYDACTYLY
Treatment of the hand with short digits (brachydac-tyly) or absent digits (adactyly or ectrodactyly) engenders much debate ( Fig 34A-8.). Since these abnormalities are usually unilateral, affected children possess considerable physical capabilities without surgical or prosthetic intervention. When digital soft-tissue sleeves are substantially longer than the enclosed skeletal elements, the skeleton may be lengthened by a nonvascularized toe phalanx transfer. The proximal phalanx of the third or fourth toe is "harvested" with its proximal volar plate and collateral ligaments. 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. Rudimentary flexor and extensor tendons may be defined and sutured to the palmar and dorsal aspects of the transferred phalanx. 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, the procedure may still be beneficial in older children. 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. 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. Vascularized toe transfers continue to grow until skeletal maturity and yield a digital length approaching the predicted length of the toe. The digit will retain the form of a toe and at best will have the range of motion of a toe. In most instances of adactyly, the proximal musculature is poorly defined with restricted excursion. When these musculotendinous units are sutured to a free-toe transfer, the resultant digital motion is often quite limited. It is rarely worthwhile to attempt to achieve prehension in an adactylous hand by transfer of two separate digits. When a well-controlled thumb is present without other digits, there may be benefit in transferring a toe to the hand to provide counterpressure to the thumb and thus achieve prehension. In some cases of brachydactyly, resection of the index or of the index and middle metacarpals may enhance prehension through "phalangization," a procedure in which prehension is shifted proximally to facilitate grasp between the thumb, ring, and little metacarpals.
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Although lower-limb amputation through the tibia occurs occasionally, amputation through the arm or forearm is rare as a result of congenital constriction band syndrome. 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. amputated electively. Prosthetic fitting of such limbs may be complicated by the insensitivity of the residual forearm. When thumb length is insufficient for prehension due to congenital constriction band amputation, second-toe or hallux transfer may provide effective augmentation of the thumb ( Fig 34A-10. ,A and B). Because the blood vessels, nerves, and musculotendinous structures proximal to the level of the amputation are normal, satisfactory ultimate neural, vascular, and motor function may be anticipated. The transferred toe will continue to grow as the child's hand grows.
SUMMARY
Children with upper-limb deficiencies may benefit from surgical reconstruction. The surgeon should consider both functional and aesthetic impact. In most instances, prosthetic fitting does not require surgical modification of the upper limb, that is, prostheses should be fabricated to fit the limb as it is. In other words, 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. References: 1. Aitken GT, Pellicore RJ: Introduction to the child amputee, in Atlas of Limb Prosthetics. St Louis, Mosby-Year Book, 1981, pp 493-500. 2. Barsky AJ: Cleft hand: Classification, incidence, and treatment. J Bone Joint Surg [Am] 1964; 46:1701-1720. 3. Barton NJ, Buck-Gramcko D, Evans DM: Soft tissue anatomy of mirror hand. J Hand Surg [Br] 1986; 11:307-319. 4. Barton NJ, Buck-Gramcko D, Evans DM, et al: Mirror hand treated by true pollicization. J Hand Surg [Br] 1986; 11:320-336. 5. Bauer TB, Tondra JM, Trusler HM: Technical modifications in repair of syndactylism. Plast Reconstr Surg 1956; 17:385-392. 6. Bayne LG, Klug MS: Long-term review of the surgical treatment of radial deficiencies. J Hand Surg [Am] 1987; 12:169-179. 7. Bora FW: The Pediatric Upper Extremity: Diagnosis and Treatment. Philadelphia, WB Saunders Co, 1986. 8. Bora FW, et al: Radial meromelia. The deformity and its treatment. J Bone Joint Surg [Am] 1970; 52:966-979. 9. Broudy AS, Smith RJ: Deformities of the hand and wrist with ulnar deficiency. J Hand Surg 1979; 4:304-315 10. Buck-Gramcko D: Congenital malformation, in Nigst N, Buck-Gramcko D, Millesi H et al (eds): Hand Surgery, vol 1. New York, Thieme Medical Publishers Inc, 1988. 11. Buck-Gramcko D: Pollicization of the index finger. J Bone Joint Surg [Am] 1971; 53:1605-1617. 12. Buck-Gramcko D: Radialization as a new treatment for radial club hand. J Hand Surg [Am] 1985; 10:964-988. 13. Buck-Gramcko D: The role of nonvascularized toe phalanx transplantation. Hand Clin 1990; 6:643-659. 14. Cheng JCY, Chan KM, Ma GFY, et al: Polydactyly of the thumb: A surgical plan based on ninety-five cases. J Hand Surg [Am] 1984; 9:155-164. 15. Dobyns JH, Wood VE, Bayne LG, et al: Congenital hand deformities, in Green DP (ed): Operative Hand Surgery, vol 2. New York, Churchill Livingstone Inc. 1982, pp 213-450. 16. Eaton CJ, Lister GD: Syndactyly. Hand Clin 1990; 6:555-575. 17. Ezaki M: Radial Polydactyly. Hand Clin 1990; 6:577-588. 18. Flatt AE: The Care of Congenital Hand Anomalies. St Louis, Mosby-Year Book, 1977. 19. Gilbert A: Congenital absence of the thumb and digits. J Hand Surg [Br] 1989; 14:617. 20. Goldberg NH, Watson HK: Composite toe (phalanx and epiphysis) transfers in the reconstruction of the aphalan-gic hand. J Hand Surg [Am] 1982; 7:454-459. 21. Lamb DW: Radial club hand. J Bone Joint Surg [Am] 1977;59:1-13.
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22. Lamb DW, Law HT: Upper-Limb Deficiencies in Children: Prosthetic, Orthotic, and Surgical Management. Boston, Little, Brown & Co, 1987. 23. Light TR: Kinesiology of the upper limb, in Atlas of Orthotics, ed 2. St Louis, MosbyYear Book, 1985, pp 126-138. 24. Light T, Manske P: Congenital hand malformations and deformities. Instr Course Led 1989; 37:31-71. 25. Manske PR, McCarroll HR: Index finger pollicization for a congenitally absent or nonfunctioning thumb. J Hand Surg [Am] 1985; 10:603-613. 26. Manske PR, McCarroll HR, Swanson K: Centralization of the radial club hand: An ulnar surgical approach. J Hand Surg 1981; 5:423-433. 27. Marks TW, Bayne LG: Polydactyly of the thumb: Abnormal anatomy and treatment. J Hand Surg 1978; 3:107-116. 28. Miura T: Congenital constriction band syndrome. J Hand Surg [Am] 1984; 9:82-88. 29. Miura T: Duplicated thumb. Plast Reconstr Surg 1982; 69:470-479. 30. Miura T, Komada T: Simple method for reconstruction of the cleft hand with an adducted thumb. Plast Reconstr Surg 1979; 64:65-67. 31. Moses JM, Flatt AE, Cooper RR: Annular constricting band. J Bone Joint Surg [Am] 1979; 61:562-565. 32. Ogden JA, Watson HK, Bohne W: Ulnar dysmelia. J Bone Joint Surg [Am] 1976; 58:467-475. 33. Riordan DC: Congenital absence of the ulna, in Lovell WW, Winter RB, (eds): Pediatric Orthopaedics. Philadelphia, JB Lippincott, 1978, pp 714-719. 34. Swanson AB, Swanson GD: The Krukenberg procedure in the juvenile amputee. Clin Orthop 1980; 148:55-61. 35. Swanson AB, Tada K, Yonenobu K: Ulnar ray deficiency: Its various manifestations. J Hand Surg [Am] 1984; 9:658-664. 36. Tada K, Kurisaki E, et al: Central Polydactyly-A review of 12 cases and their surgical treatment. J Hand Surg 1982; 7:460-462. 37. Tada K, Yonenobu K, Tsuyuguchi Y, et al: Duplication of the thumb: A retrospective review of two hundred and thirty-seven cases. J Bone Joint Surg [Am] 1983; 65:584598. 38. Toledo LC, Ger E: Evaluation of the operative treatment of syndactyly. J Hand Surg 1979; 4:556-564. 39. Tubiana R, Roux JP: Phalangization of the first and fifth metacarpal. Indications, operative technique and results. J Bone Joint Surg [Br] 1974; 56:447-457. 40. Upton J: Congenital anomalies of the hand and forearm, in McCarthy JG, May JW, Litler JW (eds): Plastic Surgery, vol 8, The Hand, part 2. Philadelphia, WB Saunders, Co, 1990. 41. Walsh RJ: Acrosyndactyly: A study of twenty-seven patients. Clin Orthop 1970; 71:99. 42. Wassel HD: The results of surgery for Polydactyly of the thumb: A review. Clin Orthop 1969; 64:175-193. 43. Watari S, Tsgue K: A classification of cleft hands, based on clinical findings. Plast Reconstr Surg 1979; 64:381-389. 44. Watson HK, Beebe RD, Cruz, NI: A centralization procedure for radial club hand. J Hand Surg [Am] 1984; 9:541-547. 45. Weeks PW: Radial, median and ulnar nerve dysfunction associated with a congenital constricting band of the arm. Plast Reconstr Surg 1982; 69:333-336.
Chapter 34A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 34B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
RECENT DEVELOPMENTS
During the 1980s, a plethora of new components, materials, and techniques were developed A specific attempt was made at the end of the decade to for the adult or geriatric amputee. redirect this effort toward the pediatric patient. Myoelectric hands, elbows, and controls were miniaturized and simplified ( Fig 34B-1.). The lighter-weight, stronger new materials could be used for children. Thermoplastic socket designs allowed for more adjustability and adaptability for growing limbs. Redesigned lower-limb components also became available for the younger amputee. In a break with the past, the U.S. government did not underwrite this developmental cost. This resulted in increased costs as the manufacturers amortized research expenses. Although we are fortunate that some entrepreneurs have been willing to invest in such a small area as upper-limb prosthetics, the substantial cost for newer technology is an ongoing concern. The modularization of upper-limb components during this period offers the potential to recycle parts into the child's next prosthesis. The preschool amputee may need a new socket annually because of growth, but the expensive myoelectric hands and electronics should be reusable in the new prosthesis, provided that the size remains appropriate. The development of simplified myoelectric control and a battery-saver circuit allows the fitting of infants with a practical control scheme. While hand opening and thumb adduction usually begin around 4 months, the development of shoulder-hand coordination is delayed until after 9 months. Because of training difficulties, cable-controlled prehension of the prosthesis is seldom feasible until 12 to 18 months. The new myoelectric circuits provide controlled opening, automatic closing when the child relaxes, and a stall condition detector to save battery capacity automatically. 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. As the child develops normal coordination of the contralateral hand, he also spontaneously improves his prosthetic function.
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technically possible." The child with a traumatic or acquired amputation should ideally be fitted within 30 days ( Fig 34B-2.) to encourage acceptance of the prosthesis and the continuation The child with a congenital condition may be provided with a passive of bimanual activities. hand within 60 to 90 days after birth. This theoretically allows the child to acquire more normal bimanual and quadripedal development. "What type of prosthesis?" is much more difficult to answer. The well-informed prosthetist can guide the physician through this ever-changing area of new terms, techniques, and technology. "Should powered or mechanical components be used?" "Both" is the best answer to that question. Each has its own advantages and disadvantages, and they can often be used in combination. Multiple prostheses with differing control patterns, however, can lead to confusion and frustration. Therefore, only one type of prosthesis should be used for the very young child. As children mature, they should be given the opportunity to experiment with different Mechanical terminal devices are lighter, have fingertip prehension, and are less susceptible to damage. Unfortunately, voluntary-opening hooks have much less pinch force than do electric hands and are not as cosmetic. Voluntary-closing devices like the Adept have a graded pinch force that is controlled by the individual. The streamlined design of hook devices permits visual inspection of the objects to be grasped, which can be advantageous. A myoelectric hand has greater pinch force and is capable of controlled opening and closing throughout the full range of motion of the arm. It also can be operated independently of elbow function. However, it cannot be submerged in water, is heavier, and is not as adept at picking up smaller items. The cosmetic gloves must be replaced routinely to prevent moisture and dirt from entering the electrical and mechanical parts. Passive, mechanical, and electric elbows are all available for the child amputee. Like the terminal devices, each has advantages and disadvantages. Weight and function are the best guidelines to use when recommending elbow components. Passive elbows are light but must be operated by the other hand. Heavy-duty use would preclude the use of a passive elbow. Cable-controlled mechanical elbows are smaller versions of the adult models. One cable controls elbow flexion, and the second controls the locking mechanism. The child must learn more complicated shoulder motions to achieve both flexion and locking of the prosthetic elbow, which is sometimes difficult. When a mechanical terminal device is used, the elbow must be locked for the cable's force to be transferred to the hook. However, if a myoelectric hand is used with the cable elbow, then terminal device and elbow function are independent. Electric elbows for children are usually switch controlled, but myoelectric controls are available for the older youth. They are heavier, more costly, and more complicated but are easier for the patient to control because they require less force, excursion, and coordination. They are often used with short residual limbs or congenital limb remnants. The acquired unilateral amputee should be fitted with the most cosmetic, functional components available. Children over 3 years of age can be trained to control all available devices. Younger patients or those with congenitally deficient limbs sometimes do not have sufficient neuromuscular control to operate complex devices. Although the fitting of a singlefunction myoelectric terminal device for infants is controversial, the 6- to 9-month-old can spontaneously develop control of the prosthesis without extensive training. Whether they will continue to use the prosthesis or reject it later in life can only be determined by a longitudinal study. It can be argued that fitting the child, despite the uncertainty of future results, will stimulate further advances in the science of prosthetics. Reliability of electric prostheses has improved significantly and will continue to do so as long as we continue fitting such devices.
RECOMMENDATIONS BY LEVEL
Infants with partial-hand amputations or congenital deficiencies probably would be best served by not fitting them with a prosthesis. Children with unilateral conditions will readily adapt to their "one-handedness," with the noninvolved side becoming the dominate hand. There is a lack of functional prostheses for the young child with only digits or metacarpals missing. The available cosmetic partial-hand prostheses compromise the sensory feedback to
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the limbs inside the prostheses. Combining this with an increase in length usually results in a rejection of the prosthesis. Transverse anomalies or amputations can be provided with an orthosis to prevent deformities or increase prehension. 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.). More effort should be concentrated on adaptability without the use of prostheses or orthoses. 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. Then the recommendation would be to give the family the option to fit the infant with a prosthesis when possible ( Fig 34B-4.). This would allow the prosthesis to become part of the child's natural development. The wrist disarticulation level raises concerns similar to those of the partial hands. Inequality of limb length and loss of sensation related to prosthetic fitting are likely to lead to rejection of a prosthesis in congenital conditions. On the other hand, 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. Recent modifications to myoelectric components also have allowed this level of amputation to be fitted before 18 months, if desired. 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. With the development of "user-friendly" myoelectric controls, the child under I years can learn to develop control of the prosthesis ( Fig 34B-5.). This allows a more natural assimilation of the prosthesis without having to battle through the "terrible twos." Although this concept has not been proved, enough positive anecdotal evidence has been reported that it should be investigated further. The younger child with a transhumeral condition should be fitted with either a static or friction elbow mechanism. The approach for hand function should parallel the transradial case. The older amputee should be provided with an active elbow joint. They can be expected to master either dual cable control of the elbow lock or electric control of the motorized elbow. Midshaft or longer transhumeral conditions with normal shoulder function do not require the heavier electric elbows. These prostheses will function more quickly and quietly and with more proprioceptive feedback (via the cable and harness) with mechanical elbows. The available electric elbows should be primarily considered for patients with shorter residual limbs. At this level, the ease of control offsets the extra weight and may increase the potential for prosthetic use. As with the traumatic transradial amputees, acquired transhumeral amputees must be fitted very quickly to allow the individual to retain normal bimanual functions. The additional requirement for prosthetic shoulder function at the shoulder disarticulation and forequarter level leads to more complications and more rejection. The prosthesis must provide a functional benefit for the amputee, or he will reject it. A compromise between weight and control simplicity must be made. All the available children's-size shoulder joints are passive, so the child must manually preposition the prosthesis' shoulder in the desired location. Elbow and terminal device choice is based on a needs assessment of the amputee. 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 needs of the bilateral upper-limb amputee are also best met by the experienced rehabilitation team. The child must learn to function both with and without the prostheses for the greatest independence. Because of their proprioceptive feedback, cable control of the terminal device of the prostheses should help the child's function ( Fig 34B-6.). As the control and speed of electronic components improve, this trend may be reversed. The bilateral amputee, who needs more than just prehension, will benefit from referral to a rehabilitation center that has experience with this type of condition. 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.
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CONCLUSION
Although technologies have changed, the challenges of the child amputee have not. The prosthetic fit of the growing limb must be revised annually. The more complicated cases, i.e., high-level and bilateral amputations, should be managed by clinic teams with more experience. The life-style of the child requires that the prostheses be functional, durable, and cosmetic. New materials and equipment are allowing the fitting of lighter and more advanced prostheses. Prospective studies of these new methods of patient treatment are needed.
ADDITIONAL READING
Atkins DJ, Meier RH III: Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1989. Rlakslee R: The Limb Deficient Child. Rerkeley, University of California Press, 1963. Lamb DL, Law HT: Upper-Limb Deficiencies in Children: Prosthetic, Orthotic and Surgical Management. Roston, Little, Rrown & Company, 1987. Scott RN: An Introduction to Myoelectric Prostheses. The Rio-Engineering Institute, University of New Rrunswick, Fredericton, Canada, 1984. References: 1. Campbell E, Bansavage J: The psychological and social factors related to successful prosthetic training in juvenile amputees-A preliminary study. Inter-Clin Info Bull 1964; 3:1-9. 2. Dillon S: Technical description: Applying the generic control system to a juvenile above-elbow amputee. J Assoc Child Prosthet Orthot Clin 1987; 22:17. 3. Hamilton R: The juvenile amputee in athletics. Inter-Clin Info Bull 1966; 6:1-9. 4. Lamb D, Scott H: Management of congenital and acquired amputation in children. Orthop Clin North Am 1981; 12:977-994. 5. Lambert C, Hamilton R, Pellicore R: The juvenile amputee program: Its social and economic value. J Bone Joint Surg [Am] 1969; 51:1135-1138. 6. Lambert C, Pellicore R, Hamilton R, et al: Twenty-three years of clinic experience. Inter-Clin Info Bull 1976; 40:15-20. 7. Lyttle D, Spencer D, Perry R: Satisfaction and self-esteem in patients attending a juvenile amputee clinic. Inter-Clin Info Bull 1976; 40:1-8.
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8. Mifsud M, Al-Temen I, Sauter W, et al: Variety Village electromechanical hand for amputees under two years of age. J Assoc Child Prosthet Orthot Clin 1987; 22:41-46. 9. Mifsud M, Literowich W, Milner M: Energy-saving power bridge for children's artificial hands. Med Biol Eng Comput 1985; 23:479-481. 10. Reid D, Fay L: Survey of juvenile hand amputees. J Assoc Child Prosthet Orthot Clin 1987; 20:51-55. 11. Sauter WF, Dakpa R, Galway R, et al: Development of layered "onionized" silicone sockets for juvenile below-el-bow amputees. J Assoc Child Prosthet Orthot Clin 1987; 22:57-59. 12. Scotland TR, Galway H: A long-term review of children with congenital and acquired upper limb deficiency. J Bone Joint Surg [Br] 1983; 65:346-349. 13. Supan T: Transparent preparatory prostheses for upper limb amputations. Clin Prosthet Orthot 1987; 11:45-48.
Chapter 34B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 34C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
Control Systems
Basically, two external control systems are commercially available: myoelectric and electric switch. Other methods have been tried experimentally but have not yet appeared on the market. Pneumatic power was used initially, particularly in Europe, but despite some
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advantages, it has some major drawbacks and currently is seldom used as a power source. The myoelectric system works by picking up the electrical activity generated by the muscles like an elec-tromyogram. This activity is picked up by an electrode, amplified, rectified and filtered, and sent to the motor. The electrode is placed over that portion of the muscle that or, in the case of young gives an optimum response as determined by a myotester children, small electric toys. The amplifier may be contained in the electrode or be separate. The signal may be processed in a digital or analog fashion. If the smooth filtered signal exceeds a certain basic threshold, the motor activates, and the component is engaged and continues its movement until its limits are reached or the signal is discontinued. The myoelectric signal therefore is simply a method of switching the component on and off In a digital mode, regardless of the strength of the muscle contraction, the component is on or off. In the analog mode, response is graded depending on the force of the muscle contraction. Electrodes are usually one site, one function or one site, two functions. Attempts have been made to insert more functions in one site, but these are not yet widely available. 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. These are usually push or pull switches. The nudge control switch is a type of push switch. Rocker and toggle switches are also available. Another type of three-position pull switch can flex and extend an elbow and operate either a prehension activator or electric hook. Any of these switches can be controlled in a variety of ways. Many are fixed to the harness to allow pull by body movements, while some are pushed by use of the chin or other hand. In the high-level congenital amputee, functional limb residuals may be used to operate switches. Switch location must be individualized and can be very innovative ( Fig 34C-3.).
Components
Most of the powered terminal devices for children are hands. There is one powered split hook commercially available, but this is not often used. There are a number of hands available from different manufacturers. Some are very small so that the very young can be fitted with an appropriate size. They are built with a three-finger pinch, the active index and middle fingers opposing the fixed thumb and the remaining fingers being passive. Although the cosmetic gloves are usually made of polyvinylchloride (PVC), there are some made of silicone. Characteristically, the fingers of the hand will open from 3.1 to 6.0 cm (1.34 to 2.36 in.) and will develop a closing force of 9.9 to 12.1 kg (4.5 to 5.5 lb). The time to cycle the fingers depends somewhat on the type of control system, temperature, moisture present in the socket, and other factors. The hand usually contains the motor and other mechanical parts. Powered elbows for children are primarily switch controlled, although myoelectric elbows are also available. Elbows are added to a child's prosthesis some time after the terminal device is fitted just as with body-powered prostheses. Occasionally the elbow will be too fast for small children until they get used to it. Although cycling the elbow while holding something in the terminal device (live lift) is possible, the elbow is primarily a positioning device, as is the wrist (forearm) rotator. These components put the terminal device in a position where it can successfully accomplish a given task ( Fig 34C-4.). Electric wrist (forearm) rotators are available for teenagers. They are also a positioning device, and their weight, along with all the other components, may make them burdensome for an amputee with a short residual They are not used nearly as often as hands and elbows. Without them, rotational limb. positioning of the hand is done passively. 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.). A common combination is that of an externally powered Another possibility is a powered hand on one elbow with a body-powered terminal device. side and a cable-operated hook on the other. There are no large series addressing this issue of combinations of power, so fitting these various components still tends to be individualized and subjective. The power source most commonly used for these prostheses is a 6-V nickel-cadmium rechargeable battery. Other voltages are occasionally used. Whenever possible, for cosmetic purposes it is fabricated into the prosthesis. 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.
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somewhat from the prosthesis. In certain selected circumstances, the battery may have to be placed remotely on a belt or some type of harness. Resistance to wire breakage with remote units has improved with the advent of new materials ( Fig 34C-6.). 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. A battery should never be completely run down before it is recharged, and it should not be overcharged. To address this problem, many chargers now have an automatic shutoff when the battery is fully charged. Typically, it takes about 12 hours to recharge a battery with a 50-mA charger. To avoid the hysteresis effect a battery should be discharged sufficiently before it is recharged. With good care a battery will last about 2 years. Extra charged batteries should be available for uninterrupted use.
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. The placement of control sites, switches, and batteries, in particular, may be highly individualized. In general, weight, (especially that of the battery) should be as proximal as possible. 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. Because of the weight of the components, suspension is especially important for powered prostheses. The flexible socket has been very helpful for the high-level amputee and seems to give superior suspension. Care must be taken to avoid "overgadgeting" amputees, especially children, to avoid frustration and prosthesis rejection.
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electrical system rarely fails, although when it does, it is expensive to repair. However, the use of these prostheses demands certain restrictions of an amputee's activities, a feature that is particularly cogent when considering very young children. For example, myoelectric prostheses cannot be immersed in water. They cannot be used to hammer, to pry objects, or to play in water without some risk of damage to the device. By far, the weakest link in this system is the cosmetic glove. Much work needs to be done to improve its durability. It tears quite easily and becomes soiled. Certain stains such as ball point pen ink and newsprint are virtually impossible to remove. The cost of replacing cosmetic gloves is significant ( Fig 34C-9.). Batteries need frequent recharging and periodic replacement. They are still quite heavy and, if they cannot be built into the prosthesis, must be located remotely. The thumb axis and hand frame commonly need repair and realignment in children. One series of 47 children wearing myoelectric transradial prostheses required 1.9 repairs per Very young children do not year, and this group included only a few very young children. understand that they must make certain concessions to avoid damaging these devices. The durability of externally powered elbows has been rather poor to date. Over a period of time, this has improved significantly, 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. sizes and tend to be heavy. The weight of externally powered prostheses is a frequent complaint of amputees using them, particularly those with short residual limbs. It does not appear to be a frequent cause for rejecting the prosthesis, but it is a common source of dissatisfaction. In addition, much of the weight is located distally in the limb, and thus an even greater force must be overcome when using the prosthesis. The greater the number of components used, the heavier the prosthesis becomes. This is particularly relevant for the higher-level amputee and for small children. It has been stated by some that proprioception, which is limited with any prosthesis, is poorer with externally powered prostheses than with body-powered prostheses, although this is disputed by others. In tests done on measured tasks, 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. 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. Powered hook-type terminal devices for children are rarely used, and only one model is commercially available. Amputees at times will complain of inadvertent cycling of a powered component. Because of the bulk of the hands, it is sometimes difficult to get the prosthesis through the sleeves of garments. A very important factor to consider in prescribing externally powered prostheses is the cost, both initially and for repairs. Although this varies in different parts of the country and is dependent on the type of prosthesis, the minimum cost for these devices is several thousand dollars. There has been reluctance on the part of many third-party payors to assume the cost of externally powered prostheses. 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. This growth factor can be somewhat ameliorated by using socket liners. In clinics fitting a number of children, establishing a limb bank and recycling components can defray the cost somewhat. At this time, the functions that can be fabricated into an externally powered prosthesis for small children include prehension and elbow motion. Not yet available commercially for small children are forearm (wrist) rotation, wrist flexion and extension, upper-arm rotation, or This is not an indictment of powered limbs since shoulder motion. These are passive only. these functions are not available in body-powered prostheses either, but one would anticipate that with further research these functions could be made available to child amputees using externally powered prostheses.
AGE CONSIDERATIONS
At what age should a child be provided with an externally powered prosthesis? Probably no
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question in the field of prosthetics in recent years has evoked so much controversy. 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. Based on the work of Sorbye and others, there are those who would recommend fitting children at a very young age with externally powered prostheses. Working in a fully funded program under ideal circumstances, they showed a high rate of compliance among their Other investigators, however, have not been able to reproduce those results, and patients. so the controversy continues. All the evidence would suggest that very young children can learn to operate externally powered prostheses, so this is not the issue. Age alone should not be the criterion by which a certain prosthesis is selected. The main requirement to be addressed in selecting a specific type of prosthesis for any amputee is the patient's needs. These needs have to be met in the most appropriate manner possible. There is no one type of prosthesis that is optimal for every amputee. To make an intelligent choice and give valuable advice to the amputee one must be aware of and consider a myriad of factors. These include life-style and activities of the amputee, available components and their advantages and disadvantages, financial considerations, availability of knowledgeable prosthetists, distance from a prosthetic facility, availability of training, characteristics of the residual limb and supporting structures, as well as the motivation, expectations, and goals of the child and parents. Additionally, in young children, comprehension, strength, and attention span must be considered. Needs of the amputee change, 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. The ability to evaluate all these factors is one of the advantages of the multidisciplinary amputee clinics. It is a common occurrence for infants and very young children to wear and use a prosthesis for some time, even for several years, before they begin to use the prehensile capabilities of the prosthesis in a meaningful fashion. 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, those who used them functionally, and those who rejected them. Among the children under 6 years of age there was a much higher percentage of "passive" wearers, that is, children who wore the prosthesis but did not use it functionally. 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. 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, widespread prescription will be warranted, but until then each amputee should be evaluated on an individual basis.
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at this level because, with the addition of the usual components, the forearm becomes disproportionately long and also because the function of the residual limb at this level, on balance, is equal or superior to that of a prosthetic device. At the carpal level, an externally powered prosthesis, usually myoelectric, can be fabricated without creating an unsightly long arm. Some of the same prosthetic problems mentioned above are encountered, specifically in regard to length and sensation, especially if some of the carpal elements are retained. One advantage of this level is that suspension can be achieved with a modification of the expandable wall socket, 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. The transradial is by far the most common and most successful level of amputation that utilizes external power ( Fig 34C-10. ). Components for children are readily available. The powered hand with a three-finger pinch is the most common terminal device used. Only one powered hook-type terminal device is available for small children, and this is seldom utilized. Suspension is usually achieved by means of a modified Munster socket, 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. The amount of elbow flexion varies with the height of the anterior trim line, which in turn, depends somewhat on the length of the residual limb and the purchase necessary to stabilize it. Long transradial amputees may have problems in concealing the battery pack so that it will not protrude from the volar aspect of the socket. Conversely, amputees with very short residual limbs, such as in the short transverse deficiencies, may have problems with suspension and in supporting the weight of the prosthesis. Midforearm length is the ideal length for a myoelectric prosthesis. Forearm rotators are available for the larger child, but clinically they are not used a great deal since they add weight and battery drain. 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. As children assume adult proportions in their adolescent years, they are able to use adult components, and this increases their options for external power. The long to midshaft transhumeral amputation is ideal to accommodate an electric elbow. If the humeral segment is long enough, they will have functional shoulder motion and be able to support the weight of the prosthesis. With the longer residual limb, selection of control sites, especially for myoelectric use, is also easier ( Fig 34C-11. ). High transhumeral, shoulder disarticulation, and forequarter amputation levels have numerous problems: the rejection rate is relatively high, and functional use is diminished. Weight is a problem, particularly in small children because the surface area available for body support of the socket is reduced ( Fig 34C-12. ). Location of adequate myocontrol sites may also be difficult. Training may be harder because these sites are situated on muscles that do not normally control the comparable prosthetic function. Sockets for these levels tend to get bulky and oppressive. They can become hot, although this can be alleviated somewhat by fenestration. The flexible socket and frame have also been helpful for these levels. It is felt by many amputees to be more comfortable, to give better suspension, and for some reason, to be cooler. Shoulder motion at these levels is only passive. A powered shoulder has yet to be made available. Successful fitting of the bilateral amputee, at any level, with externally powered prostheses has been disappointing to date. There is an extremely high rejection of external power by these amputees who are so dependent on their prostheses. In addition, bilateral amputees usually reject prosthetic hands and prefer alternative terminal devices. This choice on their part probably relates to the comparative weight, durability, reliability, and ease of operation of bodyand externally-powered types of prostheses.
MISCELLANEOUS CONDITIONS
Congenital amputees often present the clinic team with unique characteristics that require imagination and ingenuity to fit prosthetically. Vestigial limbs, as in the case of high-level transverse deficiencies (phocome-lia), may be used to control microswitches or myoelectric controls ( Fig 34C-13. ). In some cases, socket and suspension fabrication may have to be very innovative. Although congenital amputees are classified prosthetically as to certain
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functional levels, the unusual features of their vestigial limbs frequently present opportunities to fabricate a unique prosthesis. 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. Various authors recommend using a myoplastic closure in upper-limb amputations to facilitate externally powered control. This is easily accomplished in elective amputations, but in traumatic amputations this consideration may have to be sacrificed to the maintenance of length and skin coverage. There are other special considerations for amputations in children, but they are covered elsewhere in this text. However, it is worthwhile to mention again, in the context of externally powered limbs, the importance of retaining length and normal skin coverage, even if it means shifting skin flaps. This is done to cope with the weight and control site placement requirements of externally powered prostheses. Another surgical consideration is the decision about the fate of vestigial limbs or residual-limb anomalies. In general, 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, after very careful consideration, to be of no value to the amputee ( Fig 34C-14. ).
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Once the prosthesis has been fabricated, its care and maintenance should be thoroughly discussed with the amputee and the parents. The location and function of each component of the prosthesis should be fully described. The amputee or parents are then instructed on how to don the prosthesis. This is done by inserting the residual limb, although sometimes a pull sock can be used to facilitate entry. If there is difficulty in inserting the residual limb, compounds such as talc or surgical lubricant can be used. The amount of time the prosthesis is worn each day should be gradually increased. The residual limb and socket should be cleaned each day to avoid irritation and odor. At the first sign of any significant irritation or breakdown, prosthetic wear should be discontinued until the problem is rectified. Various compounds are available to control odor or excessive sweating. Antiperspirant sprays are sometimes used successfully. Wearing a prosthesis in summer can be exceedingly hot, 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. This should not be a cause for undue alarm or fears of prosthetic rejection. Cosmetic gloves are made of PVC. These gloves are quite easily stained or torn. Stains from ball point pens and newsprint are particularly hard to get out. Gentle soaps and hand lotions can be used to clean and keep the glove supple. The gloved terminal device can be immersed in water only if the glove is intact with no cuts or tears. If additional protection of the cosmetic glove from soiling or staining is needed, another ordinary glove should be worn over it. Rechargeable nickel-cadmium batteries are used to power the prostheses. The length of time they will keep a charge or their longevity is dependent on use, but in general a charge will last about a day, and the battery lasts about 2 years. Batteries occasionally can be totally discharged but should be recharged promptly. When the powered component slows down or operates erratically, the battery should be removed from the prosthesis and charged. Normal recharging time is about 12 hours. Activities that cause excessive jarring of the prosthesis should be avoided. Stress the fact that the prosthesis is a helping hand. After the operation of the individual components of the prosthesis has been learned, the next step is to apply this to the control of the assembled prosthesis on the amputee. This phase of training focuses on accomplishing individual tasks with the prosthesis. Amputees learn to operate the components in various positions. 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. 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. Children over the age of 5 years can follow this pattern. Age-appropriate games and toys are useful in the very young child. Teenage boys frequently respond to challenges to accomplish various tasks. In multifunctional prostheses, each function should be learned individually and then combined or alternated. Basic control and function must be learned before proceeding to the functional use of the prosthesis. 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, especially with the young child, than the therapist can. In the final phase of training, these learned functions are extended to include the more complex activities of daily living at whatever level is appropriate for the child's age. It is here that individuality should be stressed as well as the interaction of one limb with the other (e.g., stringing beads). Parents are invaluable in giving encouragement and suggestions to the amputee on how he might use his prosthesis in daily activities. Interaction and playing with siblings is helpful. Children 5 years and older can be taught to dress themselves, eat independently, and perform various other tasks. Older children can be instructed in the use of the internal hand switch, the method of "live lift" with a powered elbow, and how to "troubleshoot" simple malfunctions of the prosthesis.
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difficult to compare because of different variables in the study. In an interesting study done by Fishman and Kruger with a 3-year follow-up, of 120 children, 44% preferred the myoelectric prosthesis, 34% preferred the body-powered one, and 22% rejected all prostheses. They also noted that 68% were active users of their prostheses and 32% were passive wearers. H.J.B. Day found that in a study done on young children, only 25% actively used their Fishman and Kruger's study had prostheses and the rest wore the prostheses passively. 23 very young children, and the rejection rate among these children was higher than age average, which casts some doubt on the premise that the earlier the children are provided with external power, the less likely they are to reject it. The ability of the child to have the cost of his prosthesis underwritten probably also significantly affects whether or not external power is continued. Bilateral amputees are obviously very dependent on their prostheses. The results of fitting them with external power, if they have a choice of body power, has been disappointing. In higher-level amputees, that is, transhumeral and proximal, the rate of rejection also varies from series to series, although, if anything, it tends to be somewhat higher than in transradial amputees. 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. Few studies of children with higher-level amputations have been done, but in one a 50% rejection rate was encountered. At the very high levels (very short transhumeral, shoulder disarticulation, or forequarter), rejection is high among unilateral amputees. Use of prostheses, whether body powered or externally powered, is poor in small children with very high-level limb loss, as for example, phocomelia or amelia, whether unilateral or bilateral. The prostheses are heavy, cumbersome, and hot for these little children with a small body mass, as well as awkward and imprecise for them to operate. In addition, their parents will frequently look after their bodily functions, or they become particularly adept with the use of their feet if they have usable lower limbs. Available funds would be better utilized, at least initially, for adaptive equipment for this group of small children rather than spending them for externally powered prostheses, except perhaps in research situations.
Acknowledgments
We would like to express our gratitude to Donabelle Hansen, R.P.T., 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. References: 1. Brooks MD, Sharperman J: Infant prosthetic fitting: A study of the result. Am J Occup Ther 1965; 19:329-334. 2. Childress DS: Historical aspects of powered limb prostheses. Clin Prosthet Orthot 1985; 9:2-13. 3. Childress DS, Billock JN: An experiment with the control of a hybrid prosthetic system: Electric elbow, body-powered hook. Bull Prosthet Res 1970; 10:62-77. 4. Day HJB: The United Kingdom Trial of the Swedish myoelectric hand for young children: An interior report. Inter-Clin Info Bull 1980; 17:5-9. 5. Fishman S, Kruger L: Comparison of myoelectric and body-powered hands for below elbow child amputees. Review study for Shriners Hospital for Crippled ChildrenSpringfield Unit, 1989. 6. Gingras G, Mongeau M, Sherman ED, et al: Bioelectric upper extremity prosthesis developed in Soviet Union: 7. Preliminary report. Arch Phys Med Rehabil 1966; 47:232-237. 8. Glynn MK, Salway HR, Hunter G, et al: Management of the upper limb deficient child with a powered prosthetic device. Clin Orthop 1986; 209:202-205. 9. Heger H, Millstein S, Hunter GA: Electrically powered prostheses for the adult with an upper limb amputation. J Bone Joint Surg [Br] 1985; 67:278-281. 10. Hubbard S, Galway HR, Milner M: Myoelectric training methods for the preschool child with congenital below-el-bow amputation. A comparison of two training programs. J Bone Joint Surg [Br] 1985; 67:273-277. 11. Keagy RD: Amputations of the upper extremities, in Vernon MN (ed): Orthopedic Rehabilitation. New York, Churchill, 1982, pp 361-375. 12. Kritter AE: Myoelectric prostheses. J Bone Joint Surg [Am] 1985; 67:654-657. 13. Lambert TH: An engineering appraisal of powered prostheses. J Bone Joint Surg [Br] 1967; 49:333-341.
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14. Le Blanc MA: Clinical evaluation of externally powered prosthetic elbows. Artif Limbs 1971; 15:70-77. 15. Liberty Mutual Research Center: New Products Bulletin. 1989. 16. Maureielo GE: Some electronic problems of myoelectric control of powered orthotic and prosthetic appliances. J Bone Joint Surg [Am] 1968; 50:524-534. 17. Millstein S, Heger H, Hunter G: A review of the failures in use of the below elbow myoelectric prosthesis. Orthot Prosthet 1982; 36:29-34. 18. Northmore-Ball MD, Heger H, Hunter G: The below elbow myoelectric prosthesis. J Bone Joint Surg [Br] 1980; 62:363-367. 19. O'Shea BJ, Dunfield VA: Myoelectric training for preschool children. Arch Phys Med Rehabil 1983; 64:451-455. 20. Paciga JE, Gibson DA, Gillespie R, et al: Clinical evaluation of UNB 3-state myoelectric control for arm prostheses. Bull Prosthet Res 1980; 10:21-33. 21. Parker PA, Scott RN: Myoelectric control of prostheses. Crit Rev Biomed Eng 1986; 13:283-310. 22. Plettenburg DH: Electric versus pneumatic power in hand prostheses for children. J Med Eng Technol 1989; 13:124-128. 23. Schmeisser G Jr, Seamone W: A five-year review of clinical experience with Johns Hopkins University externally powered upper limb prostheses and orthoses. Bull Prosthet Res 1975, Spring, pp. 211-217. 24. Scotland TR, Galway HR: A long term review of children with congenital and acquired upper limb deficiency. J Bone Joint Surg [Br] 1983; 65:346-349. 25. Scott RN: Myoelectric control of prostheses. Arch Phys Med Rehabil 1966; 47: 174181. 26. Scott RN: Myoelectric prostheses of very young children. Techn Rep 1981; 82:1. 27. Scott RN, Porter PA: Myoelectric prosthesis: State of the art. J Med Eng Technol 1988; 12:143-151. 28. Scott RN, Tucker FR: Surgical implications of myoelectric control. Clin Orthop 1968; 61:248-260. 29. Simpson DC: Externally powered artificial arms. Proc R Soc Med 1973; 66:637-638. 30. Sorbye R: Myoelectric prosthetic fitting in young children. Clin Orthop 1980; 148:34-40. 31. Stein RB, Charles D, Walby M: Bioelectric control of powered limbs for amputees. Adv Neurol 1983; 39:1093-1108. 32. Stein RB, Walley M: Functional comparison of upper extremity amputees using myoelectric and conventional prosthesis. Arch Phys Med Rehabil 1983; 64:243-248. 33. Tervo RC, Leszczynski J: Juvenile upper limb ampu-tees:Early prosthetic fit and functional use. Inter-Clin Info Bull 1983; 18:11-15. 34. 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. 35. Trost FJ: A comparison of conventional and myoelectric below elbow prosthetic use. Inter-Clin Info Bull 1983; 18:9-16. 36. Trost FJ: Fitting above elbow amputees with externally powered prostheses. J Assoc Child Prosthet Orthot Clin 1986; 21:52. 37. Wedlick LT: External power and recent concepts in control of limb prostheses. Med J Aust 1969; 8:278-280.
Chapter 34C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
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Chapter 34D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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
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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. 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.
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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. Correctly apply and remove the prosthesis. 2. Maintain the prosthesis in good condition by washing the harness, clean the inside of the socket, and use clean stump socks each day. 3. Encourage the baby to use the prosthesis in normal play activities. 4. Learn to recognize when the socket and harness are tight. Take the child to see the prosthetist for necessary adjustments. Grandparents, siblings, baby-sitters, and other extended family members are encouraged to attend one or more sessions. Their role is vital in cooperating with parents to establish the development of a consistent wearing pattern. It is reasonable and desirable for the prosthesis to be worn the entire time the baby is awake. It may be removed when the baby sleeps, takes a bath, or swims. "However, wearing patterns may vary with climate changes and individual parental needs." When the baby receives the first prosthesis, his body and arm movements may be awkward for a few weeks or so. The family need not be overprotective, but should provide assistance if The baby is the prosthesis becomes pinned under the baby's body or caught in furniture. encouraged to include the prosthesis to stabilize body weight when creeping on all fours ( Fig 34D-2.) or when pulling to stand. Large balls or stuffed animals are presented so that the ( Fig 34D-3.). 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. The 8- to 12-month-old may try to remove the item or totally ignore it. Over time, as the parents continue to place objects in the terminal device, 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. place cubes in and out of a cup. 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 CAPP TD should have a soft spring. Since the manufacturer issues the terminal device with a regular spring, the prosthetist should be reminded to make the change.
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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. Therefore the following components and adjustments should be standard for a child's prosthesis to maximize efficiency and ease of operation. 1. 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. 2. The control attachment strap and lower axilla loop strap should pass over the lower third of the scapulae. 3. The CAPP TD needs a soft spring, the 10X hook should have a quarter to half of a rubber band, and both should open and close smoothly. 4. The cable housing should be lined with Teflon to increase the efficiency of the cable system. Whenever a new prosthesis is issued, the following care and maintenance procedures are reviewed and reinforced with the family. 1. Clean the inside of the socket each night. Wash the harness at least once a week. 2. Brush dirt or sand from the pulley system of the CAPP TD. Use an air hose at the gas station if necessary. Immerse the ball bearing of the hook in alcohol to clean. 3. Change the CAPP TD covers when they wear out. Remove all rubber bands from the hook when the elastic deteriorates. Replace with new ones. 4. Retread the neoprene lining of the hook when it wears out to maintain complete closure of the hook fingers. 5. Clean the glove of a mechanical hand with alcohol, a manufacture's glove cleaner, or a special detergent such as "Simple Green." 6. Adjust the wrist friction so that the terminal device does not inadvertently move during use. 7. Go to the prosthetic shop every 4 months. Have the harness adjusted as the child grows.
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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. (Hold the bead in the terminal device and hold the string with the sound hand). 3. Use fat felt-tipped pens with loose caps. Hold the marker in the terminal device, and remove the cap with the sound hand to scribble on paper. To master the basic control motion the child must learn to independently perform the following skills: 1. Open the terminal device, and place an object securely inside. 2. Extend the shoulder to relax tension on the control line to close the terminal device. Time the closing to prevent the object from falling out. 3. Release an object from the terminal device. Either pull it out with the sound hand, or actively release it by using the same control motion. To open the terminal device at the midline of the body the child must use biscapular motion. Some children learn automatically. Others may need assistance.
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. While functional use of the prosthesis cannot be compartmentalized, young children do not assimilate all facets of training at once. Stages of prosthetic training overlap with each other, and learning takes place over a period of time along with the acquisition of other developmental skills. The focus during this period is on the prehensile use of the terminal device. However, the child should continue to use the prosthesis as a unit to stabilize or support objects ( Fig 34D5.). Skills that relate to prehensile function are introduced as the child is ready to learn them. Initially the therapist focuses on the following skills: 1. Place an object securely and accurately in the terminal device. Reposition the object as needed. 2. Refine the size of terminal device opening, especially for small or thin items ( Fig 34D6.). 3. Reposition or change the position of the terminal device as required for different activities. 4. Actively release an object from the terminal device by using the control motion. (Learn to drop the object on the table or floor. Actively toss the object from the terminal device into space.) To assist the child to learn specific skills the therapist demonstrates the activity and provides verbal instruction. In time only verbal cues may be necessary. As new, fine-motor, manipulative tasks are presented, the child is encouraged to motor-plan and problem-solve for the new activity without assistance. If the child has difficulty, the therapist asks how the task may be done another way. This opportunity allows for a trial-and-er-ror approach before the therapist intervenes. Performance will vary depending on the child's natural abilities and motivation. The therapist may need to do part of a more complex task and then allow the child to complete the activity. There are many ways to approach an activity. If the child appears awkward when doing the task, the therapist should correct the method of prosthetic performance. For example, many children either avoid prepositioning the terminal device or repositioning an object in 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. A helpful hint about the CAPP TD No. 1 is to position it so that it mimics the sound hand. Although it will always be appropriate to place an object in the terminal device with the sound hand, the child must learn to actively grasp an item from a surface with the terminal device, especially if the sound hand is occupied. Likewise, to achieve a fluid movement pattern with the prosthesis, 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. and use a more spontaneous two-handed approach with toys such as, tike bike, tricycle, rocking horse, see-saw-swing, shopping cart, doll carriage, wheel barrow, rolling pin, and Play-Doh ( Fig 34D-7.).
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
Since the child's work is play, toys, games, crafts, and other purposeful bimanual tasks are used to integrate these skills into the child's use pattern ( Fig 34D-8.). In fact the preschool youngster does well with activities that encompass imaginary play such as a tea party, washing dishes ( Fig 34D-9.), washing doll clothes and hanging them on a line, planting flowers or seeds in a pot ( Fig 34D-10. ), grocery shopping, and dress-up play with costumes and makeup. Playing baseball with a plastic bat and a large ball as well as outdoor fun on playground equipment is also highly recommended. Before the child goes to kindergarten, the therapist introduces or reviews specific prosthetic and self-help skills. Practice in the following type of activities may help the child to function ( Fig 34D-11. ). more independently in the classroom 1. 2. 3. 4. 5. 6. Hold paper to cut with scissors. Open and close glue bottles and jars. Open a milk carton and package of cookies. Stabilize clothing to zip a jacket or button a shirt. Don and doff the prosthesis independently. Begin to learn to tie shoelaces.
The school-age child learns additional skills that are a refinement of prosthetic use. In order to hold a soft or fragile object in the terminal device, the child controls the pressure grip by maintaining a slight amount of tension on the control line. This skill is important in order to hold a sandwich or crack an egg without a mishap. To keep the terminal device closed when bending over or extending the shoulder, the child must pinch the scapulae together or shrug the harness high up on the back. 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. ). When the child acquires some degree of skill with the prosthesis, the focus in training shifts Although some children become more spontaneous than to developing more spontaneity. others, there is no magic to the training process. Practice and repetition are a definite part of building a habit pattern. While the 2-year-old delights in repetitive bimanual tasks, the therapist does much to enhance training by being creative. Parents must be present during training sessions because their involvement and cooperation are essential for ongoing success. By the time the child enters kindergarten, formal therapy is no longer necessary. However, at different developmental periods the child may need assistance with specific selfhelp, recreational, athletic, and avocational activities. Therefore the youngster should always have access to the prosthetist, therapist, or other appropriate team member.
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
provide a variety of benefits. 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. The children cite specific advantages for themselves. 1. The voluntary-closing device provides increased prehension force as well as greater control over the amount of force exerted to do an activity. 2. 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. Electric hands that are myoelectrically controlled provide excellent grip force, ease of operation, elimination of the cable and harness system, as well as good cosmesis. Use of this type of transradial prosthesis usually depends on available funding resources. Because myoelectrically-operated prostheses are more expensive than the cable-operated ones, state agencies and some insurance companies may not routinely pay for them. CAPP does not have a myoelectric program for infants. However, when funding is available, we use the Otto Bock, two-state, two-site control system and the appropriate electric hand to fit children as young as 3 years of age. An increasing number of parents will not accept any other terminal device except a hand. Therefore the child's-size mechanical hands from Steeper, Ltd., may be pleasing in ( Fig 34D-13. ). appearance and may be acceptable as an alternative to other devices Unfortunately, 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. The child must use excessive operating force to achieve only minimal opening. Depending on the spring setting, the Steeper 2-in. hand may not close completely. For the 2-year-old who is just learning active operation of the cable-controlled terminal device and for the therapist doing the training, this hand may provide more frustration than function. Older youngsters who are involved in school or community-based athletic programs are For certain activities, the usually required to remove the prosthesis for body-contact sports. youngster may wear the socket, but the terminal device is perceived to be a problem. The TRS Super Sport Hand can be used as an alternative. "This device is made of soft, flexible polymer and is shaped like a "cupped hand." The type of prostheses and components that are offered in a particular amputee center may depend on the following: 1. The center's history and experience with certain components and control systems. 2. Research components developed in a particular center. 3. Available financial resources and subsidized funding for prostheses and components. Nonetheless, 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. Over time, if the patient and/or family decides not to pursue prosthetic fitting, the clinic team should accept that decision and keep the "door open" for future assistance.
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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. Unless there is a secondary problem, development should follow a specific sequence according to the maturation of the neuromuscular system. However there are variations in the establishment of specific fine and gross motor milestones. Obviously, babies with no arms or with short transverse deficiencies above the elbow will not be able to creep on all fours. However, these children do come to a sitting position, scoot on their bottoms, and push to a standing position to walk. Some babies experience delays, while others perform developmental skills within the normal time frame. Although no special therapy is needed, the parents need to know when and how to assist the baby through various stages of neuromuscular development. Gesell describes adaptive behavior "as the child's ability to make adjustments in perception, orientation, as well as manual and verbal skills, which then allows him to initiate new experiences." With neuromuscular maturation and voluntary control over body movements, the baby explores ways to move in space and to manipulate objects in the environment. With encouragement, the baby may learn to use the parent's leg as support to push to an upright position. 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. ). 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. Schmid which imitates that of the upper extremity. Even grasp between the great and second toe occurs within the same time frame as the grasp between the thumb and finger." In addition to using the feet, children also hold and carry objects in the mouth or between the chin and shoulder.
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
is fully flexed. 2. The forearm must clear the table top when the elbow is flexed at 90 degrees.
Rubber band loading on the hook is minimal during this phase of training, and objects may easily fall out during use. An extra band placed over the hook tip will secure most thin items and prevent them from slipping. At 15 to 20 months of age the toddler begins to feed himself with a spoon. Children It is without arms may also show signs of readiness to perform this task with the feet. difficult to learn to eat with a spoon in the terminal device, but if there is interest and motivation, the activity may be introduced during this developmental time period. A swivel spoon is placed in the hook and secured by a rubber band. The push-button elbow is unlocked and placed in the free-swing mode. The child uses trunk motion to place the spoon in the dish. Soft food will stick easily. With practice the youngster will learn to scoop food by pushing the spoon against the high rim of a special dish. To bring the spoon to the mouth, the child leans the forearm on the table and forces the elbow to flex. This method of eating is very complex and requires not only practice but assistance from the parent ( Fig 34D-17. ). The child will not gain independence in this skill for several years. The method of bringing the spoon to the mouth depends on the control system that is used to power the elbow unit. 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.
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
While the hook is easy to operate, the lack of pinch force soon becomes a problem when toys and other items are easily dislodged. The other alternative is to use an exoskeletal prosthesis with a single control cable to close the hook. This type of prosthesis has a nudge control on the socket to lock and unlock the positive-locking internal elbow unit. Even with a half of a rubber band on the hook, the child does not have sufficient chest expansion to move the cable. Therefore a thigh strap control is necessary to open the hook. The potential excursion provided by the thigh strap allows for the following results: 1. Full or at least functional opening of the terminal device without undo exertion on the part of the child. 2. Potential to add rubber bands to increase grip strength. 3. "Feedback" through the cable system. 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. First, the therapist stabilizes the child's pelvis and assists the child to bend the trunk to open the hook. The youngster then assumes an upright position. Because the terminal device cannot open and close in the same position, manipulation of objects on a table surface is impossible. The therapist must place the toy in With practice the child learns to the hook instead of asking the child to actively grasp it. use shoulder elevation and trunk rotation to open the hook. This refinement allows the youngster to perform tabletop activities at the midline of the body.
Use Training
Once the control motion is refined, specific skills are integrated into the use pattern. Initially the child learns to grasp, lift, and carry toys from place to place. Later he will learn to push an object into the desired position with the unopened hook before attempting to grasp it ( Fig 34D-18. ). Sometimes an item will slide across the table when the child tries to grasp it with the hook. To minimize this problem, it is necessary to place the stationary hook finger against Rubber tubing applied to the stationary finger the object before closing the terminal device. will also provide a better friction surface. The child works best when motivated with toys such as wooden puzzles with large knobs, simple card games with cards in a rack, play food and dishes, as well as small trucks, cars, and trains. The Fisher Price barn, garage, zoo, schoolhouse, etc., provide imaginary play opportunities that encourage fine prehension and manipulation of objects with the hook terminal device. Initially, the therapist prepositions all the friction components to place the terminal device in the desired position of function. The child must master this skill as soon as possible to lessen dependence on adult intervention. The shoulder, elbow turntable, and wrist must be tight enough to maintain friction and not move unnecessarily when the child walks, plays, or uses the prosthesis for function. However, these components must be loose enough for the child to reposition them when necessary. 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. To preposition the hook or to secure an object like an eating or writing utensil in the terminal device, the child frequently uses the foot ( Fig 34D-19. ). The child may use the shoulder disarticulation prosthesis to eat, write, and carry objects. Without active shoulder motion this type of limb provides limited function. In fact, it requires extensive practice to achieve a degree of skill, speed, and proficiency with this type of prosthesis. Over time, wearing patterns vary. Some children will always use prostheses to perform selected activities, while other individuals will wear and use them for only a specific developmental time period.
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34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
bodied child attempts the task. The limb-deficient child may accomplish part or all of a task quite easily. Because dressing and toileting skills require considerable practice, coordination, and effort, the individual may not achieve independence until the teen years. For some activities, assistance may always be needed. In addition to experimentation and practice, these children need to maintain slim, flexible bodies. Any excessive weight gain or limitation or loss of range of motion may compromise adapted performance and independent function.
CONCLUSION
Most children with upper-limb loss have the potential to live full and productive lives whether they wear a prosthesis or not. These youngsters go to regular school, participate in neighborhood and community activities, and develop skills based on their natural abilities and interests. They respond positively to a treatment program that provides the following: 1. A developmental approach. 2. An understanding and experienced clinic team. 3. A treatment program that considers the psychosocial, functional, and prosthetic needs of the child and family. References: 1. Baron E, Clarke S, Solomon C: The two stage myoelectric hand for children and young adults. Orthot Prosthet 1983;37:11-12, 22-23. 2. Blakeslee B (ed): The Limb Deficient Child. Berkeley, University of California Press, 1963, pp 83-96, 157, 173, 198, 211, 240-334. 3. Brenner C: Fitting infants and children with electronic limbs. Detroit experience from 1981 to 1990. J Assoc Child Prosthet Orthot Clin 1990; 25:30. 4. Brooks MB, Dennis J: Shoulder disarticulation-type prostheses for bilateral upper extremity amputees. Inter-Clin Info Bull 1963; 2:2. 5. Brooks MB, Shaperman J: Infant prosthetic fitting: A study of the results. Am J Occup Ther 1965; 19:333. 6. Celikyol F: Prostheses, equipment, adapted performance: Reflections on these choices for the training of the amputee in occupational therapy strategies and adaptations for independent living. Occup Ther Health Care 1984;4:89-115. 7. Clinical experience, long-term observation, exchange of information with other health professionals, and accumulated lecture material from the Child Amputee Prosthetics Project, University of California at Los Angeles, 1972- 1992. 8. Crandall RC, Hansen D: Clinical evaluation of a voluntary closing terminal device for below elbow amputees. J Assoc Child Prosthet Orthot Clin 1989; 4:71-73. 9. Dennis J: Research in upper extremity prostheses for children. Presented at the Conference on Occupational Therapy for The Multiply Handicapped Child. University of Illinois, April 1965, pp 119, 186. 10. Fisher AF: Initial prosthetic fitting of the congenital be-low-elbow amputee: Are we fitting early enough? Inter-Clin Info Bull 1976; 15:8. 11. Gesell A, Halverson H, Thompson H, et al: The First Five Years of Life. New York, Harper & Row Publishers Inc, 1940, pp 108-110. 12. Gesell A, Ilg F: The Child From Five to Ten. New York, Harper & Brothers, 1946, pp 35, 121-123, 235, 366. 13. Mifsud M, Al-Temen I, Sauter W, et al: Variety Village electromechanical hand for amputees under two years of age. J Assoc Child Prosthet Orthot Clin 1987; 22:41-46. 14. New Products Bulletin. Liberty Mutual Research Center, Hopkinton, Mass, 1988, pp 46, 8, 10. 15. New Products Bulletin. Liberty Mutual Research Center, Hopkinton, Mass, 1989, pp 13. 16. Patton J: Developmental approach to pediatric prosthetic evaluation and training, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag, NY Inc, 1989, pp 137-149. 17. Patton J: Prosthetic components for children and teenagers, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, SpringerVerlag NY Inc, 1989, pp 99-118. 18. Patton J, 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. In Symposium on Congenital Malformations-Its Clinical Management. Clin Orthop 1980; 148:47-52.
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19. Pulaski MS: Your Baby's Mind and How It Grows: Pia-get's Theory for Parents. New York, Harper & Row Publishers Inc, 1978, pp 87-89, 186. 20. Setoguchi Y, Rosenfelder R (eds): The Limb Deficient Child. Springfield, Ill, Charles C Thomas Publishers, 1982, pp 14, 23, 56, 95-97, 113, 114, 140-158, 180-192, 212237, 255. 21. Schmid H: Foot studies in children with severe upper limb deficiencies. Am] Occup Ther 1971; 25:160. 22. Shaperman J: Early learning of hook operation. Inter-Clin Info Bull 1975; 14:11-15. 23. Shaperman J: The CAPP terminal device-A preliminary clinical evaluation. Inter-Clin Info Bull 1975; 14:9-10. 24. Shaperman J: The CAPP terminal device, size #2: A new alternative for adolescents and adults. Physical disabilities special interest section newsletter. Am Occup Ther Assoc 1987; 10:3. 25. Shaperman J, Setoguchi Y, Sumida C: Another look at modular prostheses, in Newsletter: Amputee Clinics, Vol 4. Washington, DC, National Academy of SciencesNational Research Council, 1975, pp 3-4. 26. Shaperman J, Sumida C: Recent advances in research in children's prosthetics, In Symposium on Congenital Malformations-Its Clinical Management. Clin Orthop 1980; 148:26. 27. Sorbye R: Upper extremity amputees: Swedish experiences concerning children, in Atkins DJ, Meier RH (eds): Comprehensive Management of the Upper-Limb Amputee. New York, Springer-Verlag NY Inc, 1989, pp 227-229. 28. Sumida W, Shaperman J: Clinical application of the infant modular below-elbow prosthesis. Inter-Clin Info Bull 1974; 13:9-14. 29. Sypniewski BL: The child with terminal transverse partial hemimelia: A review of the literature on prosthetic management. Artif Limbs 1972; 16:35-36. 30. Talbot D: The Child With A Limb Deficiency-A Guide For Parents. Child Amputee Prosthetics Project, University of California at Los Angeles, 1979, p 5. 31. Wendt J, Shaperman J: The infant with a cable-controlled hook. Am J Occup Ther 1970; 24:393. 32. Williams TW: One muscle infant's myoelectric control. Unpublished printed information flyer. Liberty Mutual Research Center, Hopkinton, Mass.
Chapter 34D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 35A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
BASIC PRINCIPLES
The physiologic differences between children and adults have already been discussed, as have general surgical considerations and planning for the care of the juvenile amputee. Emphasis should be placed on early prosthetic fitting and rehabilitation whenever possible. In general, 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. One should anticipate that the child will become ambulatory promptly, whether the deficiency is distal or proximal. By the same token, in unilateral longitudinal limb deficiency, in which it is likely that surgical revision will be necessary, a treatment plan should be developed so that, if possible, all surgical procedures can be carried out in one stage. The child should be brought to independent walking as early as possible, with surgical intervention and resultant scarring kept to a minimum and with the best physiologic restoration available. Surgical intervention on the limb-deficient child, particularly on those with longitudinal deficiencies, should be undertaken only by the experienced orthopaedic surgeon and preferably in those centers that are accustomed to dealing with these children. By their very nature and fortuitously, these deformities occur infrequently and therefore are not likely to be seen on any recurring basis in the office practice or general hospital. While in the past, limb lengthening for congenital longitudinal deficiencies has been considered and largely abandoned (with the possible exception of the congenital short femur), 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. discussing limb lengthening for longitudinal deficiency of the femur or fibula, the total predicted discrepancy must be calculated in advance, and the impact that this choice will have on the childhood of the patient must be considered. The family must recognize that when the child is just beginning to walk, a lift will be required until the child is old enough for lengthening; that at least 9 to 12 months will be required, during which period the patient will be either in the lengthening apparatus or immobilized or braced after healing; and that if overlengthened he will require a lift on the normal side. This cycle will probably be repeated as he approaches the teenage years until definitive equalization can be attempted. In effect, this path would occupy the entire childhood. Prior to embarking on such an ambitious surgical program, the family must completely understand the difficulties they will face. This problem will be further discussed under the individual deficiencies where lengthening may be an option. 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; (2) maintenance of muscular development in the residual limb; (3) prevention of progressive deformity, especially in joints proximal to the deficiency; and (4) retention of all long-bone growth plates.
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.
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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, but a positive approach to the child's immediate status and future capabilities as well. The physician should emphasize the remaining normal limbs, absence of brain damage, and expectations of the child's physical development. The new parents should be assured of the child's potential for ambulation, independence of daily living, and normal mental development. Assistance in these discussions may be sought from the social worker and pediatrician. If there is a problem with the parents, psychological or psychiatric consultations may be indicated. Many parents, on visiting a limb deficiency clinic, are impressed with the athletic accomplishments of children with limb deficiencies. These parents should be encouraged to raise their child as "a normal child," and they should encourage normal physical activity, including any sports activity that the child is capable of carrying out and in which he is interested. Competitive sports should not be prohibited for a child with a limb deficiency but, in fact, should be encouraged. Experience has shown that a child who is missing a leg can play competitive football, basketball, and tennis or, for that matter, any other sport ( Fig 35A1.,A and B). Even when an individual is missing a hand, baseball, basketball, and golf are not outside his abilities. It is particularly important to stress to the family that most limb deficiencies occur sporadically and are not genetically transmitted. Genetic consultation is important, however. In those instances in which there is a known heritable defect such as deficiency of the tibia, genetic Should pregnancy occur, parents should also be encouraged to consultation is mandatory. advise the obstetrician of the history and to be certain that a sonographic study is carried out in the early stages of the pregnancy. Once out of the hospital, and particularly if surgical conversion of the limb deficiency is anticipated, the parents should be invited to the "clinic.'' There they should be encouraged to observe older children with the same or similar deficiencies, and particularly to discuss the child's physical and social development with the parents of these older children. They should be encouraged to ask questions about the child's participation not only in family activity at home but also in social, play, and school activities. Concerns about social acceptance of the deficiency and, particularly, of indicated prosthetic restoration may subconsciously prejudice a parent against any recommended treatment program. 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. They become integral members in the planning and implementation of the program to habilitate their child. Such "group therapy" enables the parents to comprehend the need for and accept the recommendation to proceed with ablative surgery when it is indicated. Without this open communication between parents and clinic team, the more complicated problems of the limb-deficient child may be insoluble.
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be indicated until the optimal time for surgical intervention is reached. Prevention of progressive deformity is an important ingredient of the long-range planning for these patients. When surgical intervention is considered, plans should be laid out in such a manner as to anticipate the result in terms of the adult patient. To this end we must consider the many facets of surgical intervention, including the retention of all long-bone epiphyses as indicated. On occasion, as in carrying out a knee fusion in the patient with PFFD, 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. In such a case, appropriately planned, the epiphyses may be destroyed. We should also think in terms of the preservation of functional proximal joints, stabilization of proximal joints where necessary (i.e., knee fusion), and the judicious use of skin grafting when necessary.
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These decisions will be somewhat altered with regard to the bilateral limb-deficient child, but in general an effort should be made to fit prostheses as early as possible, based on the team evaluation of the child. Emphasis must be placed on the therapist's evaluation of the child's muscular coordination and ability to manage prosthetic devices. Prosthetic fitting may have to be staged or delayed until surgical intervention can reasonably be accomplished. The physiologic and, particularly, psychological differences between the child with bilateral limb deficiencies and the adult with a bilateral amputation must be recognized when contemplating the bilateral fitting. When bilateral surgical conversion or a revision procedure is planned, rehabilitation goals for the infant or juvenile should take these differences into consideration. The child who requires bilateral Syme ankle disarticulation should be expected to walk independently without crutches or canes ( Fig 35A-5.). He should be expected to take part in all normal activities, including athletics, and should be able to don and doff the prostheses independently early in life. Similarly, the child with a bilateral transtibial fitting should have very high rehabilitation goals ( Fig 35A-6.). Even as the levels of amputation go higher, one should anticipate that as long as the child has functional upper limbs with which to improve balance, he should be independently ambulatory. It is generally appreciated that the adult bilateral transfemoral amputee, if he is to walk, will require crutches or canes. The child, on the other hand, can be expected to walk independently when properly trained. Early fitting and appropriate training can be a very rewarding experience in such a patient. In the very young child, as in the very old patient with bilateral transfemoral amputations, initial fitting with stubbies is recommended. Stubbies are modified sockets with either a rocker or rubber-soled bottom. The use of stubbies permits the patient to develop balance in the erect position. When independent walking has been accomplished, the stubbies may be lengthened, thereby increasing the child's height and confidence in the erect position. The final prescription is for articulated limbs ( Fig 35A-7.). Ambulation without crutches or other external aids should be expected. The parents of the bilateral lower-limb-deficient child must be made aware of the importance of weight control. Instruction and dietary regulation should be available to the family and their responsibility at home stressed ( Fig 35A-8.). Although the problem of the patient with bilateral PFFD will be dealt with later in this chapter, it cannot be repeated often enough that this is the one situation in which any consideration of amputation of the feet should be deferred.
Skin Grafting
Skin grafting in the child is very well tolerated. Split-thickness skin grafts on the residual limbs of children will mature and withstand the shearing or frictional forces of socket contact. Denuding of a short transtibial residual limb is no indication to proceed with higher amputation in a child. Instead, skin grafting should be carried out. The resurfaced limb should then be toughened up in anticipation of prosthetic application. The surgeon should keep this philosophy in mind when dealing with the limb-deficient child. If preservation of a knee joint requires a posterior release and skin is a problem, split-thickness grafting may be carried out. The surgeon should not hesitate to use a skin graft to preserve an epiphysis where there is a deficiency of skin. Split-thickness grafting in weight-bearing areas may ultimately require revision and/or a pedicle graft ( Fig 35A-9.), but most splitthickness grafts mature and tolerate prosthetic wear well. 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. Selection of a donor site for a skin graft in the lower-limb amputee should not be casually undertaken. Consideration must be given to the ultimate amputation level and the type of prosthesis that the patient will ultimately wear. No area should be chosen as a donor site if there is the possibility that it may later interfere with prosthetic wear. As an example, the ipsilateral thigh should not be chosen as the donor site for skin grafting for a transtibial stump. There may subsequently be the need for a thigh corset, in which case the scarred thigh would be a problem. In a transfemoral amputation, 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, in which case this would be directly over the scarred area. When there is a need for a pedicle or flap graft, the operating surgeon should take into consideration the patient's ultimate amputation level. 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. Such scarred stumps require special attention
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from the pros-thetist; with appropriate prescription and prosthetic restoration, the skin graft will mature and be able to withstand the stress of a socket.
TRANSVERSE DEFICIENCIES
Phalangeal Deficiencies
Transverse deficiencies of the phalanges, whether partial or total, do not usually require revision surgery. If associated with congenital constriction bands, surgical intervention should be directed at the constriction bands. Occasionally, proximal amputation of the toes will be necessary.
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posterior capsule is divided and the heel cord dissected off the superior aspect of the os calcis. The dissection is completed by separating the os calcis from the plantar flaps and care taken not to puncture the skin posteriorly. All major bleeders are ligated, the tourniquet released, and bleeding controlled. The heel cord is now sutured to the posterior capsule. The anterior tibial tendon is sutured to the anterior capsule, and the plantar flap is brought forward. The heel pad is stabilized with a Kirschner wire or Steinmann pin through the heel pad and the articular surface and across the epiphysis. The plantar fascia flap is sutured to the anterior capsule. Drainage may be accomplished with a soft-tissue drain or suction drainage if desired. The skin is closed with loose interrupted sutures. Dressing may be done by using either the rigid dressing or dry compression technique. Drainage is discontinued at 48 hours.
Transverse Deficiency of the Leg, Total and Transverse Deficiency of the Thigh, Lower Third
Transfemoral deficiencies occur less frequently in children than do transtibial deficiencies. Surgical intervention is seldom if ever indicated. Management is prosthetic restoration ( Fig 35A-7.).
LONGITUDINAL DEFICIENCIES
Longitudinal Deficiency of the Fibula, Partial
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Partial longitudinal deficiency of the fibula may take on many forms, from a shortening of the fibula, which will frequently be associated with a ball-and-socket ankle, to almost complete absence of the fibula with only a small segment present. In between, there may be a very hypoplastic short fibula, which will be associated with a leg length discrepancy. The very small remaining segment of the fibula will frequently be treated as a total longitudinal deficiency of the fibula, whereas the full-length fibula with shortening is treated primarily as a length discrepancy problem.
Clinical Picture
As with other longitudinal limb deficiencies, one is impressed by the fact that fibular deficiency The tibia may be is a true limb deficiency, not simply the absence of a single bone (fibula). bowed and usually has an abnormality of the distal epiphysis. There may be a minimal shortening of the femur or coexistent PFFD. A congenitally short femur may be present. Deficiency also exists in the muscles, tendons, nerves, and even the skin, as evidenced by the dimpling frequently present over the deformed tibia. Hootnick et al. 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, lateral rays. with or without absence of the metatarsal rays and tarsal anomalies ( Fig 35A-15. ). For the patient with total unilateral longitudinal deficiency of the fibula, progressive length discrepancy is the major clinical problem. In the patient with bilateral fibular deficiency, this problem translates to a failure to attain normal height. Definitive treatment of patients with fibular deficiency will depend on two major considerations: (1) is it associated with PFFD, 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, with the fibular deficiency as a secondary consideration. The patient with unilateral fibular deficiency and PFFD on the contralateral side is an exception to this.
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prosthetic restoration. Reconstruction has been recommended but, in our opinion, is not optimal. Therefore, it is recommended that early conversion be carried out ( Fig 35A-16. )between 9 and 12 months of age, or as soon as the child is able to stand and indicates a readiness to commence walking. Indications for early amputation and prosthetic restoration may then be summed up as (1) length discrepancy in excess of 5 cm (2 in.) and progressing, (2) foot deformity, and (3) a normal femur. It is important that the procedure be a Syme ankle disarticulation or Boyd amputation, never transtibial 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. The distal tibial epiphysis contributes 20% of the growth of the limb as a whole and 45% of the growth of the tibia itself. Even if it is known that the distal tibial epiphysis may not be normal, it is still important to appreciate that if this epiphysis is sacrificed at 1 year of age, the child will be left with a short transtibial residual limb when he attains full growth. On the other hand, if the growth plate is retained, one may anticipate that there will be, at worst, a long transtibial stump or, at best, a good Syme-type ankle disarticulation. The disarticulation procedure also provides an end-bearing stump on which the child may walk without the prosthesis. Prior to 8 years of age, transtibial amputation is accompanied by a high incidence of bony overgrowth at the amputation site ( Fig 35A-17. ). Much has been written about bony overgrowth, its prevention, and treatment. When symptomatic, revision of the amputation is necessary. In summary, most children with unilateral fibular deficiency require ankle disarticulation and prosthetic restoration. During the operation the articular cartilage should be left on the distal portion of the tibia and the heel pad fixed to it. One should also look for the presence of an anterior tibial bow. This has been described as a kyphoscoliotic tibia and becomes a problem in prosthetic fit. It may be a result of contracture of a lateral band but is more appropriately recognized as a central defect of the tibia. One sees dimpling of the skin over this anterior bow. When indicated, this anteriorly bowed or kyphoscoliotic tibia should be corrected by rhomboid resection of bone ( Fig 35A-18. ). The presence of a lateral band should also be taken into consideration. Excision of this lateral band, which may be a deforming force, can be carried out at the same time as the rhomboid resection and straightening of the tibial bow. The procedure for ankle disarticulation has been described. In the older child, consideration should be given to modification of the disarticulation procedure. Many of these children have already undergone triple arthrodesis or other surgical procedures in an attempt to restore a functional foot. Length discrepancy is progressive and is the indication for amputation. In these patients, fusion of the ankle joint and amputation through the mid-tarsal level, or a modified Boyd procedure, retains the extra length and normal attachment of the heel pad to the os calcis. The broad stump contour does require a more bulky prosthetic socket and is cosmetically less desirable. The procedure is therefore usually reserved for boys, in whom cosmesis is not so important ( Fig 35A-19. ). Ankle disarticulation is the procedure of choice for girls.
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A retrospective study of a small group of unampu-tated patients at Shriners Hospital in Springfield, Massachusetts, concluded that 50% should have had amputation ( Fig 35A-20. ) When length discrepancy between the and prosthetic restoration to provide normal stature. tibia and femur is sufficiently great to make this decision at an early age, it is desirable to introduce parents to the limb deficiency clinic. 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. If the discrepancy in proportional length of the tibia and femur is small and there is a good foot, consideration of amputation should be deferred, but growth charts should be maintained for the patient. If the discrepancy is a progressive one and it is apparent that the patient is going to be unduly short in adult life, bilateral ankle disarticulation and prosthetic restoration may be recommended prior to school age ( Fig 35A-21. ). As the child grows older, and particularly if he has been permitted to enter his early teens without surgical intervention, the child himself should enter into the decision making concerning such ablative surgery and prosthetic restoration.
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The proximal tibial segment is exposed through an elliptical incision between it and the fibula. The distal portion of this tibial segment is dissected subperi-osteally and completely exposed. The fibula is now exposed subperiosteally at a level opposite the remaining tibia. With a sharp gouge, the medial surface of the fibula is turned proximalward, and the lateral aspect of the tibia is turned distalward. Bone graft is then packed into the defect between the two. The fascia is not sutured. The subcutaneous tissue and skin are closed in layers. Disarticulation at has described implantation the ankle is then accomplished in the usual fashion. Marquardt of the fibula into the os calcis to create an end-bearing stump. This procedure may be employed instead of simple disarticulation at the ankle. The limb is immobilized in a long-leg plaster cast with the knee in full extension for 8 weeks, or until there is evidence of firm cross-union between the tibia and fibula. If the proximal segment of the tibia is sufficiently long, tibiofibular synostosis is not necessary. Syme ankle disarticulation or a modified procedure (Boyd type) and fitting with a transtibialtype prosthesis may be carried out early in life. When the proximal tibial fragment is very small, one must wait until adequate ossification occurs and then attempt to implant the fibula into the tibial segment to create a one-bone leg. After this is done, the os calcis can be implanted into the distal end of the fibula and amputation carried out, thus treating the patient as a Syme disarticulate ( Fig 35A-27. ).
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the pterygium down to the "knee joint." 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. A lateral scar is also left, which may be bulky proximally but shrinks down rapidly thereafter ( Fig 35A-28. ). 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. If this discrepancy does not occur, distal femoral epiphysiodesis may be considered when the child is 10 to 12 years of age. If the child is seen when it is considered too late for epiphysiodesis and spontaneous differential femoral shortening has not occurred, the distal end of the femur may be modified to allow for a more cosmetic prosthetic fitting. This can include distal shortening of 2.5 to 3.0 cm, partial condylar ostectomies medially and posteriorly, and patellectomy. Femoral shortening may be considered. Newer design of joints for the knee disarticulation prosthesis may render this option unnecessary.
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and instability of proximal joints all contribute to the poor gait and complexity of treatment, it is the length discrepancy that is the ultimate indication for definitive surgery-amputation and prosthetic restoration. 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. 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 theory of proportionate growth has been expanded by Mosley in his technique of charting the proportionate discrepancy, as opposed to the growth of the normal limb. Although in most patients with PFFD the discrepancy early in life is sufficient to suggest that eventual amputation will be indicated, growth charts can be of assistance in decisions as to the total treatment plan. The clinical picture of PFFD ( Fig 35A-30. ) is that of a short femoral segment that is positioned in flexion, abduction, and external rotation. If ignored, this condition may become a fixed deformity with secondary knee flexion deformity. When associated with fibular deficiency, the length discrepancy will be much greater, and foot deformity will be present. If the tibia and fibula are essentially normal, then foot and ankle function will be normal. It is important to institute an early stretching program to prevent knee and hip deformity.
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ossification of the neck fragment is present, a Coventry screw or small Smith-Petersen nail and plate may be used. A bone graft is desirable in an effort to obtain union. 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. The wound closure is routine. Immobilization should be in a hip spica with wide abduction for a minimum of 8 to 12 weeks, or until good bony union is verified by radiographic examination. Steel et al. have described fusing the femoral segment to the pelvis in classes C and D In their technique, the femoral segment is fused to the PFFD, with success in four patients. pelvis with it parallel to the floor so that when the patient is standing, the anatomic knee is flexed 90 degrees and the tibia functions as a femur. After ankle disarticulation the transfemoral-type prosthetic knee is extended. When the patient sits, the anatomic knee extends to permit flexion of the prosthetic knee. In our opinion, this procedure offsets the weight-bearing line of the limb anteriorly and aggravates the hip limp in these patients.
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Options in definitive treatment are disarticulation at the ankle with transfemoral prosthetic restoration or Van Nes rotation-plasty. Disarticulation at the ankle may leave the prosthetic knee center below that of the normal side. In this case, distal femoral epiphyseal arrest or shortening at the time of knee fusion may be desirable. The Van The Van Nes rotation-plasty may be considered in conjunction with knee fusion. 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. Following solid healing, the ankle joint can then be expected to function as a knee joint, with dor-siflexion of the ankle providing "knee flexion" and plantar flexion of the ankle providing "knee extension." Prior to making the decision for Van Nes rotation-plasty, 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. Use of the Van Nes rotation-plasty provides the patient with a "knee joint" and a transtibial-type prosthesis ( Fig 35A-35. ). The nonconventional prosthesis will have a socket modified to accept the foot as the shank portion, with weight bearing primarily on the heel and longitudinal arch of the foot. Placement of the knee axis must be precise and the thigh corset constructed and padded to prevent pressure over the pretibial region. Torode and Gillespie have performed rotation-plasty through the knee joint and, if 180 degrees of rotation was not obtained, completed the rotation through the tibial osteotomy. Fricia et al. reported on 13 patients with rotation osteotomy for PFFD and noted that 5 required repeat osteotomy, 6 of 12 unilateral patients had excellent results and 4 had good results. They stated that 5 girls with excellent results had no objection to cosmetic appearance.
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contraindicated.
Symmetrical
Patients with bilateral PFFD and approximately equal-length limbs ambulate despite the severity of their limb anomalies, provided that they have functional upper limbs. When seen in infancy, they can begin a physical therapy program to maintain their musculature and prevent fixed deformity. Trunk-strengthening exercises should be instituted early in life, and the parents should be encouraged to permit the child maximum activity. When bilateral PFFD is associated with other lower-limb deficiencies such as fibular deficiency, it may be necessary to consider surgical intervention and/or orthotic management to control the deformity. 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. ), most of these patients with functional arms assume independent ambulation sometime between 2 and 3 years of age. It is interesting that these children spontaneously become hand walkers. When the child reaches 5 or 6 years of age, an effort should be made to allow him to use "stilts." It is at the time of entering school that a child's deficiency in stature becomes important to him. Prosthetic restoration is directed toward cosmetic rather than functional improvement. With development of good balance, the child ultimately can be fitted with articulated limbs without amputation to providing him with adequate height. It must be recognized that the energy consumption required for ambulation is great, and since the child's activity level is usually reduced, weight is gained easily. The parents must recognize that weight control is very important and institute dietary control at home. This group of patients should not be considered for amputation. The feet and ankles should be preserved so that the patient remains independent without prostheses. We have observed patients continuously using their prostheses up to 35 years of age, but what their ability will be at the age of 55 or 65 years we cannot say. It is therefore important to preserve the feet. It is wise to use a helmet for head protection for children on stilt prostheses, particularly those with upper-limb deficiencies. 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. These activities should be encouraged and are of sufficient importance to contraindicate a prescription for prostheses.
Asymmetrical
Patients with asymmetrical PFFD and one leg significantly longer than the other walk independently despite the severe deformity of both legs. When seen in infancy, the major effort should be directed toward preservation of joint function and prevention of deformity. Orthotic management will be necessary to maintain knee extension, and lifts should be prescribed as necessary to equalize leg lengths. When the discrepancy is great, as occurs when the short side has an associated fibular deficiency, disarticulation at the ankle joint on the short side is indicated. Provision of a Syme-type prosthesis will equalize length and give reasonable stature. Improvement in height by means of bilateral prosthetic restoration has been attempted in these children. The short side is fitted with an articulated limb, whereas the long side is fitted with an extension prosthesis ( Fig 35A-37. ). Since the combinations of deficiency may be varied, the treatment plan for each patient must be individualized. References: 1. Achterman C, Kalamchi A: Congenital deficiency of the fibula. J Bone Joint Surg [Br] 1979; 61:133. 2. Aitken GT: Amputation as a treatment for certain lower extremity congenital abnormalities. J Bone Joint Surg [Am] 1959;41:1267-1285. 3. Aitken GT: Proximal femoral focal deficiency-definition, classification, and
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4. 5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
34.
management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly. Washington, DC, National Academy of Sciences, publication no 1734, 1969. Aitken GT: Tibial hemimelia, in Aitken GT (ed): Selected Lower Limb Anomalies. Washington, DC, National Academy of Sciences, 1971. Amstutz HD: The morphology, natural history and treatment of proximal femoral focal deficiencies, in Proximal Femoral Focal Deficiency-A Congenital Anomaly. Washington, DC, National Academy of Sciences, 1968, pp 50-76. Amstutz HD, Wilson PD Jr: Dysgenesis of the proximal femur (coxa vara) and its surgical management. J Bone Joint Surg [Am] 1962; 44:1-24. Badgley CE, O'Connor SJ, Kudner DF: Congenital ky-phoscoliotic tibia. J Bone Joint Surg [Am] 1952; 34:349-371. Bevan-Thomas WH, Miller EA: A review of the proximal femoral focal deficiencies. J Bone Joint Surg [Am] 1967; 49:1376-1388. Bohne WHO, Root L: Hypoplasia of the fibula. Clin Or-thop 1977; 125:107-112. Borggreve J: Kniegelenksersatz durch das in der Bein-langsachse um 180 gedrehte Fussgelenk. Arch Orthop Chir 1930;28:175-178. Brown FW: Construction of a knee joint in congenital total absence of the tibia (paraxial hemimelia tibia): A preliminary report. J Bone Joint Surg [Am] 1965; 47:695-704. Brown FW: The Brown operation for total hemimelia tibia, in Aitken GT (ed): Selected Lower Limb Anomalies. Washington, DC, National Academy of Sciences, 1971. Clark MW: Autosomal dominant inheritance of tibial meromelia. J Bone Joint Surg [Am] 1975; 57:262-264. Corner EM: The clinical picture of congenital absence of the fibula. Br J Surg 1913; 1:203-206. Coventry MB, Johnson EW Jr: Congenital absence of the fibula. J Bone Joint Surg [Am] 1952; 34:941-955. Doig WG: Proximal femoral phocomelia. In proceedings of the Australian Orthopaedic Association. J Bone Joint Surg [Br] 1970; 52:394. Eaton GO, McKusick VA: A seemingly unique Polydactyly-syndactyly syndrome in four persons in three generations. Birth Defects 1969; 5:221-225. Epps CH Jr: Current concepts review. Proximal femoral focal deficiency. J Bone Joint Surg [Am] 1983; 65:867-870. Farmer AW, Laruin CA: Congenital absence of the fibula. J Bone Joint Surg [Am] I960; 42:1-12. Fixsen JA, Lloyd-Roberts GC: The natural history and early treatment of proximal femoral dysplasia. J Bone Joint Surg [Br] 1974; 56:86-95. Frankel VH, Gold S, Golyakhovsky V: The Ilizarov technique. Bull Hosp J Dis Orthop Inst 1988; 48:17-27. Friscia DA, Moseley DF, Oppenheim WL: Rotational osteotomy for proximal femoral focal deficiency. J Bone Joint Surg [Am] 1989; 71:1386-1392. Gillespie R, Torode IP: Classification and management of congenital abnormalities of the femur. J Bone Joint Surg [Br] 1983; 65:557-568. Grissom LE, Harcke HT, Kumar SJ: Sonography in the management of tibial hemimelia. Clin Orthop 1990; 251:266-270. Hillmann JS, Mesgarzadeh M, Revesz G, et al: Proximal femoral focal deficiency: Radiologic analysis of 49 cases. Radiology 1987; 165:769-773. Hootnick DR, Levinsohn EM, Packard DS Jr: Midline metatarsal dysplasia associated with absent fibula. Clin Orthop 1980; 150:203-206. Jayakumar SS, Eilert RE: Fibular transfer for congenital absence of the tibia. Clin Orthop 1979; 139:97. Johansson E, Aparisi T: Missing cruciate ligament in congenital short femur. J Bone Joint Surg [Am] 1983; 65:1109-1115. Jones D, Barnes J, Lloyd-Roberts GC: Congenital aplasia and dysplasia of the tibia with intact fibula. Classification and management. J Bone Joint Surg [Br] 1978; 60:3139. Kalamchi A, Cowell HR, Kim KI: Congenital deficiency of the femur. J Pediatr Orthop 1985; 5:129-134. Kalamchi A, Dawe RV: Congenital deficiency of the tibia. J Bone Joint Surg [Br] 1985; 67:581-587. King RE: Providing a single skeletal lever in proximal femoral focal deficiency. A preliminary case report. Inter-Clin Info Bull 1966; 6:23-28. King RE: Some concepts of proximal femoral focal deficiency, in Proximal Femoral Focal deficiency: A Congenital Anomaly. Washington, DC, National Academy of Sciences, Publication No. 1734. 1969. King RE, Marks TW: Follow-up findings on the skeletal lever in the surgical
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management of proximal femoral focal deficiency. Inter-Clin Info Bull 1971; 11:1-4. 35. Koman LA, Meyer LC: Current management of proximal femoral focal deficiency. Orthop Trans 1979; 3:40. 36. Koman LA, Meyer LC, Warren FH: Management of proximal femoral focal deficiency. Orthop Trans 1979; 3:286. 37. Koman LA, Meyer LC, Warren FH: Proximal femoral focal deficiency: A 50-year experience. Dev Med Child Neurol 1982; 24:344-355. 38. Kostiuk JP, Gillespie R, Hall JE, et al: Van Nes rotational osteotomy for treatment of proximal femoral focal deficiency and congenital short femur. J Bone Joint Surg [Am] 1975;57:1039-1046. 39. Kritter AE: Tibial rotation plasty for proximal femoral focal deficiency. J Bone Joint Surg [Am] 1977; 59:927-934. 40. Kruger LM: Classification and prosthetic management of limb-deficient children. InterClin Info Bull 1968; 7:1-25. 41. Kruger LM: Fibular Hemimelia: A symposium. Selected Lower-Limb Anomalies. Washington, DC, National Academy of Science, 1971, p 49. 42. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies. Inter-Clin Info Bull 1973; 12:7-15. 43. Kruger LM, Rossi TV: Proximal femoral focal deficiency and its treatment. J Orthot Prosthet 1975; 29:37-57. 44. Kruger LM, Talbott RD: Amputation and prosthesis as definitive treatment in congenital absence of the fibula. J Bone Joint Surg [Am] 1961; 43:625-642. 45. Ladder RF, Herring JA: Fibular transfer for congenital absence of the tibia: A reassessment. J Pediatr Orthop 1987; 1:8. 46. Lange DR, Schoenecker PL, Baker CL: Proximal femoral focal deficiency. Clin Orthop 1978; 135:15-25. 47. Langston HH: Congenital defect of the shaft of the femur. Br J Surg 1939; 27:162. 48. Lloyd-Roberts GC, Stone KH: Congenital hypoplasia of the upper femur. J Bone Joint Surg [Br] 1963; 45:557-560. 49. Mcintosh R, Merritt KK, Richards MR, et al: The incidence of congenital malformations. Pediatrics 1954; 14:505-522. 50. Marquardt E: Personal communication. 1979. 51. Mazet R Jr: Syme's amputation. A follow-up study of fifty-one adults and thirty-two children. J Bone Joint Surg [Am] 1968;50:1549-1563. 52. Mosley CF: A straight-line graph for leg length discrepancies. J Bone Joint Surg [Am] 1977; 59:174-179. 53. Ogden W, Meyer LC: Proximal femoral focal deficiency. Presented at a meeting of the South Carolina Orthopaedic Association, Hilton Head, SC, September 1970. 54. O'Rahilly R: Morphological patterns in limb deficiencies and duplications. Am J Anat 1951; 89:135-193. 55. Pappas AM: Congenital abnormalities of the femur and related lower extremity malformations: Classification and treatment. J Pediatr Orthop 1983; 3:45-60. 56. Pashayan H, Fraser FC, Mclntyre JM, et al: Bilateral aplasia of the tibia, Polydactyly and absent thumb in father and daughter. J Bone Joint Surg [Br] 1971; 53:495-599. 57. Pellicore RJ, Sciora J, Lambert CN, et al: Incidence of bone overgrowth in the juvenile amputee population. Inter Clin Info Bull 1974; 13:1-8. 58. Putti B: The treatment of congenital absence of the tibia and fibula (abstract). Int Surg 1930; 50:42. 59. Richardson EG, Rambach B: Proximal femoral focal deficiency: A clinical appraisal. S Med J 1979; 72:166-173. 60. Rogala EJ, Wynne-Davies R, Littlejohn A, et al: Congenital limb anomalies: Frequency and aetiological factors. J Med Genet 1974; 11:221-233. 61. Schatz SL, Kopits SE: Proximal femoral focal deficiency. AJR 1978; 131:289-295. 62. Scheer GB: Treatment of proximal femoral focal deficiencies. Clin Orthop 1972; 85:292. 63. Schoenecker PL, Capelli AM, Miccar EA, et al: Congenital longitudinal deficiency of the tibia. J Bone Joint Surg [Am] 1989; 71:278-287. 64. Sen Gupta DK, Gupta SK: Familial bilateral proximal femoral focal deficiency. J Bone Joint Surg [Am] 1984; 66:1470-1472. 65. Serafin JA: New operation for congenital absence of the fibula. J Bone Joint Surg [Br] 1967; 49:59-65. 66. Steel HH, Lin PS, Betz RR, et al: Iliofemoral fusion for proximal femoral focal deficiency. J Bone Joint Surg [Am] 1987; 69:837-843. 67. Stevenson AC, Johnston HA, Stewart MIP, et al: Congenital malformations. A report of a study of series of consecutive births in 24 centres. Bull World Health Organ 1966;
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34(suppl):9-127. 68. Thompson TC, Straub LR, Arnold WD: Congenital absence of the fibula. J Bone Joint Surg [Am] 1957; 39:1229-1237. 69. Torode IP, Gillespie R: Rotation plasty of the lower limb for congenital defects of the femur. J Bone Joint Surg [Br] 1983; 65:569-573. 70. Torode IP, Gillespie R: Anteroposterior instability of the knee: A sign of congenital limb deficiency. J Pediatr Orthop 1983; 3:467-470. 71. Van Nes CP: Rotation-plasty for congenital defects of the femur. J Bone Joint Surg [Br] 1950; 32:12-16. 72. Westin GW, Gunderson FO: Proximal femoral focal in deficiency-a review of treatment experiences, in Symposium on Proximal Femoral Focal Deficiency-A Congenital Anomaly. Washington, DC, National Academy of Sciences, 1969, pp 100-105. 73. Westin GW, Sakai DN, Wood WL: Congenital longitudinal deficiency of the fibula. Follow-up treatment by Syme amputation. J Bone Joint Surg [Am] 1976; 58:492-496. 74. Wood WL, Zlotsky N, Westin GW: Congenital absence of the fibula: Treatment by Syme amputation: Indications and technique. J Bone Joint Surg [Am] 1965; 47:11591169. 75. Yelton CL: Certain congenital limb deficiencies occurring in twins and half-siblings. Inter-Clin Info Bull 1962; 1:1-7.
Chapter 35A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 35B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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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. Furthermore, the child must master sitting balance and other developmental tasks before standing and walking become realistic goals. On occasion, the family may insist on prosthetic fitting, and very lightweight materials can be used. Such fittings probably have more to do with the parents' or grandparents' idea of "body image" than the child's.
7 Months to 14 Months
Most centers recommend fitting when the child is almost ready to pull to stand, which varies among individuals. The major prosthetic considerations are as follows: 1. A socket that allows for rapid linear growth 2. A suspension system that does not encumber the child 3. Regular checkups to monitor growth and proper prosthetic length
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The chief biomechanical function of the foot at this age is to fill the shoe. The child is so lightweight and the gait pattern so primitive that commercial feet are optional. 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. Knee mechanisms are unnecessary for children of this age. Most infants' prostheses are fashioned from one solid piece of balsa wood or rigid foam and covered with a lightweight plastic shell. Endoskeletal construction is also possible; one solid tube from socket to foot reduces weight by omitting the knee mechanism. When the infant with a hip disarticulation is fitted with a prosthesis, a hip joint permitting flexion is necessary to allow sitting. Once again, the knee joint is customarily omitted, and the foot is often formed of lightweight foam materials.
15 to 36 Months
During the period from 1 to 3 years of age, limb growth is the most evident change. There are several ways to accommodate the need for a longer prosthesis. At the time of initial delivery, children's prostheses are sometimes made 1.5 cm ( in.) longer than is correct with an equivalent buildup on the opposite shoe to level the pelvis. When the parents purchase new shoes in a few months (without a lift attached), the effective length of the prosthesis is increased. It is also possible to place spacer blocks between the ankle and foot mechanism up to a point; eventually, it may be necessary to cut the prosthesis in half and add material to the shin plus relaminate. Endoskeletal designs can add longer tubes until the cosmetic cover no longer stretches any further. Although foot size will seem to lag behind as the uninvolved foot grows, this is seldom significant for the growing child. Most prosthetists advise selecting the largest possible foot size for the initial fitting in anticipation of the child's future growth. As the musculoskeletal system matures, the family may notice variations in the toe-in or toeout of the prosthesis. This seldom affects the child's gait significantly and can be simply observed. Only rarely will it be necessary to realign the prosthesis due to significant postural or structural changes in the maturing child. Through careful prosthetic planning and follow-up adjustments, it is common for pediatric prostheses to remain serviceable for a full year or more despite the rapid growth that is anticipated.
37 to 72 Months
During the child's preschool years, from ages 3 to 6 years, manufactured components become available in simple and basic styles. The preschooler's active lifestyle commonly results in lost or tattered clothing after a hard day at play. The prosthesis is subjected to similar rigors and must therefore be simple, rugged, and repairable. A functional knee is commonly introduced at this age, often with a manual locking option initially. As the child masters the prosthesis, the knee can be unlocked at home and later at preschool. An extension assist aids knee stability but may need repairs from time to time. Endoskeletal designs are readily available, and the components generally fare well; the covers are another matter. Some parents gladly accept the need to replace the outside covers at intervals and eagerly embrace endoskeletal prostheses. Others prefer the ultimate durability of the exoskeletal type. Function is similar regardless of the external configuration. A few families will accept an endoskeletal device without the covering during the more destructive phases of childhood. Commercially available feet are preferable starting at this age. Almost all pediatric designs use nonarticulated feet; the high-level or bilateral case is the possible exception. The solidankle, cushion-heel (SACH) design is inexpensive and reliable; dynamic-response alternatives have recently become available. 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.
7 to 12 Years
The elementary school child goes through minor but continual growth changes. Fit and function should be maintained by regular follow-up, at least quarterly. As the preteen years approach, both boys and girls develop interests in new "outside" activities including sports, arts, and social activities such as dancing. The youth's interests begin to have an impact on the prosthetic design as limitations of the previous artificial limb become apparent. Each new fitting offers the opportunity to vary componentry to address the increasing activities of this
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age group.
13 to 18 Years
During the preteen and particularly the teen years, physiologic and psychological changes are intensified- for amputee and nonamputee alike. Cosmetic appearance naturally becomes an This is also a time of transition for the increasing concern for both boys and girls. 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. During this period any number of considerations will arise, from abrupt changes in fashion (e.g., heel heights) to pregnancy, and each must be handled with the seriousness they deserve. The ability to conform by being a nonconformist can become a prosthetic factor too. Some will demand that the prosthesis be inconspicuous and blend into the background, while others will insist on a garish neon color lamination as a statement of personal expression. The need to provide some means of protection from the stresses of competitive sports activities is common. As a general rule, the prosthetic componentry and suspension will become increasingly sophisticated as the teen approaches adulthood. By the time the youth is 18 years old, adult componentry and fitting principles are fully applicable.
Partial Foot
Treatment for the partial-foot amputee varies according to the degree of loss. Since children are lightweight and typically have excellent vascularity, they often do very well with partialfoot amputation. When only loss of the toes is involved, a simple foam filler is usually all that is required. Unlike the case with adults, it is seldom necessary to modify the shoes themselves. This is fortunate because shoe modifications would quickly become expensive for the rapidly growing child. Forefoot to midfoot amputations often do well with a modified University of California Biomechanics Laboratory (UCBL)-type insert that incorporates a toe filler. Once the proximal third of the foot is involved, suspension becomes a problem, and the modified ankle-foot Another approach is to provide a flexible laminated rubber orthosis (AFO) is one solution. "boot" for both function and better cosmetic appearance.
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seldom necessary and encumber the children. Many pediatric amputees do quite well with supracondylar suspension, particularly those who need a little extra mediolateral stability at the knee. Knee sleeves and the silicone suction socket (3S) design both provide suction suspension. Joints and corsets are rarely seen, being reserved primarily for the child with marked ligamentous damage to the knee.
Hip Disarticulation
One key factor for the hip disarticulation fitting is to plan ahead to accommodate circumferential growth of the pelvis. The knee joint is usually omitted until the child is near school age. The hip joint is provided at the outset, however, to permit sitting down. A SACH foot completes the prosthesis. Despite the simple componentry, the pediatric hip disarticulate typically does very well with a prosthesis. Presumably this is due to his small stature (short lever arms) and high energy level. Many progress to become excellent hands-free ambulators even as adults. Most centers are experimenting with thermoplastics and more flexible socket designs for all levels of amputation. Results to date look very encouraging, and further investigation is warranted.
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. This does not necessarily mean that he is
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limited; he will be as functional as society and circumstances allow. Prosthetic restoration may enhance or detract from the amputees independence, depending upon the quality of fit and function provided. Careful attention to detail, developmentally appropriate complexity, and faithful follow-up are the cornerstones of successful pediatric prosthetics. References: 1. Aitken GT: Proximal Femoral Focal Deficiency-A Congenital Anomaly. Washington, DC, National Academy of Sciences, 1969. 2. Beal LL: The impact of an anomalous child on those concerned with his welfare. Orthop Prosthet Appliance J 1962; 16:144-147. 3. Brodsky R, Kay W: The use of the SACH foot with children. Orthop Prosthet Appliance J 1961; 15:261-264. 4. Curry RN, Dorsch B: Developmental factors in the case of the adolescent amputee. Orthot Prosthet 1980; 35:17-21. 5. Dorsch MS: Prosthetics considerations for the female. Orthot Prosthet 1972; 26:3-5. 6. Imler CD: Imler partial foot prosthesis IPFP-"The Chicago Boot." Orthot Prosthet 1985; 39:53-56. 7. Leimkuehler J: Syme's prosthesis-A brief review and a new fabrication technique. Orthot Prosthet 1980; 34:3-12. 8. Ogg HL: Physical therapy for the preschool child amputee. Orthop Prosthet Appliance J 1962; 16:148-150. 9. Pritham CH (ed): New concepts in A.K. sockets. Clin Prosthet Orthot 1981; 9:4-30. 10. Setoguchi Y: Some nonstandard prostheses for children. Orthot Prosthet 1975; 29:1118. 11. Setoguchi Y: The Limb Deficient Child. Springfield, Ill, Charles C Thomas, Publishers, 1982. 12. Tablada C: A technique for fitting converted proximal femoral focal deficiencies. Artif Limbs 1971; 15:27-45.
Chapter 35B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 36A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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casting techniques for the upper limb and the fabrication of a new plastic socket. This is now well known as the Minister socket ( Fig 36A-1.). They introduced the active hook, which proved to be the most universal and most functional of all terminal devices. Their work in research and development was made easier by the German federal government providing money for prosthetic centers, first in Kiel and later in Miinster. However, despite these advances, there were still no special units for children in all of Germany. 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. I also made contact with numerous other prosthetic clinic teams in the United States, and a generous exchange of information resulted. While observing Kessler's patients with kineplasty and body-powered as well as pneumatic prostheses, 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. By watching the children with and without their prostheses, my colleagues and I realized the need to improve all of the body's own compensatory functions as the child Following these experiences, we developed the Pat-Adevelops activities of daily living. Cake prosthesis for armless babies, which allowed us to give them simple grasp at an early age. When these were fitted early, combined with prosthetic training that emphasized motivation and play, better results than had previously been thought possible were obtained. During the years 1958 to 1962, there was an enormous increase in newborn children with multiple, symmetrical, longitudinal limb deficiencies. In the upper limbs, there was a predominant reduction on the radial side of the hand and forearm; this was combined with lower-limb deficiencies in either the tibia, femur, or both.[In November 1978, 5,294 upper limbs of 2,647 thalidomide victims were reviewed and registered by the "Stiftung Hilfswerk fur behinderte Kinder" Bonn-Bad Godesberg.] These limb deficiencies were often associated with abnormalities of the spine and potentially with every other body system. These abnormalities were later shown to be associated with maternal ingestion of thalidomide early in pregnancy. These types of longitudinal deficiencies were not new and had been reported since antiquity. What was new was the enormous number that seemed to be almost an epidemic of multiplelimb-deficient children. Prior to the thalidomide episode, between 1953 and 1958, 37 children were seen in the orthopaedic hospital at the University of Heidelberg. However, from 1959 through 1962, 216 children had multiple-limb deficiencies. In the following 2 years, after the withdrawal of thalidomide from the market, only 10 children were seen with this type of limb deficiency. In view of these numbers it is understandable that a major investment in time, research, and ingenuity was directed to the multiple-limb-deficient child.
PHILOSOPHY OF TREATMENT-1960s
The simple fitting of a prosthesis or multiple prostheses for these children is not adequate. As we struggled to make them as independent as possible, a whole philosophy of care developed in our center. The The treatment of a limb-deficient child is centered in the family, not in the hospital. mother is the child's best therapist under the supervision of the clinic team-physician, occupational therapist, and physical therapist ( Fig 36A-2.). All instruction should be channeled through her, the father, or both. Whenever possible, the training, whether the child uses the prosthesis or not, should be conducted in the home. It is important that all possible sensory contact with the feet be stimulated. The infant should be permitted to see his feet uncovered and encouraged to play with them ( Fig 36A-3.). If there are small digits or hands off the shoulder they should be trained to appreciate touch and grasp. Even if they seem functionless, eventually they may have important prosthesis control functions, which will need the most acute sensory input. If there is hip dysplasia, the Pavlik harness or similar treatment is recommended, since the feet will be allowed full freedom. If there are no arms, the head must be protected from bruising as the child starts to walk. 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.). If the child can eat and play, even deformed hands are better than a prosthesis. However, if one side is functionally behind the other and cannot be used in bimanual activity, a prosthesis is necessary. The infant at 8 months of age can be successfully fitted with a passive prosthesis allowing gross grasp. At this age, it is expected the infant will incorporate the prosthesis into its body image. If it allows for increased function and activity, the prosthesis should be accepted without difficulty.
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The provision of an actively powered prosthesis starts about the beginning of the second year Shoulder movements or, if present, small digits emanating directly from the of life. shoulders can be used to control externally powered prostheses in the sixties, powered by carbon dioxide; in the eighties and nineties by batteries; in the seventies, by both in hybrid systems ( Fig 36A-5.). 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. Training of the child with the prosthesis is adapted for the stage of development present at that time. The actual technical provision of the prostheses and exercise within a therapy setting are insufficient. If these prostheses are to become functional, they must be supplemented cleverly by individual pedagogic and psychological guidance of the children and their parents, which is provided by the prosthetic team. Nevertheless, the success of bilateral arm amputees fitted with pneumatic prostheses cannot be reached by amelic and phocomelic children. On the other hand, 65 of 67 children fitted with different types of pneumatically powered prostheses have ultimately rejected them, some after years of wearing and with excellent prosthetic accomplishment. Only 2 of these 67 continued to wear externally powered arm prostheses ( Fig 36A-6.). The Heidelberg philosophy may then be summarized as follows: 1. For the upper-limb amelic child, the feet and not the arm prostheses will provide maximum function. For the phocomelic child, all digits, both upper and lower, should be used to compensate for loss of normal function. 2. In general, conventional body-powered prostheses for amelic and phocomelic children provide so little function that they are likely to be rejected, particularly by those who are able to use their feet as hands. By the same token, externally powered prostheses are too heavy and complicated. They provide too little effective function for the patients need, and this, coupled with high cost and discomfort of wearing, causes rejection. 3. Prostheses for amelic and phocomelic children are still in the experimental state. The major problem is in positioning the terminal device in space and not so much the terminal device itself. Simpson has developed a brilliant technical solution to this problem, but the weight and complexity of the mechanism have precluded its general acceptance. 4. When amelic or phocomelic individuals request an arm prosthesis at or after the age of puberty, this request is considered and discussed with the patient, along with a discussion of all pros and cons. When a decision is made to prescribe prostheses for these individuals, 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. Both are fixed on a Simpson frame. This is at best a compromise and provides the best possible appearance, the lightest weight, and some function ( Fig 36A-6.). Practically all of these individuals continue to use the feet as hands. Of major importance is the recognition of the fact that the prosthesis should never impede the child's function. When it is recognized that wearing a prosthetic device diminishes important functions, the prosthesis should be removed in favor of such function as was present without it. In 1962 and 1963, the Federal Republic of Germany opened special units for "Dysmeliekinder" in eight other centers, in addition to those clinics that already existed in Miinster and Heidelberg. Programs for research and development of prosthetic devices as well as the testing of prostheses and technical aides for limb-deficient children were developed. Annual workshops and meetings were organized, and in 1964, I made my first statement about the development of compensatory functions of the clubhand by the patient and warned against early operative intervention. In addition to developing new bodypowered and externally powered prostheses for the upper limbs, a new electrically driven vehicle was developed in Miinster by Kuhn. My Horowitz lecture in 1968, "The Total Treatment of the Limb Deficient Child," 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, which I believe should be integrated into the total philosophy of care. In the years following the thalidomide episode, in which some 2,500 children were victimized in the Federal Republic of Germany, such a philosophy was developed at Heidelberg and in the other centers. This was espoused and financed by the government and especially by the Social Security System for the benefit of these victims. On the basis of evaluation of 2,000 of
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these 2,500 children, my conclusions on the treatment and rehabilitation program have continued to develop and, in instances, to change. The care of these patients continues. Secondary damage such as arthropathy or osteoarthritis to the hip joints, knee joints, etc., as well as to the spine, are increasing problems for future years.
Stump Capping
Contrary to a generally held opinion of a few years ago, bony overgrowth has, in fact, been observed in transverse diaphyseal deficiencies. This overgrowth and its concomitant stump attenuation is particularly troublesome when it occurs in a weight-bearing segment such as the tibia and is, of course, most disabling when the opposite limb is also the site of a deficiency. Bony overgrowth of a transhumeral deficiency may be equally disabling. 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. The conventional practice in treating bony overgrowth has, in the past, taken the form of either resection of the overlying bursa and shortening of the bony stump or, in some cases, a formal reamputation at a higher level. In 1972, Swanson reported the development of a silicone rubber implant for capping a transtib-ial amputation stump. He also used this silicone cap for revising amputation stumps in which bony overgrowth had occurred. Buchtiarow attempted stump capping by using a bone and cartilage transplant for transfemo-ral stumps. Stimulated by these experiences, I have developed a technique for capping stumps with The goal is osseous overgrowth that uses autogenous cartilage-bone transplants. conversion of a transhumeral or transtibial amputation into a stump resembling that seen in a disarticulation ( Fig 36A-7.). In the case of a transtibial stump, the easiest available transplant is the head of the fibula and, in the case of a humeral stump, the spina iliaca posterior, but in the quadrimembraldeficient child, various reconstructive procedures on other parts may make a transplant source readily available . When a proximal femoral focal deficiency (PFFD), for instance, is present, the cartilaginous and bony cap from the femur may be used. In the same condition, when knee arthrodesis is planned, the articular surface of the distal portion of the femur may be salvaged for transplant. 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. In the humerus it seems preferable to use a cartilagebone transplant without a growth plate, unless there is good-quality soft tissue overlying the end of the stump or the patient has bilateral short transhumeral stumps. In the weight-bearing bones, on the other hand, it is desirable to procure a transplant with an epiphyseal plate to obtain additional length. In those cases where amputation is carried out for trauma, an epiphysis from the amputated limb may be used. When the procedure is done for overgrowth of the humerus, an effort is also made to attain optimal growth. In most instances weight-bearing training will stimulate continued growth in the proximal humeral growth plate. If the condition of distal skin permits, transplantation of a growth plate here may be carried out. For cases with severe scars at the end of the humeral stump(s), 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 latter is contraindicated in persons who need crutches or canes.
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Surgical Procedure
The incision is planned to avoid scarring in the skin of the end-bearing area. A medial or lateral longitudinal incision is made, starting a few centimeters proximal to the end of the stump ( Fig 36A-8.,B). The bursal sac is opened, and the bony overgrowth is transected at its entry into the bursa and removed. Two or three periosteal and muscular flaps are then developed on the sides of the diaphysis and are reflected proximally. 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.,C). The split ends are gently spread apart, with care taken to prevent fracturing. 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.,D). Fixation of the transplant may be accomplished with two crossed Kirschner wires or with a centrally placed long intramedullary screw. The defect between the split ends of the long bone is packed with additional autogenous cancellous bone ( Fig 36A-9.). The periosteal-muscular flaps are then reattached to the transplant with sutures passed through small drill holes in the graft. The wound is repaired so as to avoid skin tension, and in lower-limb stumps, a rigid plaster dressing is used. In transhumeral stumps a soft compression dressing is preferred.
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 on acceptance and use of a carefully designed prosthesis. These children should be maintained on a daily physical therapy program throughout growth. Just as the normal individual or the athlete requires constant conditioning to maintain maximum muscle strength and joint motion, so the limb-deficient child requires an ongoing training program. Approximately 3 months after the stump-capping surgery, the conditioning, which is called for emphasis "end-bearing training," is commenced. The therapist teaches the patient to apply weight to the reconstructed stump. Initially, 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 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. This training is conducted in coordination with the other daily exercises necessary for rehabilitation. End-bearing training should be repeated at intervals throughout the day. 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. 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. 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.
Case Report
The child in Fig 36A-10 (a-c). , Fig 36A-10 (d-f). , and Fig 36A-10 (g-j). was born on July 12, 1965, the first child of healthy parents with two normal siblings. There was no history of congenital limb deficiency in the family, nor were there other congenital anomalies. In the early pregnancy, however, the mother had had considerable illness and taken numerous medications. At the time of birth it was noted that the child had transverse deficiencies of all four limbs, with the forearm deficient in the upper third bilaterally and the leg similarly deficient in the upper third bilaterally, as well as aplasia of the fibula. Additionally the child had micrognathia and dysplasia of the tongue. She was first seen in my outpatient clinic on May 2, 1966, and in August her first stubby prostheses were fitted to her lower limbs. In January 1967, she was fitted with cable-controlled transradial prostheses and transtibial prostheses with a thigh corset, but no knee joints were prescribed. In 1968, she was fitted with a transtibial prosthesis for the left leg with supracondylar wedge suspension. On the right side, because of the extreme short transtibial stump, she was fitted with a bent-knee prosthesis, with the knee flexed at 90 degrees, and she walked independently with these prostheses. In June 1969, she received two new transradial prostheses with Miinster sockets and Dorrance hooks, as well as two new lower-limb prostheses. By December 1970, osseous overgrowth of the left transtibial stump was noted, and by October 1972, this had increased even though she had received treatment of skin traction and "extension therapy" of the skinmanual stretching by the mother. New sockets were prescribed. In October 1975, there was
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increased spiking at the distal end of the tibia, which was now being handled with liners in the plastic sockets of her prosthesis. By June 1976, she had a painful bursa about the area of spiking at the distal end of the tibia of the left transtibial stump, and there was a varus deviation of the tibia despite the fact that the fibula was absent. In July 1976, 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. In December 1976, the same procedure was carried out on the right tibia. Three months after surgery, end-bearing training was instituted, and the left side did well; however, the right showed reduction of the transplant and increased pain. It required revision in March 1978. The left transtibial stump remained healthy. Presently, 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. She wore her forearm prostheses only part-time; nonetheless, she is completely independent in all activities of daily living.
Surgical Procedure
For planning of angulation osteotomy, the length of the remaining humeral segment should be carefully measured. The planned length of the distal osteotomy fragment will depend on the volume of the stump. In a long slender stump, as little as 3 cm for the angulated distal fragment may be acceptable. To accomplish this, the osteotomy must be started 4 cm above the distal end of the stump. In a large, flabby stump, however, it is necessary to have at least 5 cm of bone in the angulated segment to provide adequate suspension for the socket. 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.
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The incision should be planned to extend no further distally than the lower level of the osteotomy site. It is important to prevent any damage to the blood supply of the distal fragment. 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. The periosteum is incised longitudinally directly over the area from which the wedge of bone is to be removed, usually anteriorly. The periosteum is carefully dissected from the area of wedge removal and further periosteal dissection carried only proximally to avoid denuding the distal fragment. Approximately three quarters of the thickness of the diameter of the bone is then removed in the shape of a trapezoid wedge. In the child, this can be most easily done with a bone-cutting forceps or rongeur. Proximally and distally the open cortex may be notched with a fine rongeur so that when the angulation osteotomy is closed, the notches will interdigitate to provide some stability and good bone apposition ( Fig 36A-11. ). The posterior cortex, supported by its intact periosteum, is now bent into the planned angulation. In the younger child this produces a fairly stable "greenstick" fracture but maintains stability. The osteotomy is then fixed with a single Kirschner wire, 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. If, during the attempt to bend the posterior cortex, fracturing occurs and inherent stability is lost, a second Kirschner wire passed parallel to the first but crossing the osteotomy should provide adequate fixation ( Fig 36A-12. ). If there is any separation at the osteotomy site, the defect may be packed with cancellous bone from the removed wedge. The periosteum is then repaired. Suction drainage is instituted, and the wound is closed in layers. A compression dressing is applied, but no plaster of paris cast is necessary. Suction tubes may be removed in 48 hours. Patients with a shorter transhumeral stump may be treated by exposing the bone on its posterior side to carry out the posterior angulation osteotomy.
Postoperative Care
At 6 to 8 weeks after angulation osteotomy the radiographs should demonstrate secure union. The Kirschner wires may be removed at this time. As with the stump-capping procedure, 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. 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. The fitting with the new prosthesis may proceed at approximately 6 to 8 weeks after the operation ( Fig 36A-13. ). In a young child it may be expected that the given angle will diminish approximately 1.3 to 1.5 degrees for every month of growth, but quicker after end-bearing training only and slower after daily traction exercises corresponding to the Bavarian "Fingerhakelu."
Surgical Procedure
In his original technique, Krukenberg used a simple U-shaped incision and bisected the forearm with either one or two V-shaped flaps, based proximally, to cover the proximal portion of the cleft of the split forearm. A large free-skin graft was necessary to cover the grasping surface of the ulnar half of the forearm. To diminish bulk, some of the muscles of the in 1949, described a similar incision but distal part of the forearm were excised. Bauer, employed radical excision of all distal muscles except the brachioradialis, pronator teres, and supinator to allow primary skin closure without grafting. Kreuz, during and after World War
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II, performed approximately 700 Krukenberg operations. He did not excise muscle in the belief that a better blood supply was thus preserved and a better grasping surface and proprioception created. Large skin grafts were, however, required on the grasping surface of the ulna. In an attempt to combine the advantages of the Kreuz and Bauer modifications and avoid the necessity of excising muscles for closure, I use, like Tubiana, an incision with two Lshaped flaps rather than the simple bisecting U-shaped incision ( Fig 36A-14. ). In closure, 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. Skin grafts are applied to the outer surfaces of the digits where sensation is less important. Interdigitating V-flaps, based proximally, are used to cover the proximal web of the cleft. It is important that the surgeon review the anatomy of the cutaneous nerves of the forearm ( Fig 36A-15. ) so that these are not transected in the incisions used for creating the flaps. After developing the skin and fascial flaps, the forearm muscles are carefully dissected into radial and ulnar groups. 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. , A). The musculature that will motor the forceps action of the reconstructed limb must be carefully The pronator dissected and preserved. The supinator will become the major adductor. teres muscle is part abductor and part adductor. The brachioradialis will open the digits. After division of the muscle groups, gentle separation of the radius and ulna is carried out to create an angle of 25 to 30 degrees. 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. If the radius is approximately 22 cm in length-an average normal for a 12- 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. Shorter stumps may have less opening, but useful function and power can be expected. In the very short stump, proximal transposition of the radial insertion of the pronator teres may be advisable to gain additional opening space and span. When the dissection is completed and the radius and ulna spread to a maximum without damaging muscle, closure is carried out. 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. The V-flaps are sutured in an interdigitating fashion to cover the cleft between the separated radius and ulna. Skin defects will be present on the outer side of each forearm branch. These are covered with splint-thickness or free full-thickness skin grafts taken from the groin. Suction drainage is placed between the V-flaps in the cleft. Closure is completed with care to avoid undue tension ( Fig 36A-16. ,B and C). Following closure, 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. ,D).
Postoperative Care
The suction drainage tubes are removed 2 days after the operation without disturbing the other dressing. All wounds are dressed at a minimum of 10 to 14 days aftersurgery. It is advisable to thoroughly wet the dressings down so that they can be removed easily without damaging the skin grafts. The voluntary If healing is satisfactory, physical and occupational therapy may be started. actions to be exploited are pronation and supination. Pronation has been converted into an opening motion as the pronator teres, acting with the biceps and with the brachioradia-lis, abducts the radius away from the ulna, which is stabilized by the triceps. Supination has been converted to a closing action since the supinator adducts the radius against the ulna. During the training period the patient must be taught to properly use and balance these muscles to gain this function. Between training sessions the patient should be provided with a well-shaped wedge to maintain maximum opening and prevent contracture. For some period of each day, however, the wedge is removed and a circumferential bandage applied to maintain the fully closed
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position. In this way maximum mobility of the joint is maintained and the contractures prevented. As the patient gains the primary function and strength in the forceps action of the stump, additional devices such as wedges or clip-ons are fabricated to hold particular instruments for writing or eating. These assistive devices increase the versatility of the stump and allow the patient to perform specially needed tasks more easily. In addition to these special devices, experience has shown that those patients who have good vision want, in addition to their Krukenberg stump, prostheses that will provide some function but are primarily desired for aesthetic reasons. These patients refer to the prostheses as their "Sunday hands." For this purpose a conventional body-powered prosthesis in which the socket is modified to accept the Krukenberg stump is usually prescribed. 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. ).
Case Report
The child in Fig 36A-18. was born Dec 20, 1963, of healthy parents with two normal siblings. There was no history of drug ingestion, but there had been a threatened abortion in the third month. At birth it was recognized that the child had bilateral total carpal transverse deficiencies of both upper limbs. The child was first seen in March 1965, at which time openend prostheses were prescribed. He was admitted for training in the use of the prostheses but preferred the tactile contact with the stumps, especially on the right side. In 1970, 10X Dorrance hooks were substituted for his earlier terminal devices and, on June 15, 1978, a Krukenberg operation of the left upper limb was carried out. 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. Postoperatively he became an excellent Krukenberg user and at first, used the right open-end prosthesis in association with his "Krukenberg." Then he rejected every prosthesis, even the myoelectric system. After high school, he studied law and is now a judge. 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.
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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. ). The contraindications should be recognized. limited elbow flexion, which, with centralization of the hand, will prevent the individual from using it for any activity approaching the neck, throat, face, or mouth. It should be recognized that the radially deviated hand, often in combination with volar flexion, provides for lifting capacity with strength not available with a weakened finger grasp. This function may be necessary in using a rail for stair climbing. When good function of the digits and of the elbow joint is present, it may indicate early surgical correction, but this should be carried out only by a hand surgeon well experienced in congenital malformations. Buck-Gramcko recommends centralization, or better, his radicalization procedure after an optimal conservative correction within the first year of life, followed by pollicization of the index. In the quadrimembralto do these surgical procedures only deficient child, however, I still prefer, as do Witt et al., after the completion of growth provided that, in spite of conscientious examination and observation, there are no major contraindications ( Fig 36A-21. ).
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Readings." As in the soft-tissue release, reduction of the hand around the shortened ulna should be carried out gently and gradually and the tension on nerves and vessels carefully observed. With correction obtained and centralization acceptable, fixation is accomplished by two crossed Kirschner wires. In addition, the tendons of the radial flexor and extensors of the wrist will be transposed to a dorsal-ulnar position, and the tendon of the ulnar extensor muscle of the wrist will be shortened. Before the wound is closed, the tourniquet is released and circulation in hand and fingers observed. If circulation is satisfactory and bleeding controlled, repair of the wrist joint capsule is carried out. Suction drainage tubes are inserted and the wound closed. Immobilization is applied with sterile dressings and plaster of paris extending from above the elbow to the proximal interphalangeal joints of the fingers. The metacarpophalangeal joints are maintained in slight flexion.
Postoperative Care
Suction drainage is removed at 48 hours. Plaster is changed and sutures removed at about 14 days postoperatively. Immobilization, however, after this procedure should be maintained a minimum of 3 months and, on occasion, up to 6 months to ensure stability. If immobilization is extended beyond 3 months, all finger joints should be freed, and physical therapy for finger motion should be instituted. When bony fusion of the ulna to the carpus is complete, the Kirschner wires may be removed and a full physical therapy program begun. Night splints maintaining full correction of the hand are employed for at least a year postoperatively.
CASE REPORTS
Retention of Feet When Hands Are Missing
Fig 36A-23 (a-b).,Fig 36A-23 (c-g)., and Fig 36A-23 (h-k). show the firstborn of a 39-yearold mother. The child was born on June 15, 1971, by cae-sarean section with total bilateral transverse deficiencies of the forearms, complete bilateral longitudinal deficiencies of the fibula, and fifth metatarsophalangeal deficiencies also present. There were numerous lesser deformities, including some hypoplasia of the right femur and, in particular, bowing of the tibias bilaterally. She was first seen in the outpatient clinic in October 1972 at the age of 16 months. Orthoprostheses were prescribed for the lower limbs, a thigh corset and knee joint
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on the right side, and more of an orthopaedic shoe on the left side. No upper-limb prostheses were prescribed. By December of the same year, the child was beginning to take her first steps in a walker. She was not seen again until April 1975, when it was recognized that she had a small rudimentary ulnar fragment present on the right. At this time upper-limb prostheses were prescribed. In October 1975, 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. New orthoprostheses were prescribed. Bilateral transradial cable-controlled prostheses were prescribed. Her parents would only consider functional hands and rejected the use of a hook. Between 1975 and 1977, the child was not seen. 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, she was independent in the activities of daily living and used her forearm stumps but not her prostheses. She did use her upper-limb prostheses when she went to a restaurant. At this time Syme ankle disarticulations for the lower limbs were considered, but after consultation with the parents, the decision was made against this, and only further correction of the tibial deformity was carried out. In February 1977, new lowerlimb orthoprostheses were prescribed ( Fig 36A-23 (a-b)., Fig 36A-23 (c-g)., and Fig 36A-23 (h-k). ). The patient continues to use her forearm stumps for all activities. In 1987, the bowing of the right tibia had increased enormously so that alignment and maintenance of appearance of this orthoprosthesis were difficult; she asked for amputation, and we constructed an endbearing modified Pirogoff stump, followed by an optimal prosthetic fitting (published with different figures in Seminars in Orthopaedics, Vol. 5, pp. 44-45, 1990). She has friends and is a pleased and happy person, completely independent in the activities of daily living as well as fully ambulatory with her lower-limb prostheses; she finished high school with excellent results and began her years of university study in 1990.
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living. He is now a philosophy student, good humored, and gifted. His upper-limb prostheses, however, got troublesome to him; he felt more comfortable without and rejected them completely without any diminution in activities of daily living or in his psychological stability. For many years, however, his upper-limb prostheses had been of importance for him as well as for his parents.
Hip Reconstruction for Proximal Femoral Focal Deficiency With Multimembral Deficiency
The child in Fig 36A-26 (a-d)., Fig 36A-26e. , Fig 36A-26 (f-i). , and Fig 36A-26j. was born on June 9, 1962, after a full-term pregnancy; the father and mother are both entirely normal, as were three older siblings. There was no family history of limb deficiency or other congenital deformity. There was, however, a history of the mother having ingested thalidomide in early pregnancy. The child was born with bilateral pho-comelic upper limbs consisting of hypoplastic rudimentary humeral segments synostosed with the ulna, a longitudinal deficiency of the radius, and total metacarpophalangeal 1 and 2 deficiency, with hypoplasia of the remaining digits. The lower limbs showed a left partial longitudinal deficiency of the femur (intermediate-the equivalent of an Aitken class A PFFD). On the right side there was coxa vara with bowing. Other congenital anomalies included a mild scoliosis, strabismus, and a pyloric stenosis corrected by surgery on the second day of life. The child was first seen in September 1962, at which time a physical therapy program was instituted as well as extension splinting of the lower limbs. In August 1964, a valgus osteotomy of the right femur was carried out, and in September 1964, she was supplied with an extension orthosis for the left leg. In 1967, the child was admitted to the hospital for self-care training, especially in the technique of using the feet as well as the vestigial hands for activities of daily living. A full physical therapy program to maintain functional mobility of the spine was likewise undertaken. At this time a left upper-limb prosthesis was prescribed. 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.). By the following year the child had rejected the pneumatic prosthesis. In 1968, she was enrolled in a special preschool for the physically handicapped. In 1969, she was supplied with an orthoprosthesis for the left lower limb with a stiff knee and SACH foot (see Fig 36A-4.). In 1974, the left subtrochanteric pseudoarthrosis was resected and the first stage of correction of the severe varus deformity undertaken, as well as correction of the severe hip flexion deformity. In 1975, the second stage for correction of the varus deformity was carried out, and 6 weeks later the patient was fitted with a new orthoprosthesis. In 1976, the hardware was removed and a Chiari osteotomy carried out to provide increased coverage of the femoral head. At this time the trochanter was also transplanted distally. After healing of this surgery a new orthoprosthesis was prescribed with a left thigh corset, free knee joint, and SACH foot. The child became fully and independently ambulatory, used her toes as well as her vestigial hands for self-care, and attended school in her own village. Years later, she is a young woman, completely independent in activities of daily living, and has her own apartment. 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. For the present, 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.
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therapy and occupational therapy program. In 1968, the left index finger was pollicized. In 1969, arthrodesis of the right knee was carried out, and in 1970, new orthoprostheses were prescribed for the lower limbs. In 1971, polliciza-tion of the right index finger was carried out in Heidelberg, and in 1974, the left subtrochanteric pseudarthrosis was resected and the varus deformity corrected, subsequent to which new prostheses were prescribed. In 1978, because of increasing flexion adduction deformity in the left knee, arthrodesis of this knee was carried out. New orthoprostheses were prescribed. In addition to all of his physical problems, this child's schooling had been much delayed by these multiple surgical procedures. Nonetheless, as indicated in Fig 36A-27 (a-d). and Fig 36A-27 (e-h)., he is independently ambulatory, and his pollicized index fingers function quite well as thumbs. Parallel to his increased walking and grasping abilities, his cognitive skills improved, and he is now in a fulltime job as an office worker; he is independent in activities of daily living, drives his own car, and is accepted and accepts himself as he is. This patient demonstrates the importance of reconstructive surgery in both the upper and lower limb prior to prosthetic fitting, but he also demonstrates the need for a better consideration of the child's psychological development if orthopaedic surgery and hospitalization are indicated. In following years we established the rooming-in system for preschool children with their mothers in the hospital, extended the hospital school, improved cooperation with the parents, developed the efficiency of the outpatient clinic, and reduced the period of hospitalization (average period in the dysmelia department: 1970, 43.4 days of hospitalization; 1980, 22.6 days of hospitalization; 1985, 14.5 days of hospitalization; and 1988, the last year of my full professional life, it had been 13.8 days).
CONCLUSION
An effort has been made to document a philosophy for management of the multimembraldeficient child. Particular emphasis is placed on using all function in tactile areas, including vestigial digits on deficient upper limbs, in the early life of these children. Substitution patterns are discussed, especially the use of the foot for prehension by the armless child. Reconstructive procedures that have special benefits for the multimembral-deficient child as opposed to the unimembral-deficient child are discussed. Prosthetic solutions are presented for both upperand lower-limb deficiencies. 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. Finally, case studies are used to illustrate the complexity of the problems involved with the quadrimembral-defi-cient child. 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.
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SUGGESTED READINGS
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Beschaftigungstherapie und Rehabilitation. 1978; 17:221-225. 10. Keyl R: Erfahrungen mit der Krukenberg-operation und deren Nachbehandlung. Verh Dtsch Orthop Ges 1949; 36:61-64. 11. Kreuz L: Die Herrichtung des Unterarmstumpfes zum natiirlichen Greifarm nach dem Verfahren von Kruken-berg. Zentralbl Chir 1944; 38:1170-1175. 12. Krukenberg H: Uber die plastische Umwertung von Ar-mamputationstumpfen. Stuttgart, West Germany, Ferdinand Enke Verlag, 1917. 13. Kuhn GG: Kunstarmbau in GieSharztechnik. Stuttgart, West Germany, Georg Thieme Verlag, 1968. 14. Lenz W: Diskussionsbemerkung, von Privatdozent Dr. W. Lenz, Hamburg, zu dem Vortrag von R.A. Pfeiffer u. W. Kosenow: Zur Frage der oxogenen Entstehung schwerer Extremitaten-Missbildungen. Tagung der Rheinisch-Westfalischen Kinderarzte-vereinigung in Diisseldorf, am 19.11, 1961. 15. Lenz W: Missbildungen nach Medikamenteneinnahme wiihrend der Graviditat. Dtsch Med Wochenschr 1961; 86:2555. 16. Lenz W, Knapp K: Die Thalidomid-Embyropathie. Dtsch Med Wochenschr 1962; 87:1232-1242. Lancet 1962; 1:45. 17. Lindemann K, Marquardt E: Information on standard prostheses for armless children, in Information on Measures for Habilitation of Children With Dysmelia. Heidelberg, Deutsche Vereinigung fur die Rehabilitation Behinderter, 1963, pp 52-55. 18. Marquardt E: Die Krukenberg-Plastik, Originalmethode und Modifikationen fur blinde Ohnhander. Beschaftigungstherapie Rehabil 1978; 17:221-225. 19. Marquardt E: Einleitung der Diskussion uber die Thera-pie der radialen Klumphand, in Monographic uber die Rehabilitation der Dysmeliekinder. Bartmann, Frechen, Bundesminister fur Gesundheitswesen, 1965, pp 48-51. 20. Marquardt E: Erfahrungen mit pneumatischen prothesen. Verh Dtsch Orthop Ges 1966; 52:346-352. 21. Marquardt E: Indications for an early treatment of children with dysmelia, in Information on Measures for Habilitation of Children With Dysmelia. Heidelberg, Deutsche Vereinigung fur die Rehabilitation Behinderter, 1963, pp 56-57. 22. Marquardt E: Osteotomia katowa kikuta ramienia, in To-maszewskiej J (ed): Protesowanie Typu Czynnego po Am-putcjach w Obrebie Konczyn Gornych. Warsaw, 1975, pp 37-50. 23. Marquardt E: Plastische Operationen bei drohender Knochendurchspiessung am kindlichen Oberarmstumpf, Z Orthop 1976; 114:711-714. 24. Marquardt E: Pneumatic arm prostheses for children, in Information on Measures for Habilitation of Children With Dysmelia. Heidelberg, Deutsche Vereinigung fur die Rehabilitation Behinderter, 1963, pp 34-41. 25. Marquardt E: Provision with active prostheses of armless babies in the second year of life, in Information on Measures for Habilitation of Children With Dysmelia. Heidelberg, Deutsche Vereinigung fur die Rehabilitation Behinderter, 1963, pp 42-51. 26. Marquardt E: Steigerung der Effektivitat von Oberarm-prothesen nach Winkelosteotomie. Rehabilitation 1972; 11:244-248. 27. Marquardt E: The Heidelberg pneumatic arm prosthesis. J Bone Joint Surg [Br] 1965; 47:425-434. 28. Marquardt E: The management of infants with malformation of the extremities, in Limb Development and Deformity: Problems of Evaluation and Rehabilitation. Springfield, Ill, Charles C Thomas Publishers, 1969, pp 363-378. 29. Marquardt E: The total treatment of the limb deficient child. The Horowitz Lectures, 1968. Rehabilitation Monograph 44. Institute of Rehabilitation Medicine, New York University Medical Center, 1968. 30. Marquardt E, Haefner O: Technical adequacy and practical application of the Heidelberg pneumatic prosthesis, New York, 1956, International Society for the Welfare of Cripples (in German). Arch Orthop Unfallchir 1956; 48:115-135. 31. Marquardt E, Roesler H: Prothesen und Prothesenver-sorgungen der oberen Extremitat, in Witt AN, Rettig H, Schlegel FK, et al (eds): Orthopadie in Praxis und Klinik, vol 2. Stuttgart, West Germany, Georg Thieme Verlag, 1981. 32. McBride WG: Thalidomide and congenital abnormalities. Lancet 1961; 2:1358. 33. McBride WG: Thalidomide and congenital abnormalities. Med] Aust 1963; 2:689-693. 34. Neff G, Marquardt E: Angeborene Extremitatenmissbildungen, in Baumgartner R (ed) : Amputation und Proth-esenversorgung beim Kind. Stuttgart, West Germany, Ferdinand Enke Verlag, 1977. 35. Neff G, Marquardt E: The radial club hand: The case for conservative therapy. Chir Plast 1979; 4:279-287. 36. Pfeiffer RA, Kosenow W: Zur Frage einer exogenen Ver-ursachung von schweren
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Extremitatenmissbildungen, Miichner Med Wochenschr 1962; 104:68-74. 37. Schollner D: Die Klumphand bei Radiusaplasie, in Aktu-elle Orthopadie, vol 5. Stuttgart, West Germany, Georg Thieme Verlag, 1972. 38. Simpson DC: An externally powered prosthesis for the complete arm. The basic problems of prehension, movement, and control of artificial limbs. Proc Inst Mech Eng [J] 1968; 183:11. 39. Simpson DC: Eine Prothese fur beidseitig armgeschad-igte Dysmeliekinder. Orthop Tech 1972; 24:363-364. 40. Spitzy H, Feldschareck: Die Versorgung beiderseits Ar-mamputierter. Miinchner Med Wochenschr 1916; 63:1181-1186. 41. Steinruck, Katthagen A: Versorgung von Hand und Ar-mamputierten mit Werkprothesen. Verh Dtsch Orthop Ges 1955; 43:193-200. 42. Swanson AB: Congenital limb defects, classification and treatment. Ciba Clin Symp 1981; 33:6-8. 43. Swanson AB: Silicone-rubber implants to control the overgrowth phenomenon in the juvenile amputee. Inter-Clin Info Bull 1972; 11:58. 44. Swanson AB: The Krukenberg procedure in the juvenile amputee. J Bone Joint Surg [Am] 1964; 46:1540. 45. Tubiana R: Krukenberg's operation. Orthop Clin North Am 1981; 12:819-826. 46. von Volkmann R: Die Muskelfunktion im Krukenberg-Arm sowie einige operative Folgerungen. Verh Dtsch Orthop Ges 1951; 38:293-297. 47. Wiedemann HR: Hypo- und aplastische Fehlbildungen der Gliedmassen (DysmelieSyndrom). Med Welt 1961; 23:1863-1866. 48. Weil S: Die Heidelberger pneumatische Armprothese. Chirurgie 1955; 26:351-354. 49. Witt AN, Cotta H, Jager M: Die angehorenen Fehlbildungen der Hand. Stuttgart, West Germany, Georg Thieme Verlag, 1966.
Chapter 36A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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Chapter 36B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
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General Principles
The early efforts in limb salvage surgery were hampered by a relatively high complication rate. In particular, this included the high local recurrence rate, wound breakdowns, and infection rates, combined with sometimes-questionable functional results that tempered the early surgical enthusiasm. 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 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.Margins of the resection must be adequate to the tumor stage, i.e., a radical or wide margin as defined by Enneking is the only admissible margin in stage IIA or IIB tumors. 1. The targeted margin must be achieved all through the surgical field and planes of resection. A single violation invalidates or jeopardizes the whole effort. 2. Adequate nerve and blood supply of the distal part of the limb must be preservable. A poorly perfused, insensitive, paralyzed limb is a poor substitute for an appropriate amputation with a functional prosthesis. 3. Muscle and skin coverage must be sufficient for at least a two-layer closure of the soft-tissue envelope. This is particularly important where foreign materials such as metal endoprostheses or allograft bone transplants are employed. In rotation-plasty careful planning of the procedure is needed to ensure viability of the skin flaps and the distal part of the limb. 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. One only has to realize that every minor wound breakdown or superficial infection in the face of immunosuppression from ongoing chemotherapy, compounded by the presence of underlying foreign material, can quickly escalate into a disaster. Even at the best of times it can lead to at least a delay in reemployment of the chemotherapy treatment, thus potentially jeopardizing a patients survival. We have found that in borderline cases, 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. 4. The surgical procedure performed should be carefully selected and discussed with the patient and his family to carefully match the patients physical, functional, physiologic, psychological, and life-style makeup to the planned operation.
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. However, 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. Specifically, Van Nes rotation-plasty can be performed in the following situations:
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1. 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. 2. 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. 3. 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. 4. 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. 5. Cases of failed reconstruction due to infection in an allograft reconstruction or local recurrence in endoprosthesis replacement, provided that the nerve supply can be safely preserved. 6. Cases of late, unacceptable sequelae of previous, more conventional reconstructions, for example, late unmanageable leg length discrepancy or long-term failure of endoprosthetic components with corresponding loss of bone stock.
SURGICAL TECHNIQUE
Careful preoperative planning is an important aspect of the Van Nes rotation-plasty technique. This is particularly so in the cases of skeletally immature children where the expected remaining growth has to be taken into consideration. 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. Ideally, 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. This gives the patient equal knee levels in both the standing and sitting positions. 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, by the distal tibial epiphysis, and by the growth of the calcaneotalar unit) and the normal thigh (contributed to by the proximal femoral and distal femoral epiphyses). 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. 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.,A and B). In the case of skeletally mature individuals, the length of the new "thigh" needs to correspond exactly to the opposite member and is made up of a femoral fragment, tibial fragment, and the calcaneotalar unit. 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.,A and B) regarding the need for vascular resection. In most cases the vessels can be preserved; however, if the vessels are either involved by the tumor or are within the reactive zone of the tumor, it is safer to resect them together with the tumor and reanastomose the transected ends.
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specimen, which includes the middle and distal portion of the femur, knee joint, and the proximal portion of the tibia, together with their soft tissue and skin covers, is then removed and submitted to pathology for assessment of margins and degree of tumor necrosis ( Fig 36B-6.). Osteosynthesis using an Arbeitsgemeinschaft fur Os-teosynthesefragen (AO, Association for Osteosynthesis) (AO) plate or intramedullary fixation is carried out between the proximal ends of the femur and tibia, with the distal fragment being turned 180 degrees ( Fig 36B-7.). Following fixation the foot points directly posteriorly. In the case of vessel resection, these are now reanastomosed to re-establish circulation to the distal part of the limb. 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, respectively. Skin flaps are then trimmed and closed ( Fig 36B-8.).
Results
Our experience is based on 27 patients, children, adolescents, and young adults, all with the diagnosis of osteogenic sarcoma. The tumor was in the distal portion of the femur in 18
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patients, in the proximal part of the tibia in 8, and in the proximal part of the femur in 1. Ten patients required resection of the main vessels with anastomotic repair because of tumor involvement. The procedure was successfully completed in all cases, and there were no intraoperative complications. Postoperatively we had one deep infection requiring debridement, but this had no influence on the eventual outcome. There was one significant wound breakdown requiring debridement and long-term management. This patient appeared to have generalized poor tissue healing because he experienced similar breakdown of a thoracotomy wound for resection of metastatic deposits. 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. Six patients had minor delayed healing that responded well to local dressings and did not interfere with either chemotherapy or prosthetic fitting. These were most likely explained by the early reinstitution of chemotherapy. More importantly, there have been no local recurrences, no neurovascular compromises, and no delayed or nonunions. Of the 27 patients, 5 have died, 4 of metastatic disease and 1 from a second malignancy (leukemia). The rest of the patients are alive and well with no evidence of disease. 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, with the exception of the one patient with wound breakdown and metastatic disease described above. Function in these patients is approaching the desired and planned-for transtibial amputee level ( Fig 36B-14. ,A-D). There were no long-term complications related to the rotation-plasty, i.e., no late derotation or psychological decompensation (two frequently mentioned objections to this procedure). 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. Virtually all of our patients participate actively in sports and athletics, many of them competing against their normal-bodied peers. Our patients run; play soccer, baseball, and badminton; participate in karate; skate; ski; and ride bicycles among many other activities.
Prosthetic Management
To permit ultimate mechanical advantage in the construction of the prosthesis the foot should be rotated precisely 180 degrees, and the ankle joint should be at a height equal to the level of the center of the knee of the sound leg. The range of motion of the ankle postoperatively varies with the site of intervention. The removal of a tumor from the femur only slightly affects the muscle motors that drive the ankle and foot. Full ankle range of motion can be realized early after the operation. 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. 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. Frequent resetting of the foot socket into plantar flexion is necessary. Therapy and an exercise program to stretch the muscles that are now activating the ankle is of utmost importance. Walking with the prosthesis contributes to improved mobility and strength. The prosthetist should delay final completion of the prosthesis until a satisfactory range of ankle motion is realized. 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. ). Plaster wrap is applied over a tailored cotton stockinette. The wrap covers the foot and extends proximal to about 7.5 cm. below the ischial tuberosity. The ankle and foot are manipulated into full plantigrade position, and the weight-bearing areas, the bottom of the heel, the shelf for the plantar ligament, and the sole of the foot are hand-molded to achieve an intimate interface. When the plaster is set to moderately bear weight, the knee center level of the prostheses is measured. In order to achieve a precise reading, spacers are placed on the floor and are built up to reach the distal end of the plaster wrap. With minimal weight in the cast the patient stands on the spacers. The anterosuperior iliac spines must be level, and the spacers are adjusted accordingly. Plumb lines are marked on the wrap anteriorly to record the
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abduction/adduction angle and laterally to record the flexion/extension angle of the hip. When filling the cast with plaster later, the holding mandrel is set in parallel with the plumb lines, and thus the recorded angles are transferred to the positive. Next the level and external rotation of the prosthetic knee axis is located and marked on the wrap. The axis is positioned horizontally at a level slightly distal to the anatomic medial malleolus and slightly proximal to the anatomic lateral malleolus. It must be approximately 1.3 cm. posterior to the actual rotation of the ankle. 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. Because of the ankle's capability to move in multiple planes, it readily accepts the superimposed forces of the prosthetic knee hinges. The cast is removed from the patient and filled with plaster of paris. After the plaster is set, the knee axis location marks are transferred by piercing the plaster wrap at these points with a scriber. During modifications of the positive mold, generous build-ups are applied to the toes. The malleoli are moderately covered with an ?-in. layer of plaster. The areas below the heel and the plantar ligament are reduced and modified to form the weight-bearing shelf. A thumb tack is pressed into place on the medial and lateral knee axis marking. The protruding head of the tack is easily detected after socket lamination and serves to identify the knee hinge location. The foot socket is laminated with conventional fabrication procedures. Additional glass reinforcement to strengthen the side hinge mounting area is recommended. The leather corset is stretched around the mold and stapled in place. 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. The hinges are contoured to match the outline of the foot socket and the corset. The lower units of the side hinges are cemented to the foot socket with acrylic resin and glass overlay. 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. The upper side hinges are marked on the corset for future reference. The foot socket is cemented to a wood base and mounted onto a gait alignment coupling, and the prosthetic foot is attached. The positive mold is removed, and the foot socket is trimmed to ease entrance for the foot. The side hinges are assembled, and the corset is fastened according to the reference marking. The side hinges and corset ensure lateral stability, and the extension stop prevents excessive stretching of the ankle. The prosthesis is suspended by a heel strap, an instep strap, and the intimate fit of the side hinges and corset. 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. Tension is adjustable via the Velcro closure. The area over the Achilles tendon is padded with Plastazote. The instep strap spans the posterior opening of the foot socket. Its purpose is twofold. In addition to providing suspension, it exerts the necessary force to the instep of the foot to stabilize the heel on the heel cup shelf ( Fig 36B-16. ). The dynamic alignment procedure follows the conventional technique described for transtibial prostheses with side joints and a corset ( Fig 36B-17. ). The prostheses may be completed in the endoskele-tal or exoskeletal configuration ( Fig 36B18. ). Full-length cosmetic foam fairings are preferred by most female patients. The selection of a suitable prosthetic foot depends on the level of activity of the individual. Dynamic-response feet perform well and are popular with athletes. Recent experiments with a soft and pliable socket limb interface to improve comfort show promise, and our work in this area will continue.
CONCLUSION
Limb salvage in skeletally immature individuals presents a number of challenges. 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. Both of these factors make standard limb salvage operations such as knee resection, arthrodesis, or internal knee arthroplasty less than optimal options because the child faces significant limitation in physical activities and leg length discrepancy. The Van Nes rotation-plasty provides a partial answer to these problems. The child can approach the activity level of a
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transtibial amputee and participate in a number of sporting activities. Modern, expert prosthetic fitting using a dynamic-response prosthetic foot allows a relatively high degree of athletic participation. As far as the leg length discrepancy is concerned, 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. Any minor discrepancy can be adjusted by the prosthetic component. Another advantage of the Van Nes rotation-plasty is the low complication rate. It is a dependable procedure with a dependable result. It can be used in cases in which other alternatives are not feasible, such as in cases of large tumors, in tumors involving skin, in cases with poorly placed biopsy incisions, or in cases in which other reconstructions have failed. The disadvantages of an exoprosthesis and cosmesis are well known. In this study group, cosmesis did not seem to cause a problem. Most patients were well aware of the appearance and function of the rotation-plasty before surgery. We now have an established network of patients who have had rotation-plasty, so every new patient who was a candidate for Van Nes rotation-plasty had an opportunity to meet a patient from the network. However, objective psychological evaluation may be a better indicator of this parameter. Use of the external prosthesis is, of course, inevitable in a procedure that converts a potential transfemoral amputee to a functional transtibial amputee. The Van Nes rotation-plasty is a worthwhile alternative for skeletally immature individuals, for patients who place function ahead of cosmesis and in cases in which the transfemoral amputation is the only other alternative.
BIBLIOGRAPHY
Bochmann D: Prosthetic devices for the management of proximal femoral focal deficiency. Orthop Prosthet 1980; 12:4. Borggreve J: Knieglenksersaty durch das in der Beinlang-achse um 18 Grad gedrehte Fussgelenk. Arch Orthop Un-fallchir 1930; 28:175. Campanacci M, Bacci G, Pagani P, et al: Multiple-drug chemotherapy for the primary treatment of osteosarcoma of the extremities. J Bone Joint Surg [Br] 1980; 62:93-101. Campanacci M, Coster P: Total resection of distal femur or proximal tibia for bone tumors. Autogenous bone grafts and arthrodesis in twenty-six cases. J Bone Joint Surg [Br] 1979; 61:455. DeBari A, Krajbich, JI: Modified Van Nes rotationplasty for osteosarcoma of the proximal tibia in children. J Bone Joint Surg [Br] 1990; 72:1065. DeBari A, Krajbich JI, Langer F: Large allografts in reconstruction procedures in children. Presented at the Pediatric Orthopaedic Society of North America Annual Meeting, Colorado Springs, May 8, 1988. Enneking WF, Shirley PD: Besection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. J Bone Joint Surg [Am] 1977; 59:223. Enneking WF, Spanier SS, Goodman MA: Current concepts review. The surgical staging of muscoloskeletal sarcoma. J Bone Joint Surg [Am] 1980; 62:1027-1030. Enneking WF, Springfield DS, Present DA: Functional evaluation of resection-arthrodesis for lesions about the knee, in Enneking WF (ed): Limb Salvage in Musculoskeletal Oncology. New York, Churchill Livingstone Inc, 1987, p 389. Fixsen JA: Rotation-plasty (editorial). J Bone Joint Surg [Br] 1983; 65:529-630. Hall JE, Bochmann D: The surgical and prosthetic management of proximal femoral focal deficiency, in Proximal Femoral Focal Deficiency: A Congenital Anomaly. New York, National Academy of Sciences, 1969.
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Jacobs PA: Limb salvage and rotationplasty for osteosarcoma in children. Clin Orthop 1984; 188:217. Jaffe KA, Gebhardt MC, Mankin HJ: Massive bone allografts for tumor and other reconstructions in children. Presented at the Association of American Orthopaedic Surgeons 56th Annual Meeting, Las Vegas, Feb 11, 1989. Knahr K, Kristen H, Bitschl P, et al: Prosthetic management and functional evaluation of patients with resection of the distal femur and rotationplasty. Orthopedics 1987; 10:1241. Kostuik JP, Gillespie B, Hall JE, et al: Van Nes rotational osteotomy for treatment of proximal femoral focal deficiency and congenital short femur. J Bone Joint Surg [Am] 1975; 57:1039. Kotz B, Salzer M: Botation-plasty for childhood osteosarcoma of the distal part of the femur. J Bone Joint Surg [Am] 1982; 64:959. Krajbich JI: Modified Van Nes rotationplasty in the treatment of malignant neoplasms in the lower extremities of children. Clin Orthop 1991; 262:74-77. Krajbich JI: The method of predicting the level of the knee in the modified Van Nes rotationplasty. Presented at the Pediatric Orthopaedic Society of North America Annual Meeting, Toronto, May 19, 1987. Krajbich JI, Carroll NC: Van Nes rotationplasty with segmental limb resection. Clin Orthop 1990; 256:7-13. Mankin HJ, Doppelt SH, Sullivan TB, et al: Osteoarticular and intercalary allograft transplantation in the management of malignant tumors of bone. Cancer 1980; 50:613. McClenaghan BA, Krajbich JI, Pirone A, et al: Comparative assessment of gait after limbsalvage procedures. J Bone Joint Surg [Am] 1989; 71:1178. McDonald JD, Capanna B, Biagini B, et al: Complications following limb-sparing surgery of the extremities. Presented at the American Association of Orthopedic Surgeons 56th Annual Meeting, Las Vegas, Feb 11, 1989. Bosen G, Murphy ML, Huvos AG, et al: Chemotherapy, en bloc resection, and prosthetic bone replacement in the treatment of osteogenic sarcoma. Cancer 1976; 37:1-11. Sim FH, Chao EYS: Prosthetic replacement of the knee and a large segment of the femur or tibia. J Bone Joint Surg [Am] 1979; 61:887. Simon MA, Aschliman MA, Thomas N, et al: Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg [Am] 1986; 68:1331-1337. Waters BL, Perry J, Antonelli D, et al: Energy cost of walking of amputees; the influence of level of amputation. J Bone Joint Surg [Am] 1976; 58:42-46. Watts HG: Introduction to resection of musculoskeletal sarcoma. Clin Orthop 1980; 153:31-38. Winkelmann W: Botationplasty for malignant tumors of the femur and tibia. Proceedings of the International Symposium on Limb Salvage in Musculoskeletal Oncology, Kyoto, Japan, 1987. New York, Springer Publishing Co Inc, 1988, p 153. Winkelmann WW: Hip rotationplasty for malignant tumors of the proximal part of the femur. J Bone Joint Surg [Am] 1986; 68:362-369.
Chapter 36B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library
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Chapter 36C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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.
PHILOSOPHY
Children with limb deficiencies, whether congenital or acquired, are conscious of being physically different when they interact with their families and peers. This recognition has a significant impact on a child's development of self-perception and self-esteem. Body integrity is threatened. Not only is acceptance of this physical difference a barrier for the child, but often it is a factor that is difficult for the parents to accept. Fear of their child's failure, rejection by peers, and potential injury all contribute to parents' sheltering and/or protecting the child from exposure to seemingly risky or challenging activities. Although parents are well meaning, they may hinder children with limb deficiencies from physically exploring their environment to learn and achieve. Since programs for children with limb deficiencies often take place in a facility that nurtures and shows concern for these children, the parents may be more inclined to "trust" their child to such a program. 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. (see Annotated Resource List, no. 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. These programs have proved to have a significant positive impact on the lives and future of these children. They find lifelong sporting activities to enjoy with family and friends ( Fig 36C-1. and Fig 36C-2.), and far greater opportunities become available to them. Recreational and sporting programs for children with limb deficiencies and other handicapping conditions are designed to promote challenge and achievement within the group. Children are accepted for who they are regardless of disability or illness. As children share similar experiences, common needs, and concerns, they develop a sense of identification within this physically challenged group, and their self-image is enhanced. Their social realm expands, and they develop a camaraderie not often found in their mainstreamed environment. Through controlled and guided group activities, physical challenges are met with success, problems and concerns are shared, and an improved level of physical fitness often results. And although these children may still perceive themselves as being physically limited, they learn to take pride in their physical abilities. 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. Children in these programs return to their environments with renewed and positive energy.
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PROGRAM PLANNING
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When developing programs for disabled children, there are many factors to consider during the program-planning stages, especially if the program involves sports or recreation. Key elements of program planning include establishing program goals, determining the participant population, selecting appropriate participants, identifying resources available to the program, determining staffing needs and training requirements, considering financial and liability issues, and identifying program needs.
Participant Population
A variety of sporting and recreational programs have been developed for children with limb deficiencies. Successful groups can vary in participant mix, or may be diagnosis-specific groups, e.g., programs for children diagnosed and treated for cancer, including children with resulting amputations (see Annotated Resource List, nos. 2 and 3). This latter group has identifiable needs in dealing with painful procedures, long hospitalizations, and life-threatening disease progress. A diagnosis-specific group also allows interaction with qualified staff who can enhance this process. 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. Groups that include children with a variety of physical limitations demonstrate that notwithstanding individual diagnoses, the children share many common concerns and needs (see Annotated Resource List, nos. 4 and 5). Such groups allow a mix of children to develop empathy, understanding, and support for one another through group involvement. Programs are often developed by specific medical disciplines or organizations according to their patient population needs. Program leaders may choose to limit participation to the facility's immediate population or may include children from other facilities and/or the community. The latter can be of great value but requires more planning, communication, and better documentation regarding each child's background and needs.
Resource Considerations
Geographic location and existing community resources are key factors in developing recreation and sports programs. For example, winter activities are abundant in the mountainous regions and northern states-both downhill ( Fig 36C-3. and Fig 36C-4.) and cross-country skiing are readily available in these areas, whereas the northern plains may be limited to crosscountry skiing. In contrast, southern states, by virtue of their milder climate, can provide activities year-round, including camping, water sports, tennis, and golf ( Fig 36C-5.). Community-based programs have flourished as the needs of disabled populations have gained recognition. Most city recreation programs now include a wide variety of activities for all individuals. Many city-owned botanical gardens have special gardening programs for children and adults with special needs. National and local organizations (see Annotated Resource List, no. 6) have developed resource lists of programs and accessible recreation facilities for disabled persons. Park systerns throughout the country are developing trails for the disabled. Existing programs and organizations can be great resources for fledgling programs because they can provide information about established teaching techniques, adaptive equipment, and training programs (see Annotated Resource List, nos. 4 and 5). They can give guidance to program leaders and, in addition, may be able to provide the actual source for the sports or recreational activity.
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Financial Considerations
Operational costs are significant for all sports and recreation programs for the handicapped. Some well-established programs may own and operate their own facilities (see Annotated Resource List, nos. 4 and 5). In most cases, programs must contract for services with these or other outside specialty resources. Transportation costs, resource contractual fees, and special equipment used for program activities all contribute to program expenditures. Staff salaries as well as food and lodging may need to be provided. Insurance coverage may need to be purchased. If the program is sponsored by a medical facility, additional liability insurance may need to be obtained to supplement the institutional umbrella. Scholarships for program fees may need to be established for participants with documented financial need. Additional costs may include awards and program souvenirs if not donated by a sponsor. Financial support for program operation may be obtained through grants, donations, and fund-raising events. Local companies and philanthropic organizations may be sources for financial scholarships for program participation. Participant fees should also be a consideration. Although these fees may not cover program costs completely, they do help to defray expenses. And regardless of the amount of financial aid provided, a payment toward the participation fee has a significant positive impact on participants' and their families' interest and investment in the program.
Liability Issues
Some degree of risk is involved in all sports and recreation activities. 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. Thus, guidance and supervision are essential for the child's safety and successful participation. Legal advice regarding liability is an important element of program planning. Adequate insurance coverage is necessary. Several considerations may need to be investigated: (1) if sponsored by a medical facility, does participation in a sanctioned activity provide adequate liability coverage for the participating children, staff, 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, no. 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. Proof of insurance should be obtained, and the type of coverage it provides should be reviewed on a regular basis and a copy kept with program files. For liability protection, staff/volunteer training requirements may be specified by the insurance carrier, and health screening of the volunteers may be necessary. Written liability releases from volunteers that acknowledge and waive the program's responsibility for potential risks
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36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library
during program participation may be indicated. In all instances, parents/guardians of participating children must sign appropriate forms to release the program sponsor and volunteer(s) in matters of emergency care, transportation, photographic and media releases, and basic program participation.
Transportation Considerations
Regulations regarding chauffeuring of clients by staff and volunteers are usually established by the insurance carrier of the sponsoring facility or organization. When program-sponsored transportation is considered, these regulations need to be examined carefully. 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. Although contractual services for transportation with a public carrier add considerable cost to the program, they should be considered. Printed documentation of the carrier's proof of insurance should be obtained annually. Additionally, the amount of coverage provided should be within the guidelines established by the quality assurance program of the supporting facility.
Equipment Needs
Specialized equipment enhances the performance and enjoyment of participation in sports and recreation activities for children with limb deficiencies ( Fig 36C-7., Fig 36C-8., and Fig 36C-9.) (see Annotated Resource List, no. 4, 5, and 8). Specialized sports equipment must be proved safe and must be maintained properly. Users, instructors, and volunteers must be adequately instructed in its use. Appropriate safety gear is essential. In addition, there continue to be dramatic changes in wheelchair design, as well as in prosthetics and orthotics. These changes include the use of lighter-weight materials and more sophisticated components and designs engineered for increased activity levels. Costs often rise dramatically with these changes. It would be ideal for a child to have a wheelchair, prosthesis, or orthosis to use solely for the purpose of engaging in a sports activity. Since children require frequent replacement of these devices for growth, the additional expense of specialized sports equipment is unaffordable for many families. To participate in recreational activities, many children must use their regular appliance(s) ( Fig 36C-10. ). Since participation in higher-level activities puts increased stress on these devices, adaptation and precaution to preserve the life of the prosthesis, wheelchair, or orthosis are imperative.
SUMMARY
Sports and recreation for the juvenile amputee should ideally be an integral part of the total rehabilitation program. Specific guidelines have been formulated to achieve this goal. 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.
Acknowledgments
The authors would like to thank the S. Karger AG, Basel, publishers of Pediatrician, for giving permission to use general information from Page CJ, Pearson J: Creating therapeutic camp and recreation programs for children with chronic illness and disabilities. Pediatrician 1990; 17:297-307.
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36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library
5. Breckenridge Outdoor Education Center (BOEC): PO Box 697, Breckenridge, CO 80404, (303) 453-6424. A facility known for providing organized outward-bound programs for the disabled. 6. Ronald McDonald Children's Charities: National Directory of Children's Cancer Camps, Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614, (312) 880-4564. 7. National Handicapped Sports (NHS): 451 Hungerford Dr., Suite 100, Rockville, MD, 20850, (301) 217-0960. National sports and recreational organization supporting the handicapped with many regional chapters throughout the United States. 8. Cheff Center for the Handicapped: Augusta, MI 49012. Well-known North American training center for horseback riding for the handicapped. References: 1. Joswick, et al: Aspects and Answers: A Manual for Therapeutic Horseback Riding Programs. Augusta, Mich, Cheff Center, 1986. 2. O'Leary H: Bold Tracks: Skiing for the Disabled. Evergreen, Colo, Winter Park Sports and Learning Center, Cordillera Press Inc, 1988. 3. Page C, Pearson J: Creating therapeutic camp and recreation programs for children with chronic illness and disabilities. Pediatrician 1990; 17:297-307.
Chapter 36C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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