Atlas of Limb Prosthetics O P Virtual Library PDF

Atlas of Limb Prosthetics | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics
Atlas of Limb Prosthetics

Part I: Introduction
Chapter 1: History of Amputation Surgery and Prosthetics Reproduced with
permission from
Bowker HK,
Chapter 2: The Choice Between Limb Salvage and Amputation Michael JW (eds):
Atlas of Limb
2A / Overview Prosthetics:
Surgical, Prosthetic, and
Rehabilitation Principles.
2B / Trauma
Rosemont, IL, American Academy
of Orthopedic Surgeons, edition 2,
2C / Major Limb Amputation for End-Stage Peripheral Vascular Disease: 1992, reprinted 2002.
Level Selection and Alternative Options
Much of the material in this text
has been updated and published
2D / Infection in Atlas of Amputations and Limb
Deficiencies: Surgical, Prosthetic,
and Rehabilitation Principles
2E / Tumor (retitled third edition of Atlas of
Limb Deficiencies), ©American
Academy or Orthopedic Surgeons.
Chapter 3: Planning for Optimal Function in Amputation Surgery Click for more information about
this text.
Chapter 4: Prosthetic Management: Overview, Methods, and

Funding for digitization
Materials of the Atlas of Limb
Prosthetics was
provided by the
Part II: The Upper Limb Northern Plains Chapter of the
American Academy of Orthotists &
Chapter 5: Kinesiology and Functional Characteristics of the Prosthetists
Upper Limb
Chapter 6: Upper-Limb Prosthetics

6A / Body-Powered Components
You can help expand the
6B / Harnessing and Controls for Body-Powered Devices O&P Virtual Library with a
tax-deductible contribution.
6C / Components for Adult Externally Powered Systems
6D / Control of Limb Prostheses
Chapter 7: Partial-Hand Amputations

7A / Surgical Principles
7B / Prosthetic and Orthotic Management
7C / Aesthetic Restoration
Chapter 8: Wrist Disarticulation and Transradial Amputation

http://www.oandplibrary.org/alp/[21/03/2013 21:52:35]
8B / Prosthetic Principles
Chapter 9: Elbow Disarticulation and Transhumeral Amputation

Chapter 10: Shoulder Disarticulation and Forequarter

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
Chapter 17: The Syme Ankle Disarticulation

17B / Prosthetic Management
Chapter 18: Transtibial Amputation

18A / Surgical Procedures and Immediate Postsurgical Management
Chapter 19: Knee Disarticulation

Chapter 20: Transfemoral Amputation

Chapter 21: Hip Disarticulation and Transpelvic Amputation

Chapter 22: Translumbar Amputation (Hemicorporectomy)

22B / Prosthetic Considerations
Chapter 23: Physical Therapy Management of Adult Lower-Limb

Amputees

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
34A / Surgical Management
34C / Externally Powered Prostheses
34D / Developmental Approach to Pediatric Upper-Limb Prosthetic

Training
Chapter 35: Lower-Limb Deficiencies

35A / Surgical Management

36A / The Multiple-Limb-Deficient Child
36B / Van Nes Rotation-Plasty in Tumor Surgery
36C / Juvenile Amputees: Sports and Recreation Program Development
O&P Library > Atlas of Limb Prosthetics
The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Prosthetics Community. Contact Us | Contribute
1: History of Amputation Surgery and Prosthetics | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 1
Chapter 1 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
History of Amputation Surgery and Prosthetics Reproduced with

permission from
A. Bennett Wilson Jr., B.S.M.E. Bowker HK,
Michael JW (eds):
No doubt artificial limbs of some type, such as a forked stick, have been used since the Atlas of Limb
Prosthetics:
beginning of mankind, but the earliest recorded use of a limb prosthesis is that of a Persian
soldier, Hegesistratus, who was reported by Herodotus to have escaped about 484 B.C. Rehabilitation Principles.
from stocks by cutting off one of his feet and replacing it with a wooden one. The oldest Rosemont, IL, American Academy
known artificial limb in existence was a copper-and-wood leg unearthed at Capri, Italy, in of Orthopedic Surgeons, edition 2,
1858, which was supposedly made about 300 B.C. Unfortunately, it was destroyed during a 1992, reprinted 2002.
bombing of London in World War II.
Artificial hands made of iron were used by knights in the 15th century. The Alt-Ruppin hand,
in Atlas of Amputations and Limb
shown along with other hands from the 15th century in the Stibbert Museum, Florence, Italy, Deficiencies: Surgical, Prosthetic,
is a good example of the work of that age. and Rehabilitation Principles
(retitled third edition of Atlas of
With respect to surgery, Hippocrates described the use of ligatures, but this technique was Limb Deficiencies), ©American
lost during the Dark Ages. It was reintroduced in 1529 by Ambroise Pare, a French military Academy or Orthopedic Surgeons.
surgeon. As a result, amputations came to be used more and more as a lifesaving measure Click for more information about
since the rate of survival was much higher when ligatures were used. this text.
Morel introduced the tourniquet in 1674, which gave another impetus to amputation
surgery. Pare carried out the first elbow disarticulation procedure in 1536. Sir James Syme
of the Atlas of Limb
reported his procedure for amputation at the ankle in 1843. Prosthetics was
provided by the
The introduction of antiseptic technique in 1867 by Lord Lister, a student and son-in-law of Northern Plains Chapter of the
Syme, contributed greatly to the overall success of amputation surgery, as did the use of American Academy of Orthotists &
chloroform and ether about the same time. Prosthetists
The concept of kineplasty to power upper-limb prostheses directly by muscle contraction was
introduced by Vanghetti in 1898 while trying to improve the function of Italian soldiers who
had their hands amputated by the Abyssinians. Vanghetti's associate, Ceci, performed the
first operation of this type on humans in 1900. In Germany, Sauerbruch and ten Horn
(1916) developed the skin-lined muscle tunnel, and Bosch Arana in Argentina carried out You can help expand the
clinical studies of this procedure in the 1920s. O&P Virtual Library with a
Bier, about 1900, in an effort to make the distal end of the cut bone able to bear weight,
recommended an osteoplastic procedure in which the cut end was covered with a flap of
cortical bone connected by a periosteal hinge. This procedure never became widespread, but
in the late 1940s, Ertl went a step further and developed a procedure for forming a bone
bridge between the cut ends of the fibula and tibia. A few years later Mondry combined the
bone bridge technique with myodesis, or attachment of the cut muscles to each other over
the distal end of the stump. Dederich, Weiss et al., and others adopted and popularized
these procedures in some areas.
Each major war seems to have been the stimulus not only for improvement of amputation
surgical techniques but also for the development of improved prostheses. Toward the end of
World War II, amputees in military hospitals in the United States began voicing their
disappointment about the performance afforded by their artificial limbs. To ensure that they
received the best care possible, Surgeon General of the Army Norman T. Kirk, an
orthopaedic surgeon by training, turned to the National Academy of Sciences (NAS) for
advice.
http://www.oandplibrary.org/alp/chap01-01.asp[21/03/2013 21:52:44]
A COORDINATED PROGRAM FOR AMPUTEES

A conference of surgeons, prosthetists, and scientists organized by the NAS early in 1945
revealed that little modern scientific effort had gone into the development of artificial limbs,
and a "crash" research program was launched later in 1945 through the NAS. This effort
was initially funded by the Office of Scientific Research and Development (OSRD). At the end
of the war when the OSRD was disbanded, the Office of the Surgeon General of the Army
continued support that was later assumed by the Veterans Administration, which had also
inherited the responsibility for the care of military amputees after discharge from the armed
services.
For the first 2 years the NAS, through the Committee on Artificial Limbs (CAL), actually
initiated and administered the program through subcontracts with several universities and
industrial laboratories. On June 30, 1947, the CAL was discharged, and the role of the NAS
became an advisory one to the Veterans Administration, which contracted directly with
various research groups. In 1947, the Veterans Administration also established its own testing
and development laboratory in New York City. The army and navy cooperated and
contributed by supporting prosthetics research laboratories within their respective
organizations. From July 1, 1947, to Dec 1, 1955, the group within the NAS was known as
the Advisory Committee on Artificial Limbs. The Prosthetics Research Board was created to
carry out the NAS responsibility from Dec 1, 1955, to June 30, 1959. In July 1959, the
Committee on Prosthetics Research and Development (CPRD) and the Committee on
Prosthetics Education and Information (later called the Committee on Prosthetics and
Orthotics Education [CPOE]), both subgroups of the board, assumed this role until their
dissolution by the parent NAS in 1976. The reason for the dissolution of these bodies has
never been made completely clear.
The Artificial Limb Program, as it came to be known, was started initially with the idea that
physicians and surgeons could provide engineers with design criteria for components such as
ankle and knee joints and that good engineering design based on these criteria coupled with
modern materials would result in devices that could solve many of the problems of the
amputee. Although some progress was made early in the program by this approach, it soon
became apparent that fundamental information on how human limbs function was needed
before adequate design criteria could be formulated. To provide such information on lower-
limb function, a project was established at the University of California, Berkeley, as a joint
responsibility of the Engineering School in Berkeley and the Medical School in San Francisco.
Eberhart et al., who had collaborated previously in a biomechanical analysis of the
shoulder, directed this program, which began by using the latest technology to refine and add
to the existing knowledge of human locomotion. A concurrent program was initiated under
Taylor in the Engineering School at the University of California at Los Angeles on the function
of the upper limbs.
At the same time design and development projects were being carried out at Northrop
Aviation, Inc.; Cat-ranis, Inc.; the Army Prosthetics Research Laboratory (APRL); the U.S.
Naval Hospital, Mare Island (which later became the Navy Prosthetics Research Laboratory,
Oakland Naval Hospital); and a U.S. Army Air Force unit at Wright Field. New York University
was engaged in 1947 to evaluate the devices that resulted from the research and
development program. The Veterans Administrations laboratory in New York also performed
evaluations primarily by means of mechanical and chemical testing projects; later this
laboratory became part of the Veterans Administration Prosthetics Center (VAPC), which
contributed heavily to development and evaluation projects established within the program.
Although progress was made with new devices and substitutions of materials, more significant
advances were in the areas of socket design and alignment of the various types of
prostheses.
As a result of a visit by a commission to Europe in 1946, a study of the suction socket for
transfemoral (above-knee) prostheses was made by the University of California, Berkeley.
The results of this study, coupled with information derived from the locomotion studies at the
University of California, Berkeley, led to a biomechanical rationale for the design and
fabrication of the socket and the alignment of transfemoral prostheses.
Innovative techniques for providing improved prostheses for Syme (ankle disarticulation),
hip disarticulation, and transpelvic (hemipelvectomy) amputees were developed by
McLaurin and his associates while working at Sunnybrook Hospital, Toronto, under the
auspices of the Department of Veterans Affairs of Canada. Much of this work was carried
to fruition at the University of California, Berkeley, after Foort transferred there in 1955 from
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
Burgess and colleagues a study to determine the feasibility of immediate postsurgical
fitting, osteoplasty, and myoplasty. Projects were also started at the Navy Prosthetics
Research Laboratory and the University of Miami. Just prior to this a team at Duke
University had been studying the effects of early fitting, that is, providing the patient with
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
between 1965 and 1975 was almost reversed from 70:30 to 30:70. This continues to have
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
developed for adults. Frantz and Aitken and the Michigan Crippled Children's
Commission initiated a project to develop methods of management for child amputees in
Grand Rapids in 1952. A similar project was launched at the University of California, Los
Angeles, in 1955, and New York University was funded to further evaluate the devices and
techniques emanating from these projects. The Children's Bureau also provided the NAS with
some funds for coordination of activities in child prosthetics. From this emerged the Child
Amputee Clinic Chiefs Program, which has held meetings nearly every year since 1958, and
the Inter-Clinic Information Bulletin (ICIB), a small monthly publication that has proved to be
useful for the dissemination of results of research and development.
After the dissolution of the CPRD (Committee on Prosthetics Research and Development) in
1976, the Child Amputee Clinic Chiefs formed the Association of Children's Prosthetic and
Orthotic Clinics to continue the educational activities of the Chiefs' group.
AMPUTEE PROGRAMS IN OTHER COUNTRIES

In Great Britain, the Limb Fitting Centre at Queen Mary's Hospital, Roehampton, expanded its
research effort shortly after the end of World War II and became known as the Biomechanical
Research and Development Unit.
The Scottish Department of Home and Health Services has sponsored research and
development at the Limb Fitting Centre, Dundee; University of Strath-clyde; and Princess
Margaret Rose Hospital, Edinburgh. The work in Edinburgh was devoted mainly to children.
At the University of Strathclyde there is a 4-year Bachelor of Science program in prosthetics
and orthotics.
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
been important. The work of Scott at the University of New Brunswick and Sauter at the
Hugh MacMillan Medical Centre (formerly Ontario Crippled Children's Centre) has made
significant contributions to externally powered artificial arms, and Foort's team at the
University of British Columbia have been the leaders in the development of computer-aided
design and computer-aided manufacturing (CAD/CAM) techniques in lower-limb prosthetics.
A number of research and development efforts were started in Germany after World War II,
but there appears to have been little coordination of these efforts. The work at the University
of Münster in body-powered upper-limb prosthetics has influenced practice elsewhere, as has
the work at the University of Heidelberg with severely involved child amputees.
Since the early 1970s research in Germany seems to have moved from the universities to
the private manufacturers. The manufacturers have had a significant influence on prosthetics
and orthotics practice throughout much of the world by providing innovative hardware.
A formal education program for prosthetists has been in operation in Germany for many
years.
The thalidomide tragedy prompted the Swedish government to expand its research and
development work in technical aids for the handicapped to include artificial limbs in 1962.
This program continues today.
During the 1960s and early 1970s, the French government expanded its support of artificial
limb research mainly through the Ministre des Anciens Combattants et Victimes de Guerre.
Research and development in artificial limbs in Italy have a long history. A research unit has
been in operation at the University of Bologna for many years, and a group at the Prosthetic
Centre in Budrio is very active in the development of externally powered upper-limb
prostheses.
Not a great deal is known about activities in Russia, but research units are located in
Leningrad and Moscow. Their contribution has been the first clinically useful myoelectrically
controlled hand.
The U.S. government, through the Surplus Agricultural Commodity Act (P.L. 480), supported
work in Poland, Yugoslavia, Israel, Egypt, India, and Pakistan from the early 1960s until funds
were depleted in the early 1980s.
Some prosthetic research has been carried out in Japan but as yet has had little effect on
practices in the United States.
RELATED ORGANIZATIONS
The American Orthotics and Prosthetics Association (AOPA) is an organization primarily of
privately operated prosthetics and orthotics facilities in the United States and Canada to
assist its members in providing the best possible services. The parent group was organized
in 1917 as the Artificial Limb Manufacturers' Association. The name was changed in 1946 to
the Orthopedic Appliance and Limb Manufacturers' Association when orthotists were invited to
join, and the present name was adopted in 1958.
The American Board for Certification in Prosthetics and Orthotics was established in 1948 as
an accreditation body to certify the professional competence of practitioners and facilities in
these disciplines. In addition to its accreditation activities, the board also seeks to advance the
highest levels of competency and ethics in the prosthetic/orthotic profession.
In 1952, the International Society for the Rehabilitation of the Disabled (now called
Rehabilitation International) appointed an International Committee on Prosthetics and
Orthotics (ICPO) to promote the dissemination of knowledge of prosthetics and orthotics
throughout the world. The chairman was Knud Jansen, and headquarters for the committee
was established in Copenhagen, where a number of very successful international seminars
were conducted in the late 1950s and 1960s. The committee also sponsored courses and
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
orthotics with the publication of Newsletter-Amputee Clinics. This bulletin continued until the
dissolution of CPRD and CPOE in 1976. Because Newsletter-Amputee Clinics was sorely
missed, the AAOP (American Academy of Orthotists and Prosthe-tists) initiated publication in
1976 of Newsletter-Prosthetic and Orthotic Clinics. In 1982, the title was changed to Clinical
Prosthetics and Orthotics. In 1988, the AOPA and AAOP combined Orthotics and Prosthetics
and Clinical Prosthetics and Orthotics to create a new quarterly entitled Journal of Prosthetics
and Orthotics.
In the late 1950s, the ICPO (International Committee on Prosthetics and Orthotics) of the
International Society for the Rehabilitation of the Disabled began publication of a technical
journal that was published sporadically until 1970. At that time the ICPO was reformed into
the ISPO (International Society for Prosthetics and Orthotics) and became a separate entity.
After volume 1, the ICPO publication was renamed Prosthetics International. Volume 2,
number 1 is dated simply "1964." From 1972 through 1976, the ISPO published the ISPO
Bulletin four times a year, primarily to keep the membership informed of administrative and
technical developments. As the ISPO grew, it was able in 1977 to replace the Bulletin with
Prosthetics and Orthotics International, a scientific journal published three times a year that
contains research reports and results of clinical evaluation of new devices and techniques.
DEVELOPMENTS IN LOWER-LIMB PROSTHETICS
Sockets and Suspension

Prior to the U.S. research program, the most common approach to the design of the
transfemoral socket was the carved "plug fit" wooden socket with a conical interior shape.
The weight of the amputee during the stance phase of walking and during standing was
transferred to the skeletal system through the muscles about the thigh.
The transfemoral socket design introduced by the University of California, Berkeley, about
1950 was shaped to permit use of the remaining musculature. It contained well-defined walls
and became known as the "quadrilateral socket." The posterior wall was shaped to provide
ischial-gluteal weight bearing. Following the German practice, an air space was left between
the distal end of the stump and the bottom of the socket, and an air valve was installed in the
medial wall in this area. Most of the patients used this system successfully, but a sufficient
number experienced edema and dermatologic problems to warrant further study.
The University of California, Berkeley and San Francisco, undertook studies of the problems
of transtibial amputees as well as those of transfemoral amputees. The result was the PTB
(patellar tendon-bearing) prosthesis, which involved total contact between stump and socket.
Further analysis of problems with transfemoral amputation and experience with the PTB
prosthesis resulted in the total-contact quadrilateral transfemoral socket, which minimized the
problems of terminal edema.
Because it was felt that the education programs strayed from the fundamental principles of
the quadrilateral design or for other reasons, some prosthetists began to feel by 1980 that a
second generation of transfemoral sockets was needed. In the early 1980s Long, Sabolich,
and others introduced designs known variously as NS/NA (normal shape-normal alignment),
CAT-CAM (contoured, adducted trochanter/controlled alignment method), and narrow ML
(medial-lateral). These widely publicized designs caused confusion in the field because not
only was it difficult to explain their rationale and thus difficult to teach but their advocates also
produced many variations. However, the one common feature was that the support of the
amputees body relied less on the ischial "seat" than the original quadrilateral design
specified. Two conferences sponsored by the ISPO in 1987 helped to clear up most of the
confusion. The "ischial containment" sockets, as they are now called, are used in many areas
with a better understanding of the underlying principles, but more study is needed if they are
to be prescribed properly.
Fabrication Materials and Methods

Immediately after World War II the vast majority of lower-limb prostheses were constructed of
a combination of wood and leather. These materials, alone and together, have many
properties desirable for the construction of artificial limbs, but they also possess properties
that make them a good deal less than perfect. Wood requires the skill of carving and shaping,
and leather absorbs perspiration and is difficult to keep clean.
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.
McLaurin and his coworkers in Toronto coupled the plastic laminating technique with a
good engineering analysis of the problem to produce the "Canadian Syme prosthesis,"
which was a significant improvement over former practices. This design and variations
developed by the Veterans Administration Prosthetics Center were adopted worldwide as
prosthetists learned to use plastic laminates. (Experience with the foot of this prosthesis led to
the development of the solid ankle, cushion heel [SACH] foot.) The same group also
conceived and developed the plastic socket "Canadian hip disarticulation prosthesis" about
1955, which was also soon adopted worldwide.
Plastic laminating techniques made total-contact sockets practical; most of the prostheses
used throughout the world now are total-contact sockets made essentially of either a plastic
laminate or thermoformed plastic.
The search for a practical method of making transparent sockets was highlighted in 1972
when Mooney and Snelson developed a method for vacuum-forming a polycarbonate sheet
over a positive model of the stump to provide the first practical transparent test sockets.
Polycarbonate has been replaced by several cheaper materials, and today use of transparent
check sockets is the rule rather than the exception. Vacuum-forming polypropylene, the
properties of which seemed to make it appropriate for definitive use, was introduced in 1975
by the Moss Rehabilitation Hospital in Philadelphia, and today polypropylene sockets used
with endoskele-tal systems are considered to be the norm.
The introduction of socket designs based on sound biomechanical analyses to take full
advantage of the functions and properties of the stump in conjunction with a rationale for
alignment undoubtedly represents the greatest achievement in prosthetics since World War II.
Suspension of the Prosthesis

Prior to the development of socket designs based on biomechanical principles, suspension of
most lower-limb prostheses presented formidable problems. Until the introduction of the
pelvic band about the time of World War I, over-the-shoulder suspenders were used almost
universally for keeping transfemoral prostheses in place. Until the development of the PTB
prosthesis, the side bars of the thigh lacers, or corset, of the trans-tibial prosthesis were bent
to conform to the medial and lateral surfaces of the thigh to provide suspension. This
arrangement was often supplemented by a waist belt.
The quadrilateral design not only permits the use of suction for suspension but makes the
suspension problem easier because the muscle action of the stump within the intimately
fitting socket also helps to hold the prosthesis in place.
Until the past few years suction was seldom used to suspend the transtibial prosthesis. The
intimate fit of the transtibial socket makes it possible in most cases to achieve quite adequate
suspension by a supracondylar strap. Variations of the original PTB prosthesis design
(supracondylar or supracondylar-suprapatellar) employ more proximal brims that are
contoured to make the supracondylar straps unnecessary.
Nevertheless, retention of the transtibial prosthesis by suction is considered desirable, and

the efforts by Kristinsson and Durr-Fillauer have resulted in the so-called 3-S transtibial
socket, which uses a closely fitting elastomeric sleeve as an inner socket to provide the
adherence needed for adequate suspension.
It has been recognized for many years that if the flexibility of socket walls could be varied to
match the properties of the underlying tissues of an amputation stump, the result would be a
more comfortable and functional socket. The most successful approach to this problem was
initiated by Kristinsson in the early 1980s, who used a semiflexible liner in a rigid outer
structure, or frame, shaped so as to provide rigidity where it is required. The concept was
adopted by a group in Sweden and then by New York University and Durr-Fillauer. Each
added slight variations.
These sockets have been well received but not widely used because the materials currently
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
of Es-slinger in Birmingham, Michigan, during the 1960s, which was undertaken on a small
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
of some experiences he had with horses, and Mooney carried out some investigations at
Rancho Los Amigos Hospital, Downey, California, in the early 1970s. In spite of encouraging
results, interest in "skeletal attachment" seems to have waned.
Computer-Aided Design/Computer-Aided Manufacturing

To accelerate the process of fitting and fabrication of artificial limbs, in the 1960s James Foort
of the University of British Columbia proposed the use of numerically controlled milling
machines with data supplied by stereophotography to produce a positive model of the stump
ready for the molding of a socket. Progress was slow until the introduction of computer-aided
design procedures and personal computers. The University College London in the late 1970s
developed an automated process for molding polypropylene sockets, called Rapidform, and it
seemed logical to develop a system that would include computer-aided design, numerically
controlled production of a positive model of the stump, and automated production of the
socket. Workers there also envisioned automated fabrication of the entire artificial limb if
alignment data could be fed into the system.
In the early 1980s University College London introduced a system that requires taking a
loose cast of the transtibial amputation stump, transferring the inside contours to a personal
computer by means of a digitizer to produce an image of a positive model, modifying on the
screen the shape of the positive model, and feeding this information into a numerically
controlled milling machine that carves a positive model from a blank of plaster of paris or
wax. At this point the positive model is ready for use in fabrication of a socket by any method
desired, but vacuum-forming of polypropylene or similar sheet plastic is the rule.
In the mid-1980s the Veterans Administration began funding several projects in the United
States to further the application of the CAD/CAM process in the fabrication of artificial limbs.
Not a great deal of progress is apparent, although the interest generated by these projects
and the availability of hardware and software for two systems from England based on the
University College London work has induced several U.S. prosthetics facilities to experiment
with the introduction of CAD/CAM on a routine basis in spite of the fact that in its current
state of development the advantages do not seem to outweigh the disadvantages.
Undoubtedly, further development will make CAD/CAM a useful tool in providing improved
service to amputees.
Prosthetic Knees
Locomotion studies at the University of California showed that swing-phase control of the
shank is as important as stance-phase control in lower-limb prosthetics. Until that time,
control of the shank during swing phase in most transfemoral prostheses was provided by
introducing friction about the knee bolt, the so-called constant-friction knee, an arrangement
that provides a smooth gait at only one cadence for a given amount of friction.
The Navy Variable Cadence Knee Unit was designed to overcome the shortcoming of the
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
ankle during the swing phase. Laboratory and clinical trials at New York University with a
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
that had been provided primarily for stance-phase control and not because of the stance-
phase 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
phase. The result was the model "B" Hen-schke-Mauch Knee Unit. The swing-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 four-
bar 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
patients. The SACH foot has had outstanding success in the marketplace primarily
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
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.
DEVELOPMENTS IN UPPER-LIMB PROSTHETICS

Early in the Artificial Limb Program it was decided that the best approach to take at that time
for upper-limb replacement was to develop a variety of components, socket designs, and
harnessing methods that could be assembled to best meet the needs of individual patients
rather than trying to develop special systems for each level of amputation.
The primary assignment to the APRL (Army Prosthetic Research Laboratory) was the
development of artificial arms with emphasis on artificial hands. Out of this effort came the
voluntary-closing APRL hand and the APRL hook. These devices were well received by a
significant proportion of the amputee population, but it was difficult for the manufacturer to
produce quality devices at a competitive price because of the close mechanical tolerances
required. These devices are still available today, but the high costs preclude widespread use.
Although the APRL hand and hook are not used widely, the basic research required led to
the development of the sizes and configurations that are now standard for most artificial
hands produced today. The manufacture of nearly all of the cosmetic gloves provided for
artificial hands is based on techniques developed at the APRL.
Northrop Aviation, Inc., produced many ingenious designs for artificial arms in addition to
introducing plastic laminating techniques. The alternating-lock elbow unit operated from the
harness for transhumeral amputees was first developed by Northrop in 1947. After becoming
available commercially, it soon replaced other available units, all of which required use of the
contralateral hand or motion against a fixed object to activate the lock. This basic design is in
use throughout the world.
Northrop also initiated a study in harness design that was later taken over by the University
of California at Los Angeles. UCLA also developed socket designs for all levels of upper-limb
amputation that were based on anatomic and physiologic principles. Refinements of these
basic socket and harness designs are still the standard for body-powered upper-limb
prosthetics.
The hardware, socket, and harness designs produced by Northrop, APRL, UCLA, and others
between 1946 and 1950 made it practical and desirable for the surgeon to save all length
possible in amputation through the upper limb. Unfortunately, except for externally powered
systems, no major advances that have found widespread use have been made in upper-limb
prosthetics since the early 1960s.
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.
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.
The thalidomide tragedy created a great deal of interest in externally powered prostheses,
especially in Germany, Sweden, England, and Canada, beginning about 1960. Initial efforts
in Germany centered around pneumatically operated prostheses, and by arrangement with
the University of Heidelberg, Kessler and Kiessling in the United States undertook
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,
Sauerbruch and ten Horn in Germany, and Bosch Arana in Argentina) appealed to a
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
devised was one involving the biceps tunnel for the transradial amputee. Although many
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.
EDUCATION AND TRAINING

Pilot courses sponsored by the University of California, Berkeley, in 1949 in prescription,
fabrication, and alignment of the suction socket transfemoral prosthesis were followed by local
courses presented in key areas of the country by the Veterans Administration Prosthetics and
Sensory Aids Service (PSAS) and the Orthopaedic Appliance and Limb Manufacturers
Association (now AOPA [American Orthotic and Prosthetic Association]). In these courses
orthopedic surgeons and pros-thetists received instructions together as teams. Prior to this,
the education of a prosthetist consisted of an informal apprenticeship program in which very
little formal instruction was available.
Although a number of prosthetists and surgeons had advocated through the years that
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
certificates of completion. One baccalaureate and 1 certificate program were discontinued
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.
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; 46:59-
76.
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.
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.
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.
Study of the Henschke-Mauch "Hydraulik" Swing Control System, New York, TR-3,
1964.
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; 39:230-
232.
2A : Overview | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 2A
Chapter 2A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
The Choice Between Limb Salvage and Amputation: Reproduced with

Overview permission from
Bowker HK,
Michael JW (eds):
John H. Bowker, M.D. Atlas of Limb
Prosthetics:
Because of the finality of amputation, both in a physical and psychological sense, it seems Surgical, Prosthetic, and
appropriate to present, in a book on amputations and prosthetics, current thought and Rehabilitation Principles.
available options regarding limb salvage as an alternative to amputation. The patient and
certainly the surgeon should be constantly looking for such options to ensure that the best 1992, reprinted 2002.
result in terms of function and disease eradication is achieved.
Whenever a patient presents to a physician regarding a serious injury or disease of a limb, has been updated and published
the first inevitable question is "Can it be saved?" The initial physician, if not a surgeon, will be in Atlas of Amputations and Limb
asked by the patient and family for a referral to a surgeon whom the primary doctor feels will Deficiencies: Surgical, Prosthetic,
give every consideration to saving the limb. A thorough evaluation of each situation will and Rehabilitation Principles
include appropriate consultation with other specialists to assure the patient and the family as
well as the amputation surgeon that all reasonable avenues have been explored. Academy or Orthopedic Surgeons.
Consultations may be sought from a vascular surgeon both in peripheral vascular disease and Click for more information about
in limb trauma involving major vessels. Since most cases of major foot infection occur in this text.
diabetics, a diabetologist as well as an infectious disease specialist has much to offer in
helping to manage the patient preoperatively and postoperatively. In tumor cases, consultation
with a surgical oncologist, preferably prior to biopsy, is suggested.
Prosthetics was
While in years past there were often no alternatives to amputation other than palliation, this is
provided by the
no longer true in many instances. In trauma cases, improved methods of fracture fixation and Northern Plains Chapter of the
vessel and nerve repair, along with the selective use of vascularized distant muscle and skin American Academy of Orthotists &
flaps, have provided many opportunities for limb salvage in cases destined for amputation Prosthetists
prior to development of these techniques. This approach to limb salvage involves the skills of
several specialists during multiple surgical procedures, often followed by prolonged
rehabilitation. To ensure cost-effectiveness, trauma rating scales based on the probability of a
good functional outcome should be applied.
In peripheral vascular occlusive disease, if immediate surgery is not required, as in dry You can help expand the
gangrene limited to the forefoot, a vascular surgeon should be consulted if limb blood flow to O&P Virtual Library with a
that area is critically diminished. Advantage should be taken of the major advances that have tax-deductible contribution.
been made in recanalization and reconstruction of vessels. Restoration of flow to the foot by
in situ and reverse vein grafting may result in salvage of most or all of the foot.
In cases of infection, prior to procedures based on abscess drainage with or without limited
distal amputation, limb blood flow should be evaluated to give the surgeon and patient
reasonable assurance that the resulting wound will heal. Infected feet, mostly related to
diabetes mellitus, can often be drained adequately with resultant salvage of most or all of the
foot. By using the method of Kritter, most feet with low-grade infection can be loosely closed
following thorough debridement, thus sparing the patient considerable morbidity.
In the past, tumors of the limbs were routinely treated with early amputation as the best hope
for cure. Powerful new chemotherapeutic agents, often combined with radiation and selective
excision of solitary metastatic deposits, have made tumor control possible in many instances.
The current limb salvage approach combines ablation of the tumor with reconstruction using
an allograft, endoprosthesis, or a combination.
Many of these advances in treatment concepts and procedures have occurred in the decade
since the first edition of this book was conceived. The tremendous increase in a patient's
2A : Overview | O&P Virtual Library
expectation of a good outcome based on technological advances is offset by the cost of many
of the more advanced procedures. 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.
2B: Trauma | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 2B
Chapter 2B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Trauma permission from
Bowker HK,
Michael JW (eds):
Roy Sanders, M.D. Atlas of Limb
David Helfet, M.D. Prosthetics:
HISTORIC PERSPECTIVE: AMPUTATION AS THE Rosemont, IL, American Academy
STANDARD OF CARE 1992, reprinted 2002.
The choice between limb salvage and amputation of the severely traumatized lower limb is a Much of the material in this text
rather modern concept. For thousands of years, an open fracture was a sentence of death, has been updated and published
and although amputation was recommended, most patients died. In 1832, Malgaigne reported
that the mortality rate for amputations performed in the hospital was 52% for major and Rehabilitation Principles
amputations overall and 62% for thigh amputations specifically. This is not surprising when (retitled third edition of Atlas of
the methods employed are scrutinized. Limb Deficiencies), ©American
Operations were conducted on the unwashed patient in his bed with the rest of the ward Click for more information about
looking on. All surgery before 1846 was performed without anesthesia. Speed was of the this text.
essence, and amputations were done with strong men holding the patient down, usually
within 3 minutes. Casual onlookers put their hands in the wound. Instruments were simply
wiped clean, often on the surgeon's shirt. Because surgeons also performed autopsies, hands of the Atlas of Limb
were not washed between pro-section and amputation. Wounds were packed with dressings Prosthetics was
made of old bedsheets and rags. Postoperatively, a pus bucket was used to wash wounds on provided by the
the ward; by the end of the day this bucket contained the blood and pus of all patients on the Northern Plains Chapter of the
ward. American Academy of Orthotists &
Prosthetists
War was even worse. The mortality rate for open fractures in the Franco-Prussian War
(1870-1871) was 50% for transtibial and 66% for transfemoral amputations. In the
American Civil War, the mortality rate for transtibial amputations was 33% and for
transfemoral amputations 54%. In 1874 von Nussbaum recorded a 100% mortality rate for 34
consecutive knee disarticulations!
The development of the germ theory, hand washing, proper sanitation, and improved nursing O&P Virtual Library with a
caused mortality rates from open fractures to virtually disappear. H. Winnett Orr in World War tax-deductible contribution.
I treated open wounds by using a protocol of wound extension, cleaning, stable reduction of
the fracture, and application of plaster with the wound left open. His mortality and
amputation rate, as a result, was extremely low. Trueta, using this technique, was able to
obtain a 0.6% septic mortality rate in 1,069 open fractures in the Spanish Civil War. It is
interesting to note that these two men simply used the principles of Ambroise Pare, who in
1540 advocated irrigation, debridement, stabilization, and open packing of open fractures.
THE MODERN ERA: LIMB SALVAGE

As death from wound sepsis disappeared and safe and effective elective surgery became
possible, salvage of the mangled limb became a reasonable consideration. The next
important advance was vascular reconstruction. In World War II, DeBakey and Simeone still
reported an amputation rate of 75% for popliteal artery injuries associated with fractures, but
the Korean War experience paved the way for successful arterial repair, and by the Vietnam
conflict, the overall amputation rate for open fractures with vascular injury was negligible.
Advances in all fields of medicine have made salvage of the massively injured lower limb a
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.
NEWER CONCEPTS: DECISION MAKING

In 1976, Gustilo and Anderson reported on a prognostic classification scheme for open
fractures that was based on wound size. They isolated the type III open fracture as having
the worst prognosis, with a high rate of infection, nonunion, and secondary amputation. In
1984, Gustilo et al. reported on a subclassification of type III open fractures, which again was
prognostic. This included the following: type IIIA, adequate soft-tissue coverage of a
fractured bone despite extensive soft-tissue laceration or flaps; type IIIB, extensive soft-tissue
injury with periosteal stripping and bony exposure, usually associated with massive
contamination; and type IIIC, an open fracture with an arterial injury requiring repair. This
classification was used by Caudle and Stern and again found to be prognostic. In their
review of 62 type III open tibial fractures, type IIIA injuries had a low complication rate, type
IIIB open fractures had significant complications, and type IIIC open tibial fractures had
disastrous rates with 100% major complications and a 78% secondary amputation rate (Table
2B-1.). These authors began to question the wisdom of salvage in type IIIB and IIIC tibial
injuries.
Similarly, Lange et al. analyzed 23 cases of open tibial fractures with limb-threatening
vascular compromise. Fourteen cases (61%) underwent amputation, and none had
complications or functional disability at the 1-year follow-up visit. In contrast, those patients
who underwent limb salvage required several operations and had persistent wound or tibia
healing problems at 1 year. The authors suggested that a realistic appraisal of functional
outcome be made when deciding in favor of salvage for limbs with type IIIC injuries inasmuch
as the overall amputation rate for these injuries in the more recent literature approached 60%
(Table 2B-2.)
Bondurant et al. reported on the financial cost of limb salvage in open MB and MC tibia
fractures. Of 263 patients, 43 ultimately underwent amputation. Fourteen patients had a
primary amputation and averaged 22.3 days in the hospital, 1.6 operative procedures, and
$28,964.00 in hospital costs. Those who had attempts at limb salvage averaged 53.4 days in
the hospital, 6.9 operative procedures, and $53,462.00 in hospital costs. The authors
suggested that with appropriate criteria, early amputation would improve function, shorten
hospitalization, and lessen the financial burden placed on both the patient and the institution.
Recently, Hansen and others have noted that when post-traumatic limb salvage patients were
candid, they frequently stated that although their limbs were saved, their lives were ruined by
the prolonged and costly attempts at reconstruction. Hansen has termed this approach the
"triumph of technique over reason." Several authors now suggest that early amputation and
prosthetic fitting are perhaps the preferred alternative to salvage of a questionably functional
lower limb. It is the goal of this chapter to offer the orthopedist information that will assist
in rational decision making in these difficult injuries.
THE TYPE IIIC TIBIAL FRACTURE-CAN SALVAGE BE

PREDICTED?
To determine when amputation is not only justified but beneficial, a predictive scale with
objective criteria is required. Well-designed, prospective, controlled multicenter studies with
large patient populations are needed to obtain these data. Although several studies have
attempted to develop objective criteria, to date no predictive scale exists that can be used
with confidence in amputation decision making. Furthermore, long-term functional outcome
studies on patients with salvage procedures are needed as well. It is uncertain whether donor
site morbidity, joint stiffness, shoe modifications, neurologic impairment, and prolonged
rehabilitation times justify salvage.
Daines evaluated 26 lower-limb fractures with vascular injuries on the basis of four variables.
These included (1) the extent of soft-tissue damage, (2) the duration and severity of
ischemia, (3) the presence of shock, and (4) the age of the patient. These authors defined a
score that was predictive of amputation and had no Overlap in data. They also felt that soft-
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, pre-
existing disease, and shock. They found a dividing line at 20, below which limb salvage was
predictable and above which amputation was 100%. This initial series was limited to only 12
cases, the fracture type was not identified, and an unspecified number of primary amputations
was included.
Lange et al. proposed a protocol based on absolute and relative indications for amputation
(Table 2B-3.). The occurrence of one absolute indication or two relative indications was felt to
warrant amputation. Unfortunately, only a minority of cases fit these criteria, and the relative
indications listed were extremely subjective and required considerable experience.
Recently, Helfet et al. have combined most of the abovementioned studies into a modified
version of the MESI to predict amputation rates (Table 2B-4.). This scoring system was
used only in documented type IIIC open tibial fractures, first retrospectively in 26 cases and
then prospectively in an equal number of cases. The scoring was performed after the
salvage-vs.-amputation decision had been made. In both groups there was a significant
difference in the mean MESI scores between those limbs that were amputated and those that
were salvaged. In both, a score of 7 or greater was 100% predictive of amputation. Although
the preliminary data base is small, this scoring system holds promise as the first objective
scoring system that can predict poor outcome and thereby justify amputation.
Given the above discussion, when should the surgeon amputate, and when should he
consider salvage in a type IIIC tibial injury? At the present time, the basis upon which to
make a sound, defensible, and reasonable decision for primary amputation is still insufficient.
Lange has recently identified certain variables that are important (Table 2B-5.), but feasibility
variables (technically salvageable) combined with advisability variables (best interest of the
patient) result in a complex prognostic-treatment interplay. A crush injury in a young laborer is
very different from the same injury in a 60-year-old diabetic. Similarly, a tibial injury may need
a different approach if severe ipsilateral foot trauma exists. It should therefore be obvious that
the majority of cases will fall into a gray zone of indeterminate prognosis. In these cases a
decision-making team and a tertiary-care facility are almost mandatory. Lange has stated that
inexperience in evaluating these injuries and the lack of multidisciplinary

consultation may render it ethically impossible for a surgeon to recommend a
primary amputation and, as well, may make successful limb salvage unrealistic.
In summary, the MESI and Lange's absolute and relative indications should be used to
determine possible need. Several surgeons should be consulted. Patient and family
conferences (perhaps with an amputee present) are required, and a frank discussion should
ensue; then a joint decision can be made with, it is hoped, better patient satisfaction.
TYPE IIIB INJURIES-THE CASE FOR SALVAGE

In type IIIB open fractures, limb salvage has a greater likelihood of success because by
definition a vascular injury requiring repair is not present. The preponderant problem in this
group of patients is infection from massive contamination and muscle necrosis. Should
attempts at salvage be undertaken, standard protocols should be used.
The patient should be examined in the emergency room, and the wound should be identified
and then sterilely covered. It is not uncovered until the operating room. Antibiotic treatment is
started, and the patient is brought to the operating room as soon as possible. Angiography, if
needed, is performed in the operating room and not in the angiography suite. In no other
injury is meticulous debridement so important. Damaged and contused skin and all obviously
necrotic muscle, tendon, and bone must be initially removed. Thereafter, irrigation with saline
is necessary to remove all particulate matter. At this point deep cultures, which will represent
true bacterial flora, are taken. After initial debridement of soft tissue and bone, bony stability is
obtained, usually with an external fixator, to prevent further soft-tissue compromise. Osseous
defects can be filled with antibiotic-impregnated methyl-methacrylate beads (made by mixing
1.2 g of tobramycin and one package of methylmethacrylate) over braided 26-gauge wire.
These beads provide a local depot of antibiotic and a space for the later bone graft.
Temporary open wound coverage (not closure!) is obtained by the use of dressing sponges or
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
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; 71:994-
1004.
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; 46:388-
392.
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.
2C: Major Limb Amputation for End-Stage Peripheral Vascular Disease: Level Selection and Alternative Options | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 2C
Chapter 2C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Major Limb Amputation for End-Stage Peripheral permission from
Bowker HK,
Vascular Disease: Level Selection and Alternative Michael JW (eds):
Atlas of Limb
Options Prosthetics:
Peter T. McCollum, B.A., M.B., B.Ch. Rosemont, IL, American Academy
Michael A. Walker, M.B., Ch.B., M.D.,M.Ch., F.R.C.S.I. F.R.C.S.Ed. of Orthopedic Surgeons, edition 2,
1992, reprinted 2002.
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 Much of the material in this text
ischemia (CLI). Estimated incidence rates of major amputations (Table 2C-1.) suggest that in has been updated and published
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 and Rehabilitation Principles
limb-fitting service because of widespread chronic arterial disease. These figures, taken in (retitled third edition of Atlas of
conjunction with recent advances in both limb prosthetics and surgical techniques, highlight Limb Deficiencies), ©American
the need for further critical appraisal of available options open to all involved in the care of Academy or Orthopedic Surgeons.
patients with a limb that may require amputation. Although trauma, tumor, and infection are Click for more information about
significant disease entities that can require primary or secondary amputation, over 90% of all this text.
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 Funding for digitization
dilemmas faced by both the patient and medical team presented with such a problem and of the Atlas of Limb
describes investigation and treatment options open to those faced with a decision whether to Prosthetics was
amputate a limb or to attempt some form of limb salvage procedure. provided by the
Northern Plains Chapter of the
LIMB SALVAGE OR PRIMARY AMPUTATION-GENERAL Prosthetists
CONSIDERATIONS
The presence of a chapter on alternative options to amputation in a book on amputation and
prosthetics highlights the difficulties and importance of decisions confronting physicians when
presented with end-stage PVD. As a consequence of newer techniques and a more
aggressive and enlightened approach to treatment, many patients who in the past would have
O&P Virtual Library with a
undergone an amputation may now be offered the chance of a limb salvage procedure. tax-deductible contribution.
However, it is also clear that advances in prosthetics and the concurrent development of limb-
fitting services have meant that a functioning prosthesis is now the likely outcome of major
limb amputation rather than a wheelchair existence. Nevertheless, this assumes that access
to such facilities is available and that the patient is fit enough to manage an artificial limb.
Furthermore, despite these advances, the prognosis of those undergoing an amputation for
CLI secondary to end-stage PVD or diabetes is very poor. In many published studies
amputation itself carries a significant mortality. Although this has been reported as up to 30%
in some series, the use of spinal and regional anesthesia combined with improved
perioperative management has been responsible for a greatly improved perioperative
mortality. In addition to perioperative deaths, up to 40% will have died within 2 years of
amputation, and a further 30% may develop CLI in the remaining limb that will require either
a second amputation or limb salvage surgery.
While there can be little doubt that saving a limb and retaining its function should always be
the primary goal of the physician, there are many situations in which limb salvage is neither
feasible nor indeed desirable. Although a high perioperative morbidity attends an
unsuccessful revascularization procedure, primary amputation should only be offered when
revascularization is deemed inappropriate. Specific examples of this include a functionally
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
is crucial to provide the best results. Several basic considerations and principles must be
followed in each case where findings suggest that either limb salvage or amputation is
deemed appropriate. Clearly, the single most important factor in this process is the projected
quality of life following the particular action taken.
QUALITY OF LIFE AND PATIENT EXPECTATIONS

Quality of life is very much dependent on the individual expectations of the patient and the
sometimes more realistic expectations of the attending staff. In a patient with a poor
prognosis, perhaps because of a stroke, it may be felt that the morbidity of a salvage
procedure is too great to achieve salvage of an already functionless limb. Conversely, in a
unilateral amputee, extra effort may be necessary to ensure that the remaining limb is
salvaged in order to keep the patient mobile. Professional judgement must also be exercised
as to whether the patient's expectations are realistic. This can be a difficult and emotional
issue. There is also no doubt that the expectations of relatives and paramedical and nursing
staff can also influence the situation. This may prove especially important and useful if the
patient has an unrealistic expectation of his future, whether it be overly optimistic or
otherwise.
It is essential not to overestimate the long-term prognosis in patients with end-stage PVD
requiring limb salvage or amputation. Life expectancy clearly depends on the natural history of
any diseases afflicting the patient. With mortality rates of at least 30%, 50%, and 70% after 5,
10, and 15 years in those with CLI, a 20% mortality rate for those undergoing amputation,
and a 2-year survival rate of 60% in those surviving initial amputation, it is clear that the
long-term outcome in the group with CLI is poor, despite an advanced age group, whatever
action is taken.
Further important factors affecting the decision to amputate or reconstruct include not only
the availability of medical facilities but also the standard of medical and paramedical care.
Plainly, the expertise and experience of a physician are vital, but equally important is the
availability of quality facilities. These include resources that are readily accessible for ancillary
care, diagnostic investigations, operative backup, postoperative support, and other treatment
options such as prosthetic and rehabilitation infrastructures. Crucial among these is the
availability of a good vascular service. In well-developed countries, it is likely that an expert
vascular opinion can be obtained within 12 hours of being sought, even if this means transfer
of the patient.
ETHICS
Quality of life is quite closely linked with the medical ethics surrounding a patient faced with
end-stage vascular disease. An important consideration in decision making relates to the
practical aspects of intervention in end-stage PVD. Is it always justifiable to subject a patient
to prolonged hospitalization and perhaps suffering in order that limb salvage can be
attempted? If so, what is the real return for the misery that can occasionally be caused in
some patients due to multiple reconstructive procedures when eventual limb salvage is not
guaranteed? Moral considerations are thus very important, and each case must be examined
on its own individual merits. There can be no standard doctrine in these difficult situations,
although, in general, a reduction in a patient's morbidity should remain the prime objective
when considering the options in a particular case.
FINANCIAL CONSIDERATIONS
No discussion on the dilemma would be complete without some mention of the financial
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. Peripheral vascular disease (PVD) and diabetes mellitus (DM)

2. Trauma
3. Infection
4. Tumor
Each of the above can lead to possible early or late amputation during the natural history of
the disease. Trauma, infection, and tumor are specific entities that are covered meticulously
elsewhere in this chapter and therefore will not be discussed in more detail here.
PERIPHERAL VASCULAR DISEASE

Of those patients requiring amputation, over 90% are a direct or indirect consequence of CLI.
With an increasingly elderly population and a significant increase in life expectancy (males,
73 years; females, 78 years in the United Kingdom) over the past 10 years, it is clear that the
number of patients presenting with critically ischemic limbs is likely to increase substantially
into the 21st century. This large group is therefore likely to continue to provide all but a few of
the patients who require major limb amputation. Most patients presenting with CLI present
with severe and debilitating pain, often at rest, that prevents them from sleeping in a bed at
night. Indeed, many patients will sit up all night rather than suffer the pain that results from
lying prone in bed.
The prevalence of intermittent claudication increases from 0.2% in men aged 45 to 55 to 0.5%
in men 55 to 65 years of age. However, there is a large group of patients with significant
hemodynamic distal arterial disease who remain asymptomatic-perhaps up to 30% show no
symptoms or do not present to a physician.
Work done within the United Kingdom suggests that anywhere between 10% and 50% of
those suffering from claudication will present to physicians, with a greater percentage of men,
but with only a few deemed serious enough to merit referral to hospital practice.
Fortunately, up to 75% of those with claudication will stabilize spontaneously over a few
months, which leaves 25% of individuals with increasing trouble from deteriorating symptoms.
Of this group, fewer than 5% will eventually come to some form of limb salvage
revascularization procedure. Thus, fewer than 2% of all patients who present with intermittent
claudication ever come to amputation.
Much of the concern over management of patients with severe PVD relates to the fact that
arteriosclerosis is a generalized disease and consequently these patients have significant
cardiac and cerebrovascular disease. Evidence suggests that approximately 15% will develop
a myocardial infarction and at least 5% a cerebrovascular accident (CVA) over a 5-year
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-1highlights the outcome of those suffering from claudication and clearly shows that
the prognosis in this group is poor. The actual life expectancy is summarized in Figure 2C-2.
Work by Szilagyi et al., who examined the long-term outcome following lower-limb arterial
bypasses, suggests that after the fifth postoperative year the annual mortality rate of patients
is greater than the graft occlusion rate.
The natural history of the generalized atherosclerosis that coexists in sufferers of claudication
and CLI shows that these groups, especially those with CLI, must be considered to represent
a population with a poorer-than-average prognosis, even in the short to medium term. Thus,
the likely length of hospitalization for the treatment option selected should be gauged against
the likely life expectancy for the patient. Most would agree that it is not in patients' best
interests to spend the majority of their remaining months in a hospital environment, although
occasionally this is an inevitable consequence of whatever course of action is taken.
MANAGEMENT OPTIONS
The decision to perform either a major amputation or major reconstructive surgery is based
largely upon clinical parameters that are undoubtedly influenced by past experience and
current prejudice. It is therefore important to be aware of the developments in other
specialties that may, it is hoped, modify these decisions. It is clear that vascular surgery, in
particular, has evolved as a fully fledged specialty in many countries and has made enormous
strides in several specific areas. Nowhere is this more apparent than in the management of
the patient with CLI. While aortofemoral bypass grafting has become well established over
the past 40 years as a reliable method of providing adequate femoral inflow, distal arterial
bypass has now also become a routine procedure in specialist vascular centers. Bypass
grafting to the tibial or pedal arteries can now be expected to salvage the limb, even in
patients with tissue necrosis and ulceration. Vein graft patency to the tibial vessels is about
80% at 1 year, with limb salvage rates somewhat higher. Indeed, the current situation is
such that few if any patients should undergo a major amputation for CLI without first having
been seen by a specialist vascular surgeon with experience in distal bypass grafting. This is
not unreasonable because most physicians in Western countries can obtain access to such
services within 12 hours of patient referral. This allows more than sufficient time for CLI
investigations and intervention to be instigated without significant deterioration in the patient's
condition.
Nonsurgical Management of Critical Limb Ischemia

There has been much interest in the use of pharmacologic agents that could be used in the
management of CLI. This is because many patients are high-risk surgical candidates and
any method that might reduce the number of patients requiring surgery, either
revascularization or amputation, would be welcome. The mainstay of medical management is
to postpone amputation either by relieving pain or by sufficiently improving the local blood
flow in the limb to render it viable until further collateral circulation develops. A broad range of
agents has been studied, including anticoagulants (heparin and warfarin), thrombolytics
(streptokinase, urokinase, tissue plasminogen activator [t-PA]), antiplatelet agents (aspirin,
dipyridamole), and various vasoactive agents (naftidrofuryl, pentoxifylline). Of these, the
use of intravenous prostacyclines and their synthetic analogues (e.g., prostaglandin I2 [PGI 2 ]
analogues such as iloprost) appears to offer the most hope for the future. Recent work with
these prostacycline analogues suggests that a small number of limbs (generally Fontaine
stage III, i.e., with rest pain) may be salvaged by prolonged intravenous infusion.
Unfortunately, many limbs in these studies would not fall under the definition of true CLI
because Doppler pressure measurements are too high in most instances. However, it is clear
that some critically ischemic limbs (perhaps 10%) are salvaged by such infusions and further
work in this area is urgently needed. In particular, the use of PGI 2 analogues appears to
convey some definite benefits.
Interventional Radiology
A further, small number of patients may be suitable for percutaneous angioplasty (PTA),
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
patients suitable for angioplasty, the patients concerned in most studies have not all had
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
popliteal-tibial or popliteal-pedal bypass will often be required.
Critical ischemia of the limb is rarely if ever seen with isolated superficial femoral occlusion.
More often, there is multilevel disease. Where there is a reasonable femoral pulse, there will
invariably be superficial femoral occlusion with tibial vessel disease also. This usually
necessitates a distal bypass with in situ vein or re-versed-vein graft techniques (Fig 2C-5A
and Fig 2C-5B ). In such patients, good results (>70% rate of 1-year patency) can be
expected where the optimal conduit (autologous vein) is available. However, if prosthetic
grafts are used to the tibial vessels, this falls dramatically to perhaps only 25% at 1 year,
although there is some evidence that the technique of an interposition vein cuff will improve
these results. In general, provided that there is autologous vein present and there is at least
one tibial artery present (this may often be the peroneal), good limb salvage rates can be
expected from vascular surgeons well versed in these techniques. Unfortunately, this is a
specialized area, and consistently good results tend to occur only in dedicated vascular units.
In planning surgical outcome, it should be remembered that a patient with digital gangrene
and rest pain will often require a prolonged admission with initial distal revascularization, later
digital amputation, and subsequent rehabilitation.
Trauma and Acute Vascular Insufficiency

In dealing with any serious limb insult in which vascular compromise is evident, it must be
realized that even urgent treatment is barely soon enough! Rapid but careful assessment by
the primary-care team and assessment of the order of treatment priorities, first of the patient
as a whole and then in relation to the injured limb, are paramount. The level of priority with
respect to the limb in trauma cases is generally vessels, nerves, bones, and then soft tissues,
although at the time of surgery it is often necessary to splint the bones first prior to attempting
vascular reconstruction in the interests of stability.
Any limb that is regarded as showing signs of acute CLI should, if possible, be rapidly
referred to a specialist in this field. Time in such cases is vital. Full and careful evaluation by
an experienced vascular surgeon followed by appropriate investigation and subsequent
treatment will provide the greatest chance of limb salvage. There is little place for treatment of
these patients by the occasional vascular surgeon if acceptable results are to be obtained,
although this may be necessary on occasion in the absence of immediate specialist
resources.
Of all those admitted with acute CLI, those with an otherwise normal vascular tree are most at
risk because there will be little if any collateral circulation present, unlike those with previous
underlying PVD. Of all those admitted with evidence of acute CLI of the legs, about 60% to
70% will leave the hospital with an intact limb. Of those surviving, up to 15% will require
amputation. Operative treatment depends upon circumstance, but general principles include
the use of autologous vein as a bypass medium if at all possible and generous
decompression fasciotomies to reduce the risk of reperfusion injury. Amputation level
selection, where necessary in this group of patients, is defined by the available viable tissue
present and depends entirely upon clinical assessment with the emphasis on preserving limb
length.
Brief mention may be given to one specific problem that, although fortunately rare, can cause
considerable difficulties with management. The increasing growth in the number of drug
abusers is inevitably leading to an increasing number of addicts presenting with arterial injury
following intra-arterial puncture and consequent microembolization following injection of a
variety of substances. Although at first sight these injuries may not seem serious, after a few
hours the injected limb can show severe signs of ischemia that is not always reversible. In
this situation, opening the diseased artery will often show massive intraluminal reaction and
edema causing a significant hemodynamic stenosis in the artery. In general, the treatment of
choice is decompression fasciotomies, intravenous anticoagulation, and prostacycline
infusions, with a "wait-and-see" policy usually justified. Vascular surgical exploration has a
very limited role, although major amputation is often the final outcome. In any dealings with
these patients, it should be remembered that a large percentage are human
immunodeficiency virus (HIV)-positive and some will have full-blown acquired
immunodeficiency syndrome (AIDS).
Infection
In patients with PVD, "dry" gangrene is a result of reduced arterial inflow or stasis in the
circulation of the limb or digit. Demarcation develops early and is usually clear-cut, with
resultant mummification showing few signs of infection. Patients with dry gangrene will
sometimes autoamputate the affected limb or digit with few if any systemic effects, especially
if the blood flow is improved to the limb by vascular reconstruction. In contrast, "wet"
gangrene may be a consequence of both arterial and venous obstruction and is also seen in
diabetics. There is always infection and putrefaction present in this process. Early
revascularization may help to reduce the volume of tissue lost in wet gangrene, although
there is a risk of graft infection in bypass cases. The decision to amputate primarily or to
attempt limb preservation can be extremely difficult, but in the case of life-threatening sepsis,
primary amputation will usually be indicated.
AMPUTATION LEVEL SELECTION

For the minority of patients with CLI in whom revascularization has failed or in whom there is
some other reason why it cannot be attempted, the alternative is major limb amputation. For
most practical purposes, there are three common "levels" of amputation to examine in relation
to PVD in the lower limb; these are transfemoral, transtibial, and digital or partial foot. With
the conspicuous exception of diabetics, digital and partial-foot amputation for end-stage
vascular disease is generally disappointing in the absence of prior successful
revascularization. When consideration is being given to one of these distal amputations, the
question of a distal bypass must always be recognized because it is almost certain that a
successful bypass will result in foot healing. Similarly, if a leg amputated at the Syme or
Chopart level shows signs of healing, it is virtually certain that there were patent tibial arteries
at the ankle to which a distal bypass could have been placed. The foot therefore might have
been salvaged with perhaps only a minor digital amputation. The only exception to this rule is
the diabetic patient without serious PVD who may sometimes heal a partial-foot amputation
without revascularization. Therefore, the main deliberation in amputation patients is whether
they will heal a transtib-ial amputation or not. Most diabetic and vasculitic patients will require
a more detailed assessment of foot viability. This is because local excision of dead tissue can
often be effected successfully if accompanied by vigorous antibiotic therapy and careful
debridement and protection of neurotrophic ulcers and skin with appropriate plaster slippers
and splintage.
Clinical Assessment
It is not adequate to merely perform angiography in patients with CLI who are being
considered for amputation and/or limb salvage revascularization. This is simply because the
absence of visible vessels does not necessarily portend failure for surgery. In many
instances, it is simply a failure of radiologic technique where contrast is not seen at the foot
level. In such cases, exploration of the ankle or pedal vessels will generally reveal an
adequate recipient artery. This quite common failure of angiography to show distal vessels is
well recognized and has led to the development of other methods to demonstrate patent
ankle and foot vessels.
If, despite all this, amputation is felt to be required, further investigations may be needed to
aid in selection of the optimum level of amputation. While it is generally agreed that there are
certain clinical factors (such as a severe flexion contracture of the knee) that precipitate an
amputation at a particular level, the physician's ability to select the optimum level of
amputation based upon clinical appreciation of tissue viability is poor. Criteria such as poor
skin edge bleeding at the time of surgery and absence of pulses do not correlate well with
failure to heal despite the fact that they are still commonly used standards. Although clinical
judgement alone will produce reasonable results when it is carried out by an experienced
amputation surgeon, it is clear that this form of assessment is not very objective and is
probably ineffective in the majority of patients. This is particularly so where attempts are being
made to save the knee joint in cases of marginal viability.
Angiography
As already stated, arteriography ought to have been performed already in almost all
preamputation patients as a preliminary to possible arterial reconstruction. It has, however,
been shown to be of little value in deciding the optimum level of amputation. Robbs and Ray
found no difference between healing and failure to heal in terms of the number of major
patent vessels present in a study of 84 amputees. Other workers have also found
arteriography to be of little value, although Roon et al. maintained that a patent profunda
femoris was of major importance in the presence of a superficial femoral occlusion and
should be ensured before attempting a transtibial amputation. Certainly, occlusion of both
profunda and superficial femoral vessels would seem to indicate a poor prognosis for healing
in transtibial amputations.
Segmental Systolic Pressure Measurements

Although they are necessarily an indirect assessment of tissue perfusion and not reliable in
situations where arteries are calcified, Doppler-derived segmental pressure measurements
have been utilized in the assessment of CLI for many years. Indeed, the working party of the
International Vascular Symposium set out a definition of CLI based upon segmental pressure
criteria in 1983, although this definition has now undergone further refinement in a
consensus conference. While these are useful moves aimed at identifying patients with CLI
and allowing reasonable comparison of patient groups between different studies, the criteria
are of little help in deciding upon the level at which to amputate. There was considerable
initial enthusiasm for ankle Doppler pressure measurements, but this was tempered by the
failure of later studies to substantiate initial reports. In particular, ankle pressure
measurements appear to be of little or no value in partial-foot amputations and also in
diabetics. This is probably largely because of arteriovenous shunting in the foot giving rise
to nonnutritional blood flow and also because of the difficulty in compressing calcified vessels
with consequent artificially high "systolic pressures" in diabetics. In contrast, thigh pressure
measurements appear to be predictive of success in transtibial amputation surgery. Several
workers have demonstrated that transtibial amputation healing is likely to occur at thigh
pressures greater than 70 mm Hg and possibly between 50 and 70 mm Hg. The
widespread adoption of this baseline standard alone would certainly reduce the number of
transfemoral amputations currently being performed, with very little, if any, consequent
increase in morbidity.
Infrared Thermography
Infrared thermography has been used to delineate areas of nonviability and to try to identify
specific skin flaps for lower-limb amputations over the past two decades. Although there is
a good relationship between skin blood flow and thermography, recent work suggests that
much of the "heat" seen on the thermogram derives from two main sources: convective heat
where the transfer is primarily from arterioles >50 µm in diameter and conducted heat where
there is a temperature gradient from the deeper structures to the skin. Good results have
been obtained from specialized units using this technique, but the cost and difficulty of
interpretation of such images combined with a difficulty in accurately quantitating the image
other than by additional skin blood flow measurements render it useful mainly as a
development tool in specialist centers. It is, however, one of the few tests that provides an
indication of specific skin flap viability.
Skin Fluorescence
As with thermography, the principle of being able to outline nonviability of specific skin flaps
has been used by several workers. The absence of uptake of fluorescein when injected
intravenously has been used to examine healing in amputations, and more recently, a
technique of quantitative fluorometry has been developed in an effort to provide more
objective criteria for the method. Since it is both fairly cheap and reasonably easy to
perform, there is some promise in this methodology, and it is to be hoped that other units will
validate the data found by Silverman and his colleagues. Despite the technique being
available for many years, however, it has not found widespread popularity, and there is still
some difficulty in interpretation of results, especially where there is associated inflammation.
Skin Blood Flow Measurements

The application of "point source" measurements to assess tissue viability is epitomized by the
use of skin blood flow measurements. The principle of skin blood flow techniques is to
measure the washout of an intra-dermally injected radioisotope tracer and from this to derive
a result that is a function of capillary skin blood flow. By using an original principle devised by
Kety, the precise skin blood flow can be calculated. The advantages of this technique are
that it appears to measure nutritional blood flow and it provides an absolute measurement for
blood flow. The problems with the technique principally relate to both its invasive methodology
and the need for a radioactive tracer. Testing is also relatively slow to perform and requires
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
lower limb, skin blood flow measurements in the foot are very variable, and a high skin
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
of the region as a whole, and this is particularly so in the foot. In any event, the healing of
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
pressure, pioneered in Denmark. The principle of the method is to note the blood pressure
at which the capillary return to the skin is abolished. The detection technique may be the
clearance of a radioisotope or the use of a photo-spectrometer. The method has the
advantage of ignoring specific values for skin blood flow but has the disadvantage that there
can be great difficulty in deriving absolute pressure values at the very low clearance rates
found in critically ischemic skin. There is some debate as to what absolute skin perfusion
pressure should be used to predict healing, and this may reflect the methodology involved.
Transcutaneous Oxygen Measurements

Since transcutaneous oxygen pressure (TcPO 2 ) measurements were first used to aid in the
assessment of tissue viability, there has been an explosion of published data discussing its
value in PVD, especially in relation to amputation level. Although the transcutaneous
electrode was originally designed to reflect arterial po 2 in the newborn, since then its
application has been widened to include the evaluation of ischemic tissue. Unfortunately,
electrode design has not been modified to allow for the skin characteristics of the adult,
and there is a great variation in results between different workers using different machines.
Variables affecting TcPO 2 measurements in normal skin such as Pao 2 , skin thickness,
electrode response, skin blood flow, local oxygen availability, and others are overshadowed
by a maximal vasodilatory response to the integral heater. Fortunately, ischemic skin does
not respond in the same way and is much more affected by other variables, particularly by
the underlying perfusion pressure.
The great attraction of the method is its simplicity and ease of use. However, the difficulties of
calibration and interpretation are usually greatly underestimated or not considered and result
in data that at best are insensitive. In early reports of the method, there were wide variations
in conclusions as to what TcPO 2 value reliably predicted amputation healing at the transtibial
level. This was highlighted by several reports that healing took place in a number of
amputations where the TcPO 2 was zero. The addition of 100% oxygen inhalation undoubtedly
improved the sensitivity of the technique immeasurably but may be inconvenient and time-
consuming.
It therefore appears that TcPO 2 levels greater than 35 mm Hg at the calf reliably predict
transtibial amputation healing but that values below this give an unpredictable outcome. If
oxygen inhalation is added to the test, then discrimination between healers and nonheal-ers
is improved dramatically. TcPO 2 values in the foot are of little predictive value.
SUMMARY
Several other techniques have also been tried in an attempt to aid in amputation level
selection. These include laser Doppler studies, 99m Tc pertechnetate scanning, muscle
pH studies, and others. Of these, the laser Doppler has the most potential because it offers
the ability to interrogate the microcirculation in a noninvasive mode.
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
correlate well with outcome. A mean skin blood flow of less than 2.5 mL/100 mg/min may
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.
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
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
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 femoro-
popliteal 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.
2D: Infection | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 2D
Chapter 2D - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Infection permission from
Bowker HK,
Michael JW (eds):
Prosthetics:
The vast majority of limb-threatening infections occur in the foot, mostly in patients with long- Surgical, Prosthetic, and
standing diabetes mellitus. A number of risk factors for infection exist in this group. The most Rehabilitation Principles.
widely recognized risk factor, sensory neuropathy leading to ulceration, appears to be directly
related to the duration of the diabetic condition. Neuropathic patients are unsure that 1992, reprinted 2002.
properly sized footwear really fit their feet and will tend to wear shoes that are too tight, thus
inducing ulcer formation. They also may see no harm in walking without shoes, at least in the Much of the material in this text
house, and thereby expose themselves to penetrating wounds from various objects left on the has been updated and published
floor. Motor neuropathy may affect the foot and toe dorsiflexors and allow a rapid uncontrolled in Atlas of Amputations and Limb
descent of the forefoot following heel strike. This slapping gait can result in damage to the
skin under the metatarsal head area. This effect will be aggravated by paralysis of the foot (retitled third edition of Atlas of
intrinsics, which leads to shifting of the metatarsal fat pad distally as the toes go into a Limb Deficiencies), ©American
clawed position, thus leaving the skin under the metatarsal heads with little protective fat Academy or Orthopedic Surgeons.
padding. In addition, autonomic neuropathy results in extremely dry skin, which then develops Click for more information about
fissures that provide sites of entry for bacteria. this text.
In the absence of normal pain sensation, it is quite common for diabetics to exhibit marked
denial even in regard to open sores. They can also become quite depressed, especially if
they have experienced chronic problems with their feet. While many are naturally quite fearful Prosthetics was
of amputation as an outcome, because of denial they may fail to come in during the early provided by the
stages of an infection. A displaced locus of control is manifested by an inability to take Northern Plains Chapter of the
responsibility for the care of their feet and/or diabetic state in general. All of these basically American Academy of Orthotists &
psychological difficulties may lead to poor compliance with a preventive foot care regimen. Prosthetists
Infection in diabetic patients is further complicated by decreased chemotaxis and
phagocytosis by leukocytes, especially in hyperglycemic states.
Other infections in the lower limb may also lead to amputation. Calf abscess, usually seen in
immunosup-pressed patients, should be treated aggressively by wide incision and
debridement if the foot is viable. This may be followed by later split-thickness skin grafting. You can help expand the
Chronic osteomyelitis secondary to open tibial fracture usually presents with a long-standing O&P Virtual Library with a
draining sinus. A preoperative sinogram will determine the origin and full extent of the sinus, tax-deductible contribution.
while an intraoperative injection of methylene blue mixed with a small proportion of hydrogen
peroxide will assist in complete removal of the sinus by staining all passages and loculations.
All sinus tissue should be carefully examined microscopically for evidence of carcinomatous
change.
MANAGEMENT OF ACUTE PROBLEMS
Diagnosis
The approach to management of foot lesions in the diabetic patient is greatly simplified by
use of the Meg-gitt-Wagner foot lesion grading system (FIG 2D-1.). This is based on the
presumption that most of these problems, other than dry gangrenous changes related to
proximal arterial occlusion, are secondary to a penetrating lesion, either beginning in an ulcer
or by direct puncture of the foot. Grade 1 and 2 lesions are ulcers that have not involved
bone and joint. Although frequently colonized with bacteria, they are not overtly infected and
may be readily treated by various non-weight-bearing devices including total-contact casts for
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 weight-
bearing 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-
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.
The methodology originally described by Kritter is quite simple. A small polyethylene

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 2D-
6.). 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.
REHABILITATION OF THE INFECTED FOOT

As noted above, the inability to loosely close the wound primarily over a wash-through
system results in prolonged morbidity as the wound slowly granulates and shrinks. This
process may go on for 3 to 6 months or more. At the end of that time, it may still be
necessary to skin-graft the wound to obtain adequate durable coverage. If it has been
possible to close the wound loosely over an irrigation system, the sutures may be removed at
3 weeks. The patient should probably be non-weight bearing for a minimum of 5 to 6 weeks.
If minimal removal of forefoot bony structure has been possible, changes in footwear may be
limited to simple fillers attached to an insole, combined when necessary with a fairly rigid
rocker sole on an in-depth shoe. Properly designed shoewear should provide the partial-foot
amputee with a stable platform, proper padding of bony prominences, and protection of the
foot from external trauma.
In our facility, following the healing process the patient is referred to the Patient Family
Education Clinic. This program, operated by master's level nurse-educators, provides long-
term follow-up care, including nail and callus trimming, referral for proper shoe fitting, and
counseling regarding self-care of the feet. It features a hotline so that patients can call in at
any time regarding early treatment of incipient foot problems. They will be seen promptly and
appropriately treatedand referred to avoid the long emergency department waits common to
many large public hospitals. A great deal of attention is also paid to psychological
reorientation to overcome denial, depression, and other problems affecting compliance.
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 self-
care.
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; 66:305-
318.
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 wound-
healing 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.
2E: Tumor | O&P Virtual Library
Search
GO
O&P Library > Atlas of Limb Prosthetics > Chapter 2E
Chapter 2E - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Tumor permission from
Bowker HK,
Michael JW (eds):
Walid Mnaymneh, M.D. Atlas of Limb
Prosthetics:
Limb salvage surgery is any procedure that effectively removes a bone or soft-tissue tumor Surgical, Prosthetic, and
while preserving the limb with a satisfactory functional and cosmetic result. For many years Rehabilitation Principles.
amputation was the conventional surgical treatment of malignant bone and soft-tissue tumors.
However, since the midseven-ties and as a result of advances in adjuvant chemotherapy 1992, reprinted 2002.
and radiotherapy newer staging studies of tumors, and improved surgical techniques of
skeletal and soft-tissue reconstruction, there has been an upsurge of interest in limb-saving Much of the material in this text
procedures in lieu of amputation. Moreover, limb-saving procedures have proved to be as has been updated and published
effective as amputation in terms of local tumor control without compromising survival. in Atlas of Amputations and Limb
The treatment plan for malignant tumors is a mul-tidisciplinary one utilizing surgery, and Rehabilitation Principles
chemotherapy, and radiotherapy as well as the supportive services of psychologists,
prosthetists, physical therapists, and social workers. It is based mainly on the surgical stage Academy or Orthopedic Surgeons.
of the tumor as well as its size and anatomic location. The surgical stage of the tumor is Click for more information about
based on its histogenic type (as determined by biopsy) as well as on its local extent and any this text.
existing metastasis 8-11 (as determined by radiologic studies including radiographs, bone
scan, computed tomography [CT], and magnetic resonance imaging [MRI]). Funding for digitization
The biopsy is done after completion of the radiologic staging studies and should be carried Prosthetics was
out by the surgeon who will perform the definitive surgery. A poor biopsy technique may have provided by the
a profound adverse effect on the subsequent definitive surgical treatment and in fact may Northern Plains Chapter of the
preclude the execution of an otherwise feasible limb-saving procedure. The biopsy incision American Academy of Orthotists &
should be longitudinal rather than transverse and should be correctly placed in line with the Prosthetists
planned incision of the subsequent surgery so that in case a limb-saving procedure is done,
the biopsy tract can be excised in continuity with the resected tumor. Deeper dissection
should avoid intermuscular planes and should stay clear of the major neurovascular
structures. Intraosseous biopsy material is obtained through a round or oval cortical window.
Plugging the intraosseous biopsy site with methylmethacrylate cement may be done to
prevent soft-tissue spread of the tumor hematoma. A frozen-section tissue preparation for You can help expand the
immediate appraisal of the adequacy of the specimen for diagnosis is recommended. In a O&P Virtual Library with a
multicenter study, Mankin et al. reported an almost 20% incidence of significant problems in
patient management caused by inappropriate biopsy technique. It was found that 8% of the
biopsy procedures produced significant adverse effect on prognosis and that 4.5% of the
patients who might have had a limb-saving procedure required an amputation as a result of
an ill-planned biopsy. Moreover, errors in diagnosis occurred twice as commonly when the
biopsy was done in a community hospital as opposed to when it was done in an oncologic
center. Hence, it is recommended that patients be transferred to a specialty center before
rather than after the biopsy.
The new staging system that has been adopted by the Musculoskeletal Tumor Society8-11
and that is currently utilized by most orthopaedic oncologic surgeons applies to bone as well
as soft-tissue tumors. It categorizes benign tumors into three stages designated by Arabic
numerals: stage 1 (latent), stage 2 (active), and stage 3 (aggressive). Malignant tumors are
categorized into three stages designated by Roman numerals: stage I (low-grade malignancy
without metastasis), stage II (high-grade malignancy without metastasis), and Stage III (any
malignant grade with regional or distant metastasis). Both stage I and stage II are subdivided
into A (intracompartmental) and B (extracompartmental).
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
sarcomas are treated preoperatively with either chemotherapy or radiotherapy, or both,
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
the efficacy of the preoperative chemotherapy and hence will help in selecting the
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-of-
life parameters between patients with limb-saving and amputation procedures. A study
specifically targeting tumors about the knee showed no significant difference in psychological
and physical function, whereas another study showed that patients whose limbs were
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.
INDICATIONS FOR LIMB-SAVING PROCEDURES

Conceptually, limb-saving procedures are indicated if all the following criteria are deemed
attainable:
1. An oncologically sound wide or radical resection of the tumor can be achieved.

2. Limb reconstruction is technically feasible.
3. The prognosis, in terms of survival and local recurrence, is not compromised.
4. The cosmetic and functional results are superior to those of an amputation, with due
consideration given to the patient's life-style, needs, and demands. The ultimate goal
is not merely "salvaging" the limb but reconstructing a functional and cosmetically
appealing limb.
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.
In general, limb salvage procedures are technically more complex than amputations. In bone
tumors, it comprises two procedures: tumor resection and skeletal reconstruction. In soft-
tissue 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.
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
diaphyseal defect. Unlike an avascular fibular allograft, the healing potential is greatly
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 graft-
host 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.
To help solve some of the problems encountered with customized prostheses, in terms of
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
distal ends of the femur and proximal parts of the tibia and humerus. This system depends
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. Whole-
joint 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.
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
successful, the pelvis allograft restores anatomy, stability, function, and leg length. (Fig 2E-
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.
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 knee-
ankle-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.
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
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 relapse-
free 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
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
O&P Library > Atlas of Limb Prosthetics > Chapter 2E
3: Planning for Optimal Function in Amputation Surgery | O&P Virtual Library
Search
GO
Planning for Optimal Function in Amputation Surgery Reproduced with

permission from
Thomas J. Moore, M.D. Bowker HK,
Michael JW (eds):
Although most surgeons consider amputation to be the ultimate surgical failure, a well- Atlas of Limb
Prosthetics:
planned and executed amputation can remove a painful, dysfunctional limb and allow
rehabilitation with a prosthetic limb to a functional, painless state. In this regard, amputation Rehabilitation Principles.
surgery may be considered reconstructive surgery, with results similar to amputation of an Rosemont, IL, American Academy
arthritic femoral head and prosthetic replacement (total-hip replacement). of Orthopedic Surgeons, edition 2,
Amputation surgeons must recognize the global problems associated with amputation
surgery. In the United States, the most common reason for lower-limb amputation is Much of the material in this text
peripheral vascular disease. Oftentimes, these patients have the same process in the
contralateral limb, as well as coronary artery and cerebral vascular disease. Several series of Deficiencies: Surgical, Prosthetic,
dysvascular amputees in the 1960s and 1970s reported contralateral limb amputation rates of and Rehabilitation Principles
15% to 28% within 3 years of the initial amputation and a 50% mortality rate during the same (retitled third edition of Atlas of
time period. Despite significant improvements in the care of the dysvascular amputee Limb Deficiencies), ©American
(diabetic management, nutrition, antibiotic management, vascular reconstructive procedures, Academy or Orthopedic Surgeons.
etc.) the contralateral limb amputation rate and long-term survival rates have not significantly Click for more information about
this text.
changed.
The role of the amputation surgeon involves much more than the actual surgical procedure. Funding for digitization
The initial, most basic decision is whether to proceed with amputation or to attempt limb of the Atlas of Limb
salvage. In peripheral vascular disease, advances in vascular reconstructive procedures have Prosthetics was
allowed limb salvage in both nondiabetic and diabetic patients. Advances in trauma provided by the
management such as arterial and venous repairs, bony stabilization, and free-tissue transfers Northern Plains Chapter of the
have resulted in limb salvage in severely traumatized limbs that previously would have been American Academy of Orthotists &
Prosthetists
amputated. Improvements in adjunctive chemotherapy and surgical technique have allowed
en bloc resection of certain bony tumors and limb salvage with either custom prosthetic
implants or allograft replacement.
Once an amputation is decided upon, preoperatively the most distal level of amputation
compatible with wound healing and subsequent satisfactory prosthetic fitting should be
determined by clinical evaluation and laboratory evaluation. The environment for wound You can help expand the
healing should be maximized by evaluating the patient's nutritional status, control of diabetics' O&P Virtual Library with a
blood glucose, and the use of antibiotics in infected patients. Appropriate surgical technique
should be utilized to produce an acceptable stump for subsequent prosthetic fitting.
Postoperatively, appropriate judgment should determine prosthetic candidacy in elderly
dysvascular amputees.
Modern amputee management involves a multidisci-plinary approach to address the global

problems (medical, surgical, social, rehabilitative, and economic) involved in amputees.
Planning for optimal function in amputation surgery should consist of preoperative, operative,
and postoperative considerations.
PREOPERATIVE CONSIDERATIONS
Amputation vs. Limb Salvage
Trauma
Modern advances in trauma management such as fracture stabilization and free-tissue
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
recent series. In addition, several series have shown that there is significant morbidity,
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.)
Peripheral Vascular Disease

The largest number of amputations done in the United States are for peripheral vascular
disease. As the population of the United States ages, more patients will be evaluated for
dysvascular disease in lower limbs. Oftentimes, early amputation at the most distal level
possible and rehabilitation with a prosthesis offer the best solution for a painful, dysvascular
limb. However, before undergoing amputation, many of these patients should be evaluated
for consideration for vascular reconstructive procedures that may allow either limb salvage or
a more distal amputation level.
Vascular reconstruction in limbs at risk for amputation may have some drawbacks. Arterial
reconstructive surgery is expensive and may delay eventual definitive treatment, and the
outcome is uncertain. However, several series have demonstrated no adverse effect of failed
vascular reconstructive procedures on the ultimate level of amputation or clinical outcome.
The vast majority of lower-limb amputations for peripheral vascular disease occur in diabetics.
Often diabetics with dysvascular disease are thought to have "small-vessel disease" not
treatable with vascular reconstructive procedures. This concept probably originated in an
article by Goldenberg et al. in 1959 that described arteriosclerosis in the arterioles of
diabetics that was thought to be unique. However, subsequent series have not confirmed
small-vessel disease as unique to diabetes mellitus. In addition, multiple series have
demonstrated that when modern techniques of vascular reconstructive surgery are applied to
diabetics, long-term limb salvage rates are comparable to nondia-betics treated in a similar
manner. Therefore, diabetics should not be automatically excluded for consideration for
vascular reconstructive procedures in limb-threatening conditions. (See Chapter 2C for a
detailed discussion.)
Tumors
The field of musculoskeletal oncology is rapidly evolving. In the 1960s and early 1970s, 5-
year 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
developed in the last decade. Several institutions report similar overall survival rates of
patients who underwent primary amputation and of those who underwent segmental limb
resection. Survival rates may actually be improved in those patients who undergo an en
bloc resection because the patients selected for this treatment are likely to have more limited
disease. At the present time, en bloc resection with limb salvage in osteosarcoma should
probably be restricted to centers with a large oncology section and is probably con-
traindicated 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
compatible with wound healing to achieve the optimal potential for ambulation. Several well-
documented studies have shown that energy expenditure with prosthetic ambulation is
markedly increased in more proximal amputations. Waters and coworkers found that
energy expenditure during ambulation, as measured by oxygen consumption per kilogram of
body weight per meter traveled, was significantly increased in transfemoral amputees vs.
transtibial amputees. Fisher et al., in a review of previous energy studies in amputees,
found that lower-limb amputees expend more energy (kilocal-ories per meter) in ambulation
than do nonamputees and have a compensatory decrease in gait velocity. Huang and
associates showed that oxygen consumption during ambulation was increased 9% in
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
amputation is likely to be successful. Clinical parameters such as the lowest palpable
pulse, skin temperature, and bleeding at surgery have been used with varying success to
predict healing of amputation sites. The use of Doppler ultrasonography to measure arterial
blood pressure at the proposed amputation site has been advocated as a predictor of
amputation success. Barnes and coworkers found that transtibial amputations healed in all
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
&#2265 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 44°C 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
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.
Jensen and associates reported a 42% incidence of laboratory-proven malnutrition in
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
coworkers have shown a statistically significant decrease in wound infections in
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,
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
infection. In some series, healing of amputations of lower limbs in patients with diabetes
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.
POSTOPERATIVE CONSIDERATIONS
In the immediate postoperative period, amputation stumps should be splinted with well-
padded rigid dressings to prevent joint contractures. The use of an immediate postoperative
prosthesis (IPOP) has been advocated to allow early prosthetic ambulation, decrease stump
edema, and diminish postamputation depression. However, others have found significant
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
psychological problems, or additional musculoskeletal problems such as rheumatoid
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
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;
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.
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
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.
4: Prosthetic Management: Overview, Methods, and Materials | O&P Virtual Library
Search
GO
Prosthetic Management: Overview, Methods, and Reproduced with

Materials permission from
Bowker HK,
Michael JW (eds):
Michael J. Quigley, C.P.O. Atlas of Limb
Prosthetics:
PROSTHETIST'S ROLE AND PRACTICE Rehabilitation Principles.
The prosthetist of today is a highly skilled individual who must meet significant educational of Orthopedic Surgeons, edition 2,
and professional standards prior to obtaining board certification. Training in limb prosthetics 1992, reprinted 2002.
has advanced from apprenticeship programs without formal academic standards in the 1940s Much of the material in this text
to the present requirements for a baccalaureate degree, supervised internship, national has been updated and published
certification examinations, and mandatory continuing education. in Atlas of Amputations and Limb
The prosthetists role in the rehabilitation team has become more significant as a result. In the and Rehabilitation Principles
period following World War II, prostheses were relatively simple, and prescriptions were (retitled third edition of Atlas of
therefore extremely specific, with the prosthetist given little latitude in exercising clinical Limb Deficiencies), ©American
judgement. Given the complexity of todays componentry, many of the details regarding Academy or Orthopedic Surgeons.
Click for more information about
prosthetic configuration are now based on clinical results observed by the prosthetist during
this text.
the dynamic alignment procedure. The prosthetists function as a consultant to rehabilitation
programs and hospitals is also now more clearly defined, and board certification in prosthetics
is usually required if the rehabilitation programs are to receive national accreditation. Funding for digitization
The vast majority of prosthetists are small businessmen or employees of small businesses. Prosthetics was
The field of orthotics is closely aligned with prosthetics, and many individuals achieve provided by the
certification in both disciplines. Large rehabilitation hospitals may have their own prosthetic Northern Plains Chapter of the
and orthotic department or may contract with local private prosthetists and orthotists to have
Prosthetists
on-site provision of services.
Prosthetists work within the same constraints as other health care workers, including the
ubiquitous problems of rising malpractice insurance costs, federal and state cost containment
programs, and increased difficulty in dealing with third-party payers. Most patient referrals
come directly from orthopedic, physical medicine, and vascular physicians. Referrals also
come from physical therapists, insurance carriers, and recommendations by former patients. You can help expand the
The field of prosthetics in the United States is represented by three national associations. The tax-deductible contribution.
American Orthotic and Prosthetic Association (AOPA) was founded shortly after the turn of
the century and deals with business issues. The American Board for Certification in
Prosthetics and Orthotics, Inc. (ABC), is a certifying body that sets educational standards for
prosthetists, holds examinations, maintains records, and accredits facilities that are
accessible, clean, and well equipped. The third association is the American Academy of
Orthotists and Prosthetists (AAOP), whose members must be certified by the ABC. The
AAOP provides numerous national and regional meetings, maintains a mandatory continuing
education program, and produces a number of publications including the Journal of
Prosthetics and Orthotics, published jointly with the AOPA.
PATIENT EDUCATION AND ORIENTATION

When amputation of a limb is being considered, it is important to inform the patient as early
as possible about future rehabilitation. It is not unusual for the recent amputee to become
depressed, withdrawn, or angry; in fact, it is unusual when amputation seems to have no
effect on the persons attitude. Patient education and counseling can come from several
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
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.
GENERAL PRESCRIPTION GUIDELINES
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 impact-
absorbing 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
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 hand-
molded 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.
POSITIVE MODEL RECTIFICATION

The positive model of the residual limb is rectified or modified by the prosthetist to improve
the pressure distribution. Judicious addition or subtraction of material relieves the bony
prominences and tender areas while increasing pressure to more tolerant areas such as soft
tissue and broad expanses of bone or tendon (Fig 4-3). For example, in the transtibial
(below-knee) prosthesis, pressure is increased by removing material at the following areas:
patella tendon, pretibial muscles, flare of the tibia, popliteal area, and the calf musculature.
Conversely, pressure is relieved by adding material in the following areas: tibial crest, distal
portion of the tibia, fibula head, hamstring tendons, and patella.
Positive model modification is a difficult and time-consuming procedure requiring much skill
on the part of the prosthetist. With proper modification, the prosthetist can create a
comfortable and stable socket with good suspension characteristics and can relieve any
particular problem areas that the patient has experienced in the past.
COMPUTER-AIDED DESIGN/COMPUTER-AIDED
MANUFACTURING
An alternative method of socket design and fabrication is beginning to enter clinical practice:
use of the microcomputer to automate repetitive portions of the fabrication process. Current
computer-aided design/ computer-aided manufacturing (CAD/CAM) systems consist of three
major components:
1. A digitizer that converts information from the negative impression of the patient's
residual limb into numerical data that are read by the computer.
2. A software system that provides a visual image of the patient's residual limb on a
video screen.
3. A carver that reads the modified computer image of the patient's residual limb and
carves a rectified plaster model.
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
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
4. Freedom of motion at the next proximal joint
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
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 tendon-
bearing (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.
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.
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 4-
13) 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
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.
5: Kinesiology and Functional Characteristics of the Upper Limb | O&P Virtual Library
Search
GO
Kinesiology and Functional Characteristics of the Upper Reproduced with

Limb permission from
Bowker HK,
Michael JW (eds):
Shahan K. Sarrafian, M.D. Atlas of Limb
Prosthetics:
The functional capacity of the upper limb is determined by the shoulder complex, elbow, wrist, Surgical, Prosthetic, and
and hand developing multiple integrated spheres of action. Given the normal proportion of Rehabilitation Principles.
limb segments, this capacity is limited in relation to the surrounding space. In the standing
position the upper-limb field of motion reaches the midthigh region. Any more distal point on 1992, reprinted 2002.
the lower extremity or on the ground is reached through mobility provided by the hip, knee,
ankle, and trunk (Fig 5-1). Furthermore, a distant point in space comes within the reach of Much of the material in this text
the upper-limb action through a functional integration with gait. has been updated and published
A maximum arcuate field or envelope of action termed "Ex" (Fig 5-2) is traced by the most Deficiencies: Surgical, Prosthetic,
distal point of the upper extremity through the motion of the shoulder complex, all other joints and Rehabilitation Principles
being held in extension. Within this envelope, the elbow, wrist, and hand develop their own
fields of motion, E2 , E3 , and E4 . These contained capabilities enrich the functional Academy or Orthopedic Surgeons.
performances of the upper extremity. Click for more information about
this text.
SHOULDER COMPLEX
Motion in the Frontal or Coronal Plane Prosthetics was
provided by the
When the arm and forearm are held in the anatomic position, the antecubital surface facing Northern Plains Chapter of the
anteriorly, the upper limb sweeps a circular surface in the frontal plane. The very distal point American Academy of Orthotists &
of the extremity traces an envelope of action E1 (Fig 5-3). Prosthetists
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 You can help expand the
this second arc of motion the elbow explores the segment of the space through its action O&P Virtual Library with a
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.
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.
Electromyographic study of these muscles (Fig 5-10) indicates that the deltoid action
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).
Motion in the Sagittal Plane

From a neutral rotational position the upper limb moves in the sagittal plane and sweeps the
surface from position 1 to 3 (Fig 5-19). The elbow, wrist, and hand are capable of functioning
in this plane through their envelopes of action E2 , E3 , and E4 .
In position 3 the elbow action extends farther posteriorly, the hand reaching the posterior
aspect of the shoulder. Further movement in the posterior half of the field is possible through
the internal rotation of the shoulder followed by gradual external rotation to bring the limb to
its neutral initial position (Fig 5-20). Elevation of the upper limb, or flexion from position 1 to
3, is determined by the anterior segment of the deltoid, biceps, coracobrachialis and clavicular
head of the pecto-ralis major (Fig 5-21). The rotator cuff is also active in stabilizing the
humeral head. The scapulothoracic mechanism participates in the motion through upward
scapular rotation at a ratio of SH/ST=2/1. From the elevated position 3 the upper limb is
brought down by the posterior segment of the deltoid, long head of the triceps, latissimus
dorsi, and pectoralis major (Fig 5-22). Beyond neutral the motion continues as extension, and
all motors continue their action except the pectoralis major. The range of extension is 60
degrees (Fig 5-23). Contributors to this motion are gravity and downward rotators of the
scapula.
Motion in the Horizontal Plane

When the upper extremity is elevated to 90 degrees in the frontal plane, the distal point of
the limb scans the horizontal plane and traces an arc of 165 degrees (Fig 5-24). The
flexors and extensors of the scapulo-humeral joint control the motion.
Rotary Capability of the Shoulder Complex

When the upper extremity is held in the neutral rotational position at the shoulder and the
elbow is flexed at 90 degrees, the distal point traces an arc of internal rotation of 80 degrees
and an arc of external rotation of 60 degrees. With the shoulder elevated 90 degrees in the
frontal plane, this rotary capability changes to 90 degrees of external rotation and 70 degrees
of internal rotation (Fig 5-25).
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
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 pronation-
supination. 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 pronation-
supination. 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 5-
36) 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
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 extrinsic-
intrinsic motors commanded by the motor cortex.
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
automatically extends the distal joint. This is another mechanism of coordination on the
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
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
determined by the intention and not necessarily by the shape of the object. A scalpel is
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
exception; here the flexor superficialis pattern predominates. The thumb brings its
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; 160:261-
271.
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
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.
6A: Upper-Limb Prosthetics | O&P Virtual Library
Search
GO
Upper-Limb Prosthetics: Body-Powered Components Reproduced with

permission from
Charles M. Fryer, B.S., M.S. Bowker HK,
Michael JW (eds):
John W. Michael, M.Ed., C.P.O.
Atlas of Limb
Prosthetics:
OVERVIEW Surgical, Prosthetic, and
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 1992, reprinted 2002.
operate such components comes from mechanical transmission of muscular effort generated
elsewhere in the body, remote from the amputation site. Much of the material in this text
When body power is insufficient or undesirable, externally powered components may be in Atlas of Amputations and Limb
utilized. "External power" comes from a source outside the body; contemporary versions are Deficiencies: Surgical, Prosthetic,
battery-powered electronic devices, although pneumatic, hydraulic, and other power sources
have been utilized in the past. Limb Deficiencies), ©American
As a group, body-powered devices enjoy the triple advantages of low cost, light weight, and Click for more information about
high reliability due to mechanical simplicity. Their widespread application today throughout the this text.
world verifies the practical advantages offered by such components.
They also share significant disadvantages, however. The harness required to transmit muscle Funding for digitization
forces inevitably restricts the amputee's work envelope and often encumbers the noninvolved of the Atlas of Limb
side. The amputee must exert effort to generate sufficient force and excursion to operate the Prosthetics was
provided by 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 American Academy of Orthotists &
remnants (see Chapter 6B). Finally, the robotlike appearance of some body-powered Prosthetists
components can be disconcerting to the general public as well as to the amputee.
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 You can help expand the
have no moving parts and require no cables or batteries for operation, they are typically O&P Virtual Library with a
extremely lightweight and reliable.
Passive Terminal Devices

The most commonly prescribed passive terminal device is the passive hand (Fig 6A-1.).
Chapter 7C discusses the custom-sculpted hand in more detail and emphasizes the functions
of static grasp and social acceptance offered by these devices. A much less expensive
production hand is also available. The production passive hand is created from a donor mold
that is similar to (but not identical to) the missing appendage and offers acceptable cosmesis
to some patients.
Another category of passive terminal devices resembles children's mittens, and hence they
are called "mitts." The passive mitt is usually a soft, flexible humanoid shape similar to the
cupped human hand. They are often recommended for infants and for sports activities. Some
have specialized shapes to facilitate particular activities (Fig 6A-2.). The prosthetist may also
design specialized passive terminal devices as is illustrated in Chapter 12C, which discusses
sports and recreational devices in more detail.
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.
Voluntary-Opening Hook Terminal Devices

Hosmer-Dorrance is the name associated with a broad range of body-powered, voluntary-
opening hook terminal devices. Many have a similar characteristic shape and differ principally
in size and materials. Originally designed by an upper-limb amputee in 1912, the versatility
and reliability of the voluntary-opening hook with canted fingers made it the most commonly
prescribed terminal device in North America (Fig 6A-3.).
The series 5 hooks are intended for adults and were originally manufactured only in stainless
steel. Steel remains available but is usually reserved for the heavy-duty, transradial (below-
elbow) user. The letter "X" indicates the addition of neoprene rubber finger linings to improve
friction and grasp. The letter "A" indicates aluminum alloy and reduces weight about 50%
over the steel versions. The alloy hooks are satisfactory for all but the most rugged users.
The series 8 hooks are slightly smaller and intended for females but offer similar options in
materials and finger linings. The series 9 hooks are for adolescents, series 10 is for children,
and series 12 is an infant's hook. Addition of the letter "P" indicates that it has been coated
with "plastisol," a soft rubber material available in both Negroid and Caucasion tones.
A second characteristic shape is the "work hook," identified by the large opening between the
two fingers that is designed to grasp shovel handles and similar objects (Fig 6A-4.). This is a
heavy-duty, stainless steel device reserved almost exclusively for adult male amputees. The
specialized fingers also have a number of subtle contours that facilitate holding, grasping, and
carrying such items as buckets, chisels, knives, nails, and carpentry tools. It is sometimes
referred to as a "farmer's hook" but has value for anyone engaged in manual tasks including
workshop activities. Variations add a larger opening or a locking mechanism to the basic
hook.
The term canted refers to the slanted configuration of the hook fingertips, which facilitates
visual inspection during fine motor tasks. Since no prehensor yet offers sensation, the
amputee must rely on vision to confirm that grasp has been successful.
Some hook fingers offer a more symmetrical shape that grasps cylindrical objects such as
bottles more readily than the canted approach (Fig 6A-5.). The "two-load" hook has "lyre-
shaped" fingers for this reason. As its name suggests, a small switch at the base of the
thumb permits the amputee to engage either one spring (1.6 kg, 3½ lb) or two springs (3.2
kg, 7 lb) to vary the pinch force. Because the fingers are hollow alloy, it is not suitable for
heavy-duty use. The Dorrance "555" series has more rugged solid fingers in the same "lyre"
shape and is available in steel or aluminum alloy (Fig 6A-6.).
The "contour" hook is a recent addition that uses two "C"-shaped fingers to facilitate
cylindrical grasp. Since most amputees find the canted approach satisfactory, the specialized
shapes tend to be more commonly prescribed for the bilateral upper-limb amputee, but on
one side only. The combination of one canted hook and one straight hook offers two different
grasp patterns.
A few other manufacturers offer voluntary-opening hooks. The United States Manufacturing
Company (USMC) hook is a steel design similar to the series 5 type. It has a small triangular
opening in the stationary finger that can latch onto a serrated attachment. Hand tools and
sports equipment can be modified by mounting serrated attachments that allow the amputee
to lock the implements securely onto the hook. In some cases, the movable hook finger can
then be used to pull the trigger on a drill, pistol, or similar object (Fig 6A-7.).
The CAPP terminal device (originally developed at the Child Amputee Prosthetics Project at
UCLA) offers a voluntary-opening utilitarian shape that is not a hook. Clever use of contours
and rubber materials provides a reasonably secure grasp despite a limited pinch force.This
device is most popular for small children, whose ability to generate body-powered force is
limited, but it is also available in adult size (Fig 6A-8.).
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
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 body-
powered 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 (½-in.) increments (e.g., 6, 6½, 7, 7½, 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 (½-in.) increments from size 6½ 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 voluntary-

opening 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, 7½, 8, 8½, 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, 6½, and 5½.
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.
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.
Friction Wrist Units

Commercially available wrist units permit the amputee to substitute for supination and
pronation by manually rotating the terminal device with the remaining normal hand (Fig 6A-
21.). Bilateral amputees usually preposition the terminal devices for use by striking one
device against the other, thereby rotating it to the desired position of function.
Friction wrist units are available in aluminum or stainless steel in the adult size (5-cm [2-in.]
diameter) and medium size (4.4-cm [l¾-in.] diameter).
Oval-shaped friction wrist units are available in adult and medium sizes (Fig 6A-22.). The
oval configuration provides better cosmesis in cases of long transradial levels of amputation.
Also, since most prosthetic hands have an oval base, the oval-shaped wrist unit provides for
a smoother transition from the prosthetic hand to the prosthetic forearm. This wrist unit does
not provide constant friction.
Friction wrist units designed specifically for wrist disarticulation levels of amputation are made
as thin as possible to conserve the length of the prosthetic forearm (Fig 6A-23.). These
wrists do not provide constant friction and function in the same manner as previously
described units. The units are available in two sizes: adult (5-cm [2-in.] diameter) and
medium (3.4-cm [1 3/8-in.] diameter).
The foregoing wrist units do not provide constant friction. As the terminal device stud is
screwed into the wrist unit, a rubber washer is compressed to create friction. As the terminal
device is unscrewed, friction is reduced. It is highly desirable that wrist units provide constant
friction. Modern units permit the amputee to rotate the terminal device through 360 degrees of
motion without a change in the effective friction.
Constant-Friction Wrist Units

Constant-friction wrist units are designed to provide constant friction throughout the range of
rotation of the terminal device. Most units of this type employ a nylon-threaded insert with
steel lead threads (Fig 6A-24.). Turning a small set screw in the body of the wrist causes the
nylon thread to be deformed against the stud of the terminal device, thus creating constant
friction. Damage to the insert threads may be repaired by simply removing and replacing the
entire insert.
Constant-friction wrist units are available in both the round and oval configurations (Fig 6A-
25.). In the round configuration, four sizes are available: infant (3.1 cm, l¼ in.), child (3.8 cm,
1½ in.), medium (4.4 cm, 1¾ in.), and adult (5 cm, 2 in.). In the oval configuration two sizes
are available: adult and medium.
Quick-Change Wrist Units
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. Remove the terminal device from the wrist unit

2. Replace the terminal device with a different terminal device
3. Manually position the terminal device in supination or pronation
4. 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
loading can be easily adjusted by the amputee.
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 split-
socket 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.
Elbow Units for Elbow, Transhumeral, and Below-Shoulder

Disarticulation Amputees
Loss of function of the anatomic elbow joint requires a mechanical substitute that permits
controlled flexion and extension through a range of approximately 135 degrees. In addition,
the unit must permit the amputee to lock and unlock the elbow at numerous points throughout
the 135-degree range of motion.
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.
Inside-Locking Elbow Units

Amputations through the humerus approximately 5 cm (2 in.) proximal to the elbow joint
provide adequate space to accommodate inside-locking elbow mechanisms. Inside-locking
units permit the amputee to lock the elbow in any of 11 positions of flexion (Fig 6A-38.). In
addition, inside-locking units incorporate a friction-held turntable. The turntable permits
manual preposi-tioning of the prosthetic forearm as a substitute for external and internal
rotation of the humerus.
Flail Arm Hinges

Flail arm hinges contain an oversized clock spring mechanism to partially counterbalance the
weight of the forearm. They may be used singly or in pairs depending upon the degree of
counterbalance desired. They may also be combined with a single free joint or a single
locking joint, as necessary.
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.
Spring Lift Assist

The spring lift assist is a clock spring unit, similar in function to the flail arm hinge, that can
be added to any mechanical elbow. The function is to counterbalance the prosthetic forearm
and reduce the force necessary for elbow flexion. Reduced force requirements may permit
subtle harnessing adjustments that require less excursion from the amputee. Although
optional, the spring lift assist is commonly prescribed, particularly for use with heavier steel
terminal devices or hand prehensors.
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-and-
socket configurations permit universal passive motion. Most are available in small, medium,
and large sizes.
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.
NUDGE CONTROL UNIT

The nudge control unit is a paddle-shaped lever that can be pushed by the chin or
phocomelic digit or against environmental objects to provide a small amount of cable
excursion. It is usually prescribed when other body motions are not available. Although
originally designed to provide elbow locking and unlocking, it can also be adapted to operate
other body-powered components, including flexion and rotation wrist units.
ENDOSKELETAL UPPER-LIMB PROSTHESES

Two endoskeletal upper-limb prosthetic systems are currently available in the United States.
They are composed of tubular humeral and forearm elements, and the components allow for
encasement in cosmetic foam covers. After final shaping and covering with a skin-colored
stockinette, the completed prosthesis affords a high degree of cosmetic acceptability (Fig 6A-
41.). In addition to improved cosmesis and softness, modular prostheses are lighter in weight
than conventional artificial limbs.
The Otto Bock Pylon Arm system for transhumeral and shoulder disarticulation amputees
permits passive or cable-operated elbow flexion with manual locking (Fig 6A-42.). Passive
prepositioning of the humeral segment in internal or external rotation and the forearm in
supination or pronation is achieved by the use of rotation adaptors.
The system hands (Fig 6A-43.) provide a wide variety of terminal device options: cable-
controlled, voluntary-opening or -closing units and a passive hand unit with a spring-activated
thumb and fingers. For the shoulder disarticulation level, the Otto Bock system offers two
friction-loaded, passively positionable shoulder units: a ball-and-socket joint and a flexion-
extension, abduction-adduction hinge (Fig 6A-44.).
The endoskeletal system of the Hosmer-Dorrance Corporation includes components for

transradial, trans-humeral, and shoulder disarticulation levels of amputation (Fig 6A-45.). All
terminal devices with the standard W-20 thread can be used with the Hosmer-Dorrance
system. Socket attachment turntables permit passive rotation of the humeral and forearm
segments. A separate wrist unit allows for manual prepositioning of the terminal device in
flexion.
Three elbow units are available for either cable-controlled or manual operation: a constant-
friction elbow, an elbow with a manual lock, and an elbow joint with a cable-controlled locking
mechanism. For the shoulder disarticulation level, a manually positionable flexion-extension,
abduction-adduction hinge is available.
6B: Harnessing and Controls for Body-Powered Devices | O&P Virtual Library
Search
GO
Upper-Limb Prosthetics: Harnessing and Controls for Reproduced with

Body-Powered Devices permission from
Bowker HK,
Michael JW (eds):
Charles M. Fryer, B.S., M.S. Atlas of Limb
Prosthetics:
In body-powered upper-limb prosthetic applications, the functions of control and suspension Surgical, Prosthetic, and
are closely interrelated. The prosthesis is suspended on the residual limb by the intimacy of Rehabilitation Principles.
the socket fit and by a system of Dacron straps collectively referred to as a "harness." In a
well-designed harness the same straps are strategically positioned in relation to the shoulder 1992, reprinted 2002.
girdle and/or thorax so that the amputee can control the prosthetic components with a
minimum of exertion and body motion. To understand the two main functions of a prosthetic Much of the material in this text
harness it is first necessary to examine the mechanical operating principles of prosthetic has been updated and published
control systems. in Atlas of Amputations and Limb
MECHANICS OF THE BELOW-ELBOW (TRANSRADIAL) (retitled third edition of Atlas of
CONTROL SYSTEM Academy or Orthopedic Surgeons.
The transradial prosthetic control system is a one-cable or "single-control" system. A this text.
stainless steel control cable is firmly attached at its proximal end to one of the Dacron straps
of the harness (Fig 6B-1.). Distally, the cable terminates at some type of prehension device
(Fig 6B-2). of the Atlas of Limb
Prosthetics was
Prehension devices, usually referred to simply as "terminal devices," may be either prosthetic provided by the
hands with one or more movable fingers or two-fingered devices with a hook-type Northern Plains Chapter of the
configuration. With this type of terminal device the amputee uses shoulder motion on the American Academy of Orthotists &
amputated side to apply tension to the control cable (Fig 6B-2.). The cable tension is Prosthetists
transmitted to the operating lever or "thumb" of the terminal device and causes one finger of
the hook to move away from the other stationary finger (Fig 6B-2.,A). When cable tension is
relaxed, the movable finger closes on the stationary finger (Fig 6B-2.,B). The force of
prehension is, in this particular case, determined by the number of rubber bands located at
the bases of the hook fingers. As a general rule each rubber band produces approximately
0.45 kg (1 lb) of prehensile force between the hook fingers. You can help expand the
For most of its length the control cable is encased in a flexible stainless steel housing (Fig tax-deductible contribution.
6B-3.). At its upper end, the housing through which the control cable passes is attached to
the triceps pad of the prosthesis by a fixture called a "crossbar assembly." A base plate and
retainer serve to anchor the distal end of the cable housing at approximately the midforearm
level of the prosthesis.
The cable housing is an integral part of the transradial single-control system. In effect, the
housing maintains a constant length of the control cable regardless of the angular attitude of
the anatomic elbow joint. The amount of body motion used to operate the terminal device
remains essentially the same with the elbow flexed to 135 degrees or with the elbow
completely extended (Fig 6B-4.).
STANDARD TRANSRADIAL HARNESS

The standard harness for the unilateral adult transradial amputee is composed of 2.5-cm (l-
in.)-wide Dacron webbing. The webbing is arranged to form a horizontally oriented figure of 8
(Fig 6B-5.).
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.).
HEAVY-DUTY TRANSRADIAL HARNESS

A major disadvantage of the standard figure-of-8 harness for transradial amputees relates to
the axilla loop. The axillary portion of the loop should always be padded and worn on top of
an undergarment. Even so, whenever significant tension is applied to the anterior support and
control attachment straps, the tension drives the loop vertically upward into the axilla on the
nonamputated side. Over a period of time, excessive pressure in the axillary area may cause
skin irritation and, in extreme cases, produce neurotrophic changes from brachial plexus
pressure. When it is anticipated that the transradial amputee will engage in very strenuous
work activities, particularly the repeated lifting of heavy objects, it is recommended that a
nonstandard transradial harness system be considered.
The nonstandard transradial harness is generally referred to as a "heavy-duty" or "shoulder-

saddle" harness. With the heavy-duty harness, tension loading on the prosthesis is distributed
over the shoulder on the amputated side rather than being transmitted to the axilla on the
nonamputated side. This redistribution of loading is accomplished by fitting a fairly wide,
leather shoulder saddle on the amputated side. Two support straps are extended from the
posterior portion of the shoulder saddle through D-rings located on the medial and lateral
surfaces of the triceps pad and terminate on the anterior surface of the saddle. The shoulder
saddle is anchored in place by the use of a chest strap. Since the control attachment strap is
located in essentially the same place as in the standard harness, the midscapular level, the
amputee uses glenohumeral flexion and/or scapular abduction for terminal device operation
(Fig 6B-13. and Fig 6B-14.).
BILATERAL TRANSRADIAL HARNESS

The harness pattern for the bilateral transradial amputee differs only slightly from the
previously described standard transradial harness. Viewed from the rear, the control
attachment strap for operation of the right terminal device extends obliquely upward across
the back and terminates as the anterior support strap for the left prosthesis (Fig 6B-15.).
Likewise, the control attachment strap for operation of the left terminal device becomes the
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.
TRANSRADIAL HARNESS MODIFICATIONS

Step-up hinges used with a split socket may be used for a short transradial stump to provide
a 2:1 ratio of elbow flexion to stump motion but require the amputee to use approximately
twice as much force to flex the prosthetic forearm. Since split sockets are used only at very
short transradial levels of amputation, the extra force requirement may cause considerable
discomfort on the volar or radial surfaces of the remaining portion of the amputee's forearm.
In such instances, a relatively simple control system modification may be used to minimize
discomfort and facilitate elbow flexion.
The modification consists of splitting the cable housing into proximal and distal segments
similar to those used for the above-elbow (transhumeral) prosthesis. The proximal piece of
housing is attached to the triceps pad and the distal piece to the prosthetic forearm. The
control cable is now exposed as it passes anterior to the elbow joint. Tension applied to the
control cable by glenohumeral flexion on the amputated side assists in elbow flexion (Fig 6B-
16.).
In selected instances the unilateral transradial amputee can be fit with a socket, which
obviates the need for the suspensory function of a harness. Such self-suspending prostheses
are held on the residual limb by the intimacy of the socket fit proximal to the olecranon and
humeral epicondyles and in the antecubital fossa. Since these fittings eliminate the need for a
triceps pad and anterior support strap, the harness consists of a simple axilla loop around the
shoulder on the nonamputated side. Extending obliquely downward across the amputee's
back, the control attachment strap runs from the axilla loop to the terminal device control
cable. As in the case of the standard harness, shoulder flexion and/or scapular abduction on
the amputated side are the control motions for terminal device operation (Fig 6B-17.). The
disadvantage of this type of harnessing is that long-sleeved clothing is difficult to wear.
MECHANICS OF THE TRANSHUMERAL CONTROL SYSTEM

Transhumeral prostheses are usually operated by two distinctly separate control cables (Fig
6B-18.). One cable serves both to flex the prosthetic elbow joint and to operate the terminal
device. A second cable permits the amputee to lock and unlock the prosthetic elbow.
Elbow Flexion/Terminal Device Control Cable

The housing through which the elbow flexion/terminal device cable passes is split into two
separate parts (Fig 6B-19.). The proximal portion of the split housing is attached to the
posterior surface of the humeral section of the prosthesis. The distal portion of the split
housing is fixed to the prosthetic forearm by a device called an "elbow flexion attachment."
The elbow flexion/terminal device control cable originates at the control attachment strap of
the harness (Fig 6B-19, point C). Passing through the proximal portion of the split housing,
the control cable is exposed anterior to the mechanical elbow axis (Fig 6B-19., point D). The
elbow flexion/terminal device control cable continues through the distal portion of the split
housing and terminates with its attachment at the terminal device (Fig 6B-19., point E). Since
the housing is in two separate pieces and the control cable passes in front of the elbow axis,
tension applied to the cable causes the prosthetic elbow to flex. The flexion is limited to the
gap between the two cable housings.
The ease with which the amputee can operate the elbow unit and terminal device depends, to
a considerable extent, on the location of the elbow flexion attachment. Greater force and less
cable excursion are required where the elbow flexion attachment is closest to the elbow axis.
Conversely, a more distal placement of the attachment requires less force but greater cable
excursion.
Generally, the longer the residual limb, the further the elbow flexion attachment may be
placed from the elbow axis. Higher transhumeral levels of amputation require a more proximal
placement of the attachment to minimize the excursion required.
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.).
Elbow Lock Control Cable

The proximal end of the elbow lock control cable originates at the anterior suspension strap
(Fig 6B-21.). Passing down the anteromedial surface of the humeral section of the
prosthesis, the distal end of the cable engages the elbow locking mechanism. The elbow lock
works on an alternator principle: pull and release to lock, pull and release to unlock. An
excursion of 1.3 cm (½ in.) and a force of approximately 0.9 kg (2 lb) are necessary to cycle
the elbow unit.
In summary, the operating sequence of the two cable systems used with most transhumeral
prostheses is as follows: (1) tension applied to the elbow flexion/terminal device control cable
causes the elbow to flex; (2) when the desired angle of elbow flexion is achieved, the rapid
sequential application and release of tension on the elbow lock control cable locks the elbow;
and (3) with the elbow locked, the reapplication of tension on the elbow flexion/terminal
device control cable permits operation of the terminal device (Fig 6B-22.).
STANDARD TRANSHUMERAL HARNESS

Full operation of the terminal device of a transradial prosthesis requires only 5 cm (2 in.) of
cable excursion. More than twice that amount of excursion is required for full elbow and
terminal device operation of a trans-humeral prosthesis. Consequently, much greater attention
must be paid to the details of fitting the trans-humeral harness. Precision in the location of
the harness and control system components is essential for achieving satisfactory comfort
and function.
Like the standard transradial harness, the transhumeral harness consists of a system of
interconnected Dac-ron and elastic straps laid up in a figure of 8 (see Fig 6B-21). The
common elements of the standard trans-humeral harness are the axilla loop, anterior support
strap, lateral support strap, control attachment strap, and elbow lock control strap.
The axilla loop acts as the fixed anchor from which other harness components originate.
Some of the straps originating at the axilla loop serve to suspend the prosthesis on the
residual limb, while others provide the amputee with volitional control of the prosthetic
components.
The anterior support strap, sometimes referred to as the elastic suspensor, originates at the
axilla loop (see Fig 6B-21., left). Passing over the shoulder on the amputated side, the strap
continues down the anteromedial surface of the humeral section of the prosthesis. The
anterior support strap terminates with its attachment on the anterior surface of the prosthetic
socket slightly proximal to the mechanical elbow joint (see Fig 6B-21, right). When viewed
from the front, it should be noted that the distal two thirds of the anterior support strap
consists of elastic rather than Dacron webbing (see Fig 6B-21, left).
The anterior support strap serves several functions in the transhumeral harness systems.
Anchored to the axilla loop posteriorly and to the humeral section anteriorly, this strap helps
to suspend the prosthesis against axial loading. However, since the anterodistal two thirds of
the strap consists of elastic webbing, suspensory function is obviously limited.
A second function of the anterior support strap is to help prevent rotation of the prosthetic
socket on the residual limb during prosthetic usage. The transhumeral amputee uses
glenohumeral flexion on the amputated side to flex the prosthetic elbow and/or operate the
terminal device. Since the proximal control cable housing is attached on the posterolateral
surface of the humeral section of the prosthesis, glenohumeral flexion tends to cause the
socket to externally rotate on the residual limb. The anterior support strap running downward
mediolaterally resists external rotation of the socket.
As a key element of the entire harness, the axilla loop should encircle and fit the shoulder on
the nonampu-tated side as securely as possible. A small, snug axilla loop, one that does not
compromise amputee comfort to an excessive degree, provides the most positive prosthetic
suspension and control. To maintain a fairly snug axilla loop, the posterior intersection of the
harness straps should be positioned slightly toward the nonam-putated side of the body (Fig
6B-23.).
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 (4½ 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 (½ in.),
the body motion is somewhat complex. The amputee applies tension to the elbow lock
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.
SHOULDER DISARTICULATION HARNESS

At the shoulder disarticulation level of amputation the absence of glenohumeral flexion as a
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 (l½-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 (2¼ in.) of chest
expansion produces the 11.3 cm (4½ 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 6B-
34.). 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
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.
6C: Components for Adult Externally Powered Systems | O&P Virtual Library
Search
GO
Upper-Limb Prosthetics: Components for Adult Reproduced with

Externally Powered Systems permission from
Bowker HK,
Michael JW (eds):
Craig W. Heckathorne, M.S.E.E. Atlas of Limb
Prosthetics:
During the last decade, externally powered components have been used with increasing Surgical, Prosthetic, and
frequency in upper-limb fittings. There is also evidence that the percentage of persons Rehabilitation Principles.
continuing to use prostheses having these components has increased. Many factors have
been suggested as contributing to the increase in clinical utilization of electric-powered 1992, reprinted 2002.
components, but four factors stand out as contributing to the increase in the numbers of
successful implementations, as measured by continued use of a prosthesis: Much of the material in this text
Technological advances in actuators, materials, and controllers in Atlas of Amputations and Limb
Conceptual advances leading to designs with improved performance characteristics
The accumulation of a body of experience guiding successive clinical fittings (retitled third edition of Atlas of
The willingness of a diverse community of prosthe-tists, engineers, therapists, Limb Deficiencies), ©American
designers, physicians, social workers, and exemplary users to share their knowledge Academy or Orthopedic Surgeons.
and experience Click for more information about
this text.
Community knowledge is fundamental. It is the pool into which individual accomplishments
flow and from which the art and science of prosthetics, as a field of endeavor, is nourished. Funding for digitization
This section on electric-powered components is drawn from that pool of knowledge and thus of the Atlas of Limb
represents the contributions of many individuals. It is, of necessity, a distillation intended to Prosthetics was
acquaint the reader with the topic. The content has been selected to emphasize design provided by the
aspects influencing the performance and use of these components and is limited to Northern Plains Chapter of the
components intended for adults, commercially produced, and readily available in North American Academy of Orthotists &
Prosthetists
America.
The text is divided into four sections: prehension mechanisms, wrist mechanisms,
enhancements to body-powered elbows, and elbow mechanisms. (There are no commercially
available electric-powered shoulder components.) Each section begins with a general
description of the components to be covered. Common characteristics and features are
described, and where data are available, comparisons are drawn to the physiologic You can help expand the
counterpart for which the device is intended as a replacement. Following the general O&P Virtual Library with a
description are detailed subsections describing each of the components available within the
category. The component sections include construction and mechanical specifications for
each device, performance characteristics, and control systems offered by the manufacturer of
the device, as well as compatible control systems offered by other manufacturers.
Writing on this topic is hampered by the absence of a standardized terminology. The difficulty
is most evident in the variety of descriptive names given to the control systems, even among
those that are essentially similar in character. Further confusion results when the same word
is used in different contexts, such as the term "proportional." One manufacturer uses the term
in the context of "time proportional," to indicate that the response of the device to the control
signal is proportional to the duration of time the signal is applied. Other manufacturers use the
same term to denote that the action of the device is proportionally determined by the
amplitude of the control signal. Both uses are technically accurate, but the controllers differ
significantly in the capability they offer to regulate the action of the device.
An effort has been made throughout the discussions of control options to clarify differences
and similarities. In addition, a common control terminology is used in association with the
name assigned by the manufacturer to identify the number of distinct control sources and
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

appearance. This preferential effort grew out of two broad, mutually reinforcing
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
acceptance. In addition, the broad contact surfaces of the electric hand and frictional
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
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
characteristics not constrained by fidelity to a handlike shape. Use of body-powered
prostheses with hook-type prehensors is frequently cited in association with use of electric-
powered 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.
General Characteristics of Commercial Electric Prehensors

Otto Bock Orthopedic Industry, Inc., and Hugh Steeper (Roehampton, England), Limited, both
manufacture adult prehension devices with a handlike shape and devices not shaped like the
hand. Hosmer Dor-rance Corporation also manufactures an electric prehensor that does not
have a handlike shape. Specific characteristics of these devices are presented in Table 6C-1
for handlike devices and in Table 6C-2 for devices that do not have a handlike appearance.
Both the Bock and Steeper handlike prehensors are configured for palmar prehension-the
opposition of the distal palmar pad of the thumb with the distal palmar pads of the index and
middle fingers-and only the thumb and these two fingers are driven. Of the prehension
patterns identified by Schlesinger, Keller et al. determined that palmar prehension
predominated in the holding of objects for use. The persistence of this configuration in
prosthetic hand designs and its general acceptance over the years supports their observation.
To achieve the palmar prehension pattern, the fingers of both types of electric hands are
fixed in slight flexion at positions approximating the interphalangeal joints. The resulting finger
shape also creates a concave inner prehension surface that is useful for cylindrical grasp.
Additionally the frictional properties of the entire surface of the cosmetic glove of the electric
hand provides for fixation and stabilization of objects against surfaces or against the body.
The prehension patterns of prehensors that do not have a handlike shape (those in Table
6C-2) are considered in the separate sections describing each type of device.
Table 6C-1 and Table 6C-2 list a variety of mechanical characteristics. Of these, the
maximum prehension force, the maximum width of opening, and the speed of movement of
the fingers merit some discussion because of their impact on the prehensile function of the
devices.
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
grasp. More recent studies of larger populations have produced slightly different means
but generally support the UCLA results.
Studies of forces applied in holding objects with the physiologic hand using palmar
prehension and opposition of the thumb and index finger have shown that the static
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
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

newtons (15 lbf) were necessary to carry out a variety of activities of daily living. Peizer et
al., reasoning that higher forces could only improve the prehensile utility of a prosthetic
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
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.
Otto Bock System Electric Hands (Adult Size)

The Otto Bock System Electric Hand is the most common type of electric hand prehensor
used in North America. It is available in three adult sizes denoted by the circumferential
dimension (in inches) at the knuckles. The 7 1/4 electric hand is suggested for adult females
and juvenile males. The 7 3/4 size and 8 size hands are designated as being for adult males.
The mechanism for all three hand prehensors, shown in Fig 6C-1.,B, is the same regardless
of size. Different sizes are determined by the dimensions of a plastic hand-shaped form that
is pulled over the skeletal mechanism, as in Fig 6C-1.,A. Gender differences and cosmetic
coloration are provided by a separate glove made of PVC that is pulled over the plastic form.
As described by Nader, each hand prehensor is therefore composed of three separate
parts: the inner mechanism, a handlike form, and a cosmetic glove.
The hand mechanism (shown in Fig 6C-1.,B) includes the electric motor (mounted in line with
the long axis of the arm), an automatic gear transmission, a support structure, and the finger
assembly. Only the thumb and index and middle fingers are part of the mechanism and are
oriented to provide palmar prehension. The motor drives the fingers (as one unit) and the
thumb simultaneously in a plane perpendicular to the axis of the finger joints. The plastic form
added over the mechanism incorporates the smaller two fingers. A wire frame within the form
links these fingers to the middle finger so that they move somewhat in concert with the
mechanized fingers.
When the fingers are in motion (i.e., not gripping an object), the transmission is in high gear,
which allows the fingers and thumb to move at the speed noted in Table 6C-1. When an
object is grasped, the transmission remains in high gear until the prehension force reaches
15 newtons (3.4 lbf), at which point it will automatically downshift to drive the fingers slower
but at higher torque to a maximum prehension force of about 80 newtons (18 lbf). Without
this automatic transmission, it would not be possible to achieve both the speed and maximum
prehension force of the Bock hand with a single-motor design. In general, single-motor drive
units are limited by a trade-off between speed and torque (the higher the speed, the lower
the torque). The elegance of the Bock transmission is not without compromise. When an
object is gripped tightly, it is not possible to release it immediately because the transmission
must reduce the prehension force while in low gear until it reaches the lower limit, at which
point it can shift to high gear and open the fingers.
The drive mechanism also includes a back-lock feature to maintain the prehension force
when the motor is off and to prevent the fingers from opening. It is, however, possible to
override the effect of the back lock, if necessary, by levering the hand to create very high
forces at the fingertips and exceed the torque setting of a slip clutch. Operation of the slip
clutch does not damage the mechanism, and the fingers can be closed manually, for
appearance, until the control problem is corrected.
Although the back lock obviates the need to power the motor to maintain the prehension
force, it is still possible to drive certain System Electric Hands in stall. Users of these
particular prehensors must be advised to avoid this condition to conserve battery power. Bock
has recently introduced an "energy-saving" design (in addition to their existing models) that
senses the motor current and automatically cuts off power to the motor when a stall condition
exists.
As previously mentioned, the primary prehension pattern of the System Electric Hand is
palmar prehension. The mechanical arrangement of the thumb and fingers also provides
cylindrical grasp for objects of moderate dimensions. For very wide objects (near the limit of
the hand opening), the fingers are not able to encircle the object to secure it, but the plastic
of the cosmetic glove provides friction that maintains a reasonably effective grasp. The use of
a pliable hand form over the mechanism also improves the grasp, in general, because the
inner surfaces of the hand are able to accommodate to the shape of objects, thus giving many
points of contact between the prehension surfaces and the object being grasped.
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 two-
source, 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.
Steeper Electric Hands (Adult Size)

Two adult-sized Electric Hand prehensors are available from Hugh Steeper and are denoted
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, two-
function myoswitch controller using two of the Ampli-fier-Myoelectrodes. Alternatively, one
can configure a two-source, two-function hybrid controller by using one Amplifier-
Myoelectrode 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
adapter itself provides the second function automatically. This type of arrangement can be
used to provide voluntary opening with automatic closing (up to the maximum prehension
force) or voluntary closing with automatic opening (to full opening and activation of the limiting
microswitch in the prehensor). The second option is the One-Muscle Two-Threshold Control,
and as indicated by the name, it can be applied only if a myoelectric site is available. This
single-site, two-function controller produces a "closing" command when the myoelectric signal
crosses the lower of two thresholds and an "opening" command when the signal crosses the
higher threshold.
The University of New Brunswick (UNB) single-site, three-state (single-site, two-function)

controller can be used as an alternative to the Steeper single-site, two-function controller. The
UNB controller can be adjusted more specifically to the characteristics of an individual's
myoelectric control signal, a feature that may be helpful if the myosignal is marginal.
UNB also offers a two-site, two-function myoswitch controller compatible with the Steeper
Myoelectric Hands and a single-site, single-function myoswitch controller that provides
voluntary-opening control with automatic closing.
The second type of Electric Hand, the Steeper Servo Hand, offers a control method unique
among commercial electric components. With this controller, the opening of the hand
prehensor is determined by the degree to which a cable attached to a position transducer is
pulled. (Fig 6C-2.). The further the cable is pulled, the more the prehensor opens, and the
more the cable is slackened (and retracted by a spring in the transducer), the more the
prehensor closes. The opening of the prehensor is therefore proportional to the displacement
of the cable attached to the transducer, with full opening corresponding to about 9 mm (3/8
in.) of cable displacement. When the fingers close on an object, the force automatically
increases to a maximum of 25 newtons (5.7 lbf) before the current sensor cuts off the motor.
It is important to note that although a cable is used to position the fingers, this control
technique is not like an electric-power-assisted version of a body-powered voluntary-opening
prehensor. In the case of a body-powered prehensor, the user has a direct sense through the
control cable of not only the position of the prehensor's finger but also of its speed of
movement and the force (inversely) exerted by it. With the Steeper servo hand, the user is
linked by cable only to the transducer, which is remote from the prehensor and linked
electrically to it. Therefore, the user directly perceives only the action of the transducer and
force exerted on it, and not the action of the fingers and forces exerted by them.
Otto Bock System Electric Greifer

The System Electric Greifer, shown in Fig 6C-3., was developed by Otto Bock as an
alternative to the System Electric Hand in work situations that require higher prehension force
or that might damage the mechanism of the hand prehensor or damage or discolor the
cosmetic glove. It can be easily interchanged for the hand prehensor when used with the
Bock quick-disconnect wrist unit. The Greifer is available in one size and can be either a right
or left unit. The mechanism is encased in a multiple-piece shell made of a durable hard
plastic and is available with or without rubber pads lining the prehension surfaces of the
fingers.
The Greifer's two fingers are broad surfaced and arranged to move symmetrically in
opposition. They are articulated so that as they move, the distal prehension surfaces remain
parallel to one another. The shape and articulation of the fingers provide lateral prehension
and, for moderate-sized objects, cylindrical prehension. Adjustable tips, with or without rubber
lining, provide tip prehension for handling smaller objects. The tips can be replaced with
optional blanks machined for specific applications. (A screwdriver is required to adjust the
position of the tips or to interchange them.)
In comparison to the System Electric Hand, the Greifer is longer by 3 cm (1.25 in.) and
slightly heavier and has about the same maximum width of finger opening. In terms of
mechanical performance, the Greifer is slightly faster and can develop significantly higher
prehension force, 50% or 75% greater depending on the Greifer model.
The Greifer also incorporates an automatic transmission to enable the fingers to move
relatively fast through space but to exert high forces when closed on an object. When the
Greifer first closes on an object, it will grip up to a maximum force of 15 newtons (3.4 lbf),
after which the transmission will downshift for gripping at higher forces. The short delay
before the transmission downshifts enables users to grasp lighter and more delicate objects at
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 two-
source proportional controllers from Motion Control, Hosmer Dorrance, and Universal Artificial
Limb Co. Therefore, an interchangeable Greifer and System Electric Hand can be used with
any one of these controllers.
Hosmer NU-VA Synergetic Prehensor

The NU-VA Synergetic Prehensor, shown in Fig 6C-3., was designed as an alternative to a
hand prehensor and with speed and force characteristics approaching those of the physiologic
hand. It was developed by the Prosthetics Research Laboratory of Northwestern University
with the support of the Department of Veteran Affairs and is manufactured by Hosmer
Dorrance Corporation. The performance objectives of the prehensor are achieved with a two-
motor design utilizing the concept of synergy.
Separate motors and gear trains are used to drive the two opposing fingers such that one
finger is driven at high speed but low torque and the other finger is driven at low speed but
high torque. Therefore, in the act of grasping an object, the prehensor's fast finger can quickly
close on the object and the high torque finger apply the force, as necessary, to secure the
object. The synergetic design also permits immediate release of objects when an "open"
signal is generated because the high torque and high-speed fingers are driven
simultaneously. In keeping with the design objectives, the maximum speed of movement of
the fast finger of the Synergetic Prehensor is approximately that of the average speed of
functional physiologic finger movements, and the maximum prehension force applied at the tip
of the high-torque finger is approximately that measured for palmar prehension of adult
males.
The mechanism and support structure of the prehensor are encased in a two-piece plastic
shell, and the fingers of the Synergetic Prehensor are the same removable hook-shaped
fingers as developed for the body-powered APRL (Army Prosthetics Research Laboratory)
Voluntary-Closing Hook. The hook-shaped fingers provide powered lateral and tip prehension
and passive hook prehension. For objects of moderate diameter with respect to the size of
the prehensor, the lyre-shaped contour of the opening between the fingers provides for
cylindrical grasp. The fingers are lined with neoprene to achieve higher contact friction during
grasping. Neoprene pads are also arrayed on the case to facilitate activities in which the
prehensor body is used to hold objects in place against other objects or to exert pushing
forces on objects.
The drive train of the fast finger incorporates a back-lock mechanism that prevents the high-
torque finger from pushing the faster, lower-torque finger back as objects are grasped. The
back-lock, as with other prehensor designs, also enables objects to be held without continued
operation of the motors. Should the prehensor not respond to an "open" signal when closed
on an object, the fingers can be opened by a safety breakaway when external forces on the
fingers exceed 133 newtons (30 lbf). This mechanism can be manually reset, and its
operation does not damage the prehensor.
In addition to near-physiologic speed and force, the synergetic design is also energy efficient.
Once the fast finger closes on an object and ceases to move, its motor is electronically cut
off; therefore it does not run in stall during the application of force by the high-torque finger.
To close on an object and grasp it with a force (at the fingertips) of 75 newtons (17 lbf), the
prehensor draws an average of 138 mA or about 1.2 W. With a 100-mAh (milliampere
hour), rechargeable 9-V transistor-type battery, the prehensor can perform approximately
1,300 cycles of opening and then closing to 75 newtons prehension force on a single battery
charge. Therefore, it is possible to use these relatively small readily available batteries for a
full days' use of the Synergetic Prehensor.
If the Synergetic Prehensor is used in association with an Otto Bock System Electric Hand, it
is not advisable to use the 9-V transistor-type battery because of the current draw of the
System Electric Hand. The Otto Bock battery could be used for this arrangement; however, its
lower voltage will reduce the speed and force characteristics of the Synergetic Prehensor. For
fittings of this type, it is recommended that an array of six or seven rechargeable AA batteries
be used to provide the voltage requirements of the Synergetic Prehensor and the current
requirements of the System Electric Hand.
Control of the Synergetic Prehensor is best achieved with a proportional system because of
the speed of response of the device. A two-site, two-function proportional myoelectric
controller is available from Hosmer Dorrance. This controller differs somewhat from other
proportional myoelectric controllers in that the myoelectric signal is not smoothed by filtering
but is used to generate full-voltage pulses that increase in width and number in proportion to
the amplitude of the myoelectric signal. By processing the muscle signal in this manner
and using the mechanical smoothing inherent in the drive system, the time delay associated
with electronic filtering is eliminated, and the stiction of the mechanism is overcome. These
two factors contribute to the almost instantaneous response of the Synergetic Prehensor and
the ability to have good control even at low signal levels.
The two-source, two-function variable-speed controller from Universal Artificial Limb Co. can
also be used with the Synergetic Prehensor. As noted, this controller can accept signals from
myoelectrodes or from position or force transducers. The characteristics of the method of
signal processing may result in some difference in the response time of the prehensor.
Steeper Powered Gripper

As has been the driving force for the design of all non-hand prehensors, the Powered Gripper
was developed by Hugh Steeper, Ltd., to address various functional deficiencies associated
with existing hand prehensors, constrained by their handlike shape and appearance.
Interchangeable with the Steeper Myo-Electric Hand, the Powered Gripper (Fig 6C-3.)
weighs approximately 25% less, moves with about twice the finger speed, and generates
70% higher maximum prehension force than does the adult Electric Hand. The improved
performance was achieved by the synergetic action of separate drive systems and a different
geometric arrangement for each of the two fingers.
The Powered Gripper uses the concept of one finger driven at high speed but low torque and
the other at high torque but low speed, similar to that used in the design of the Synergetic
Prehensor; however, the effect is produced differently. In the Synergetic Prehensor, the two
fingers are pivoted about the same axis but are driven with greatly different gear ratios to
achieve their individual speed/torque characteristics. With the Steeper Gripper, the fast finger
has a gear ratio similar to that of the gear ratio of the slow finger, but its axis of movement is
considerably closer to its drive screw than is the axis of the slow finger. The effect of the
different pivot locations is a fast finger that moves over eight times faster than the slower
finger but a slower finger that can produce four times the force of the fast finger. In
comparison to physiologic performance, the fast finger of the Powered Gripper moves at
about 70% the average velocity measured for functional finger movements and generates a
prehension force about 63% the maximum palmar prehension force of adult males.
The body and fingers of the Powered Gripper are metal castings. The fingers are contoured
to provide passive hook prehension and have flattened opposing surfaces for powered lateral
and tip prehension. The opening between the fingers is also contoured to accommodate
cylindrical objects. The prehension force of the Powered Gripper is made more effective by
the use of relatively soft frictional rubber pads to line the fingers. The pads are grooved over
a portion of their surfaces, and the fingers are hollowed beneath the material. The grooves
and hollowing allow the pads to deform and mold to the shapes of held objects, which
distributes the prehension force over a broader contact area.
The mechanism of the powered griper includes a drive screw and nut assembly as the last
stage in actuating the fingers. As with the Steeper Electric Hands, this assembly cannot be
back-driven and therefore provides a back-lock feature keeping the fingers in place when
unpowered. The drive screws for both fingers are connected to plastic wheels on the outside
of the pre-hensor's case. These wheels can be turned manually to open the fingers in the
event that the prehensor does not respond to an "open" command.
The same control schemes as used for the Steeper Myoelectric Hand are compatible with the
Powered Gripper. (There is no Servo version of the Gripper.) In closing, the fingers operate
sequentially. The fast finger first moves to establish contact with the object to be grasped and,
at a force of 15 newtons (3.4 lbf), stalls. A 600-ms delay follows before the slow finger
becomes active. Since the Steeper controller does not provide proportional control of motion,
the delay gives the user time to cease the closing signal if a low-force grasp is wanted. If the
closing signal is not interrupted during the 600-ms delay, the slow finger is activated,
increasing the prehension force to 60 n ewtons (13.5 lbf), at which point the slow finger stalls.
It is important to note that the Steeper electronics prevents the motors from running in a
stalled condition. Therefore, only one motor is active at a time, and once the slow finger
stalls, no additional motor current is drawn while an object is held. The opening sequence is
the reverse, with the slow finger opening first (if it had been activated in closing), followed,
without a delay, by the opening of the fast finger.
As mentioned, the control schemes for the Steeper Powered Gripper are switchlike, and the
user cannot regulate the speed at which the fast finger moves or the rate at which the slow
finger increases the force. This arrangement is compatible with the Otto Bock "digital two site"
(two-site, two-function) myoswitch control and the Otto Bock electromechanical switch
controllers. Versions of the Gripper are made with an Otto Bock quick-disconnect wrist for
interchange with Otto Bock System Electric Hands using either of these control schemes.
NY-Hosmer Prehension Actuator

The NY-Hosmer Prehension Actuator (PA) is not of itself a prehension device and for that
reason is not listed in Table 6C-2. The PA, shown in Fig 6C-4., is a motorized winch that
provides electric-powered operation of the cable-actuated Hosmer Dorrance voluntary-
opening split hooks. It was originally designed by William Lembeck of New York University
as a complete forearm setup for use with a body-powered or electric-powered Hosmer
Dorrance elbow. In that configuration, the mechanism occupies the distal 10.8 cm (4.25 in.) of
the forearm with a rotation joint proximal to the mechanism. The forearm segment proximal to
the rotation joint contains the forearm saddle assembly for the elbow and, because of the
saddle's dimensions, has a minimum length from the elbow axis of 9.5 cm (3.75 in.). The
complete forearm setup has a minimum length from the elbow axis to the distal face of the
wrist of 20.3 cm (8.0 in.). Longer forearms are provided by lengthening the distal forearm
segment, thus keeping the weight of the mechanism (about 218 g; 0.48 lb) as proximal as
possible. Rotation to orient the split hook is done proximal to the PA in order to maintain an
efficient alignment between the cable attachment post of the split hook and the cable leading
from the actuator mechanism.
The PA is typically powered by a 6-V battery pack and, at that voltage, can open a split hook
having four or five rubber bands. The time to open the hook to its limit is dependent on the
number of bands used with the hook but is on the order of one second.
Operation of the PA is with a single-source controller. Hosmer offers a single-site, single-

function myos-witch controller and a variety of single-function electromechanical switches. A
three-function cable pull switch is also available for operation of the PA and the NY-Hosmer
electric elbow by using one control action. (This is the configuration shown in Fig 6C-4.). The
first two functions of the switch are for the elbow; the third is for the PA.
Controlled activation of the PA causes it to pull the split hook open. If the control signal stops
before the PA pulls the hook to full opening, the hook is closed by the rubber bands. If the
control signal is maintained after the hook reaches full opening, the PA is electrically cut off
(so that it does not draw motor current), and the motor is dynamically braked. The dynamic
braking, which is maintained as long as the control signal is present, allows the split hook to
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 self-
suspending socket and does provide some advantage over fitting of an electric prehensor by
shifting most of the weight proximal to the wrist.
Commentary on Electric Prehensors

The interplay of psychological and social aspects associated with the human hand and the
need for prehension function and independent capability are complex. Generalizations
favoring one type of prehensor over any other are limiting, and there is little consensus
among users of prosthetic prehensors as to which device is best suited as a replacement for
the physiologic hand. Even the similarity to the anatomic hand that is possible with the
present-day Electric Handlike prehensors is not universally desired. Some persons,
particularly those with bilateral amputations, are sensitive to the prehension and performance
advantages of prehensors not having a handlike shape. Other persons, finding the apparent
cosmesis of Electric Hands insufficient and being repelled by it, prefer a device that has a
form "truer" to its gripping function. Until a more versatile anthropomorphic prehension device
is developed, the need for a variety of options will remain.
WRIST MECHANISMS
Studies of persons using their hands to perform various common activities and occupational
tasks have shown significant utilization of forearm rotation and wrist motions in the
performance of these actions. Most of the activities studied revealed a range of motion
through which the joint moved during the course of an activity as opposed to a variety of
fixed positions across the activities. In studies having many different activities, the total range
of motion spanned was found to be approximately 100 degrees for forearm rotation, 80
degrees for wrist flexion and extension, and 60 degrees for wrist radial and ulnar deviation.
For the specific task of eating, the total range of motion was about 100 degrees for forearm
rotation, 30 degrees for wrist flexion and extension, and 30 degrees for radial and ulnar
deviation of the wrist.
Except for the Otto Bock Electric Wrist Rotator, all commercial prosthetic wrist components
are purely mechanical. There are many factors that make development of electric-powered
wrist components particularly difficult. From a component design viewpoint, there are the
constraints of size and weight imposed by the location of the joint. The device must fit within
a cylinder of about 5 cm (2 in.) in diameter and occupy as little length as possible so as to
accommodate (ideally) a variety of residual-limb lengths.
The component must also be relatively lightweight to minimize counterforces exerted on the
residual limb in the case of a transradial fitting or minimize the counter-torque that would
reduce the lift capacity of a prosthetic elbow in higher-level fittings. And although lightweight,
the structure of the component must be robust enough to withstand the forces exerted on the
prehensor and transferred back to the residual limb through the wrist joint. Also a
consideration with respect to weight is the need for relatively low power consumption to
eliminate an additional battery if used in conjunction with other electric components.
With regard to function, there is the question of what joint motions should be provided. The
anatomic forearm and wrist joints can be approximated by a triaxial joint with the axes of
rotation, flexion, and deviation (roll, pitch, and yaw) having a point of intersection near the
base of the prehensor. All three motions have been shown to contribute to functional
activities.
There is the issue of control. At least one additional control source would be needed for each
powered joint of wrist motion, unless the control system operates in a sequential manner.
Even sequential control would require at least two control sources-one for selection and one
for movement control.
Finally, the performance of the component must be exceptionally better than the alternatives
for the user to be attracted to its operation. For the person with a unilateral amputation, the
primary alternative is the intact limb, which can be preferentially used for activities involving
significant forearm and wrist motion. On the prosthetic side, one could use compensatory
motions of proximal physiologic joints and have manually positioned mechanical wrist
components that would offer adjustable fixed orientations of the prehensor. Although
operation of these components typically involves the physiologic hand, the operation is
relatively quick and straightforward. (The fact that this technique is so widespread
underscores the remarkable qualities of the physiologic wrist. Persons using this technique do
so without giving much thought to what they are doing with their intact wrist and hand while
using them to position the prosthetic wrist.)
For persons with bilateral arm amputations, there are alternative methods for actuating and
positioning mechanical wrist components that do not necessarily require the contralateral
limb. However, these components cannot, in general, be operated so as to perform work such
as turning a handle. Neither can they typically be adjusted dynamically during a motion, such
as adjusting the wrist attitude while raising a utensil to one's mouth. Although these
deficiencies have inspired many designers to attempt a more versatile electric-powered wrist,
advances have been slow to come, and no multiaxis components have been realized
commercially.
Otto Bock Electric Wrist Rotator

The Electric Wrist Rotator developed by Otto Bock, shown in Fig 6C-5., addresses many of
the difficulties outlined in the preceding section to provide the functional analogue of forearm
rotation. The drive unit is a single motor with a gear reducer having a rotation axis in line
with the longitudinal axis of the forearm. It is structurally supported within the lamination collar
of the Bock quick-disconnect wrist and can fit any of the three sizes of wrist lamination
collars, which have diameters of 4.0, 4.5, and 5.0 cm (1.6, 1.8, and 2.0 in.). Its length is 6.7
cm (2.6 in.) from the distal edge of the lamination collar to the proximal surface of the motor
housing.
The rotator is relatively lightweight at 96 g (0.21 lb), approximately 20% of the weight of a
Bock System Electric Hand. It is also relatively energy efficient and draws a no-load current of
150 mA. (The stall current is 700 mA.) The power requirements are such that it is feasible to
operate a Bock System Electric Hand, or Greifer, and the Electric Rotator from a single 6-V
Bock battery. However, the ability to get through a full day's use on one battery will vary
according to the degree to which the devices are utilized.
The rotator mechanism is also protected from external forces through its attachment to the
wrist lamination collar. Side forces and axial forces exerted on the prehensor are transferred
to the lamination collar and prosthetic forearm rather than to the rotator mechanism.
Excessive torques on the prehensor will cause the ratchet of the prehensor's portion of the
quick-disconnect wrist to slip rather than back-drive the wrist mechanism.
The coaxial electrical coupling of the Bock quick-disconnect wrist allows the rotator to turn an
electric prehensor continuously in either direction. In general, however, the performance
characteristics of the rotator have been compromised to achieve the necessary size, weight,
and power characteristics. The rotator does not generate high torque and cannot be used for
work, e.g., turning valves or door handles, unless the resistance is minimal. The rotation is
primarily for preposi-tioning and changing the orientation of the prehensor prior to an action
or while the prehensor is holding a lightweight implement, such as a utensil with food or a
cup of liquid. The speed of response is also compromised. At a no-load speed of 8.33 rpm
(0.87 radians/sec or 50 degrees/sec), it is perceptibly slower than physiologic forearm
rotations. Physiologic forearm rotation can achieve time-averaged maximum velocities in
excess of 14 radians/sec (800 degrees/sec) for pronation and 20 radians/sec (1,150
degrees/sec) for supination.
Otto Bock provides two control schemes for the Electric Wrist Rotator: control by
electromechanical switches or myoswitch control in conjunction with a Bock electric
prehensor. The Bock two-function switches include a cable pull switch, a harness pull switch,
and a rocker switch. The myoswitch control, termed "four channel control", is a two-site, four-
function controller that operates both an electric prehensor and the wrist rotator. In this
system, one muscle site controls one function of the prehensor (e.g., closing) and one
function of the rotator (e.g., pronation) by using the magnitude and rate of contraction to
distinguish the component to be controlled. The second muscle site controls the other
function of each component, again using the magnitude and contraction rate to direct the
control to the appropriate component. Both muscles are needed to control each of the
components. As with all Bock control systems, the performance of the component is not
influenced by the amplitude of the myosignal once the component is selected. The rotator will
operate at a single speed.
Motion Control provides a two-site, four-function version of their proportional myoelectric

controller to operate both an electric prehensor and the electric wrist rotator. This system
channels the signals from both muscle sites to each component and uses cocon-traction of
the agonist-antagonist pair to switch from prehensor to rotator and vice versa. The approach
has the advantage, in comparison to the Bock two-site, four-function controller, of allowing
the user to regulate the action of either selected component in proportion to the amplitude of
the myosignal. In practice, the proportional control is of more obvious a benefit for operation
of the prehensor. The speed of the rotator is such that users appear to operate it near its
maximum even for small corrective actions.
The rotator can be independently controlled by the proportional two-site, two-function

myoelectric controller from Hosmer Dorrance. It can also be controlled with the two-source,
two-function "variable speed controller" from Universal Artificial Limb Co. As described in the
section on prehensors, this controller can accept input from myoelectrodes or from force or
position transducers.
Wrist Flexion Units

Although there are no commercial components that provide electric-powered wrist flexion, this
is an important function for the person with bilateral arm amputations and for some persons
with unilateral amputations. Therefore, it is useful to know how this function can be provided
in prosthetic fittings involving electric prehensors.
The Otto Bock System Electric Greifer is unique among commercial prehensors because it
incorporates a flexion joint within the prehensor. The joint is a manually positioned friction
joint that can be adjusted for more or less friction. The range of motion is plus and minus 45
degrees and occurs in a plane perpendicular to the prehension surfaces of the fingers.
For other electric prehensors, engineers and pros-thetists have devised a variety of
techniques for adapting commercially available mechanical flexion components for use with
electric prehensors. The Sierra Wrist Flexion Unit, the Hosmer Flexion-Friction Wrist, and the
United States Manufacturing Company (USMC) E-Z Flex Wrist have all been used in clinical
electric-powered fittings. Modifications to both the wrist component and the wrist coupling of
the prehensor may be required, depending on what specific components are being used
together. The Hosmer Universal Shoulder Joint, with appropriate-sized proximal and distal
lamination collars, has been adapted as a friction-type wrist flexion joint. In any of these
configurations, the important considerations are to provide a pathway for the electrical wires
to the prehensor and to limit, with a mechanical stop, any rotation joint crossed by the wires
so that the wires will not be damaged by unrestricted continuous rotation in one direction.
A configuration developed to use a flexion wrist unit with the Bock Electric Wrist Rotator in a
forearm setup used with a prosthetic elbow is shown in Fig 6C-6.. The forearm is
composed of two sections joined by a Bock quick-disconnect wrist. The proximal section
contains the wrist rotator, positioned as close to the elbow as possible without interfering with
the full flexion of the elbow. The distal section, essentially a hollow cylinder, incorporates a
modified Bock quick-disconnect adaptor at the proximal end to mate with the wrist rotator and
a flexion wrist unit at the distal end, which may require an adaptor to mate with a specific
prehensor. The rotator is electrically operated. The flexion unit is manually positioned.
Commentary on Wrist Components

The significant participation of forearm and wrist motions to provide fine orienting and
positioning of the human hand is well documented. The need for this capability in a prosthetic
limb is no less great. It is even possible that the prosthetic wrist takes on more significance in
the context of the total prosthesis. Prosthetic fingers cannot be repositioned within the
prehensor to accommodate orientation needs as changes in the position of physiologic fingers
can be made to complement the anatomic wrist position. And compensatory motions of
proximal physiologic joints may be restricted by the suspension of the prosthesis or the
harnessing for control actions. As one considers persons with bilateral amputations,
especially persons with amputation levels above the elbow, the need for assisted wrist
function, on at least one side, becomes even more demanding. The technological obstacles
and control problems are severe. However, the potential functional advantages of better wrist
components will likely continue to drive development efforts.
ENHANCEMENTS TO BODY-POWERED ELBOWS

Hugh Steeper, Limited, offers two optional electrical enhancements for its body-powered
mechanical elbows. The first is the Steeper Interlock System, which is an electromechanical
switch actuated by the locking mechanism of the elbow. The second is the Steeper Electric
Elbow Lock, which is a motorized lock for an otherwise body-powered elbow.
Steeper Interlock System

The Interlock System was developed to allow single-cable control of a mechanical elbow and
an electric-powered cable-actuated Steeper Servo Hand. In this configuration, the control
cable is routed from the control harness, through a forearm flexion attachment, and to a
termination on the position transducer (mounted distally in the forearm) that operates the
Servo Hand. When the elbow is locked, the elbow interlock switch is in the "on" state, and
pulling on the control cable operates the Servo Hand. When the elbow is unlocked, pulling on
the control cable both flexes the elbow and actuates the transducer for the Servo Hand.
However, the interlock switch within the elbow is in the "off state, and the Servo Hand is
prevented from responding to the transducer actuation. Therefore, pulling on the control cable
operates one or the other component depending on the state of the elbow lock.
While this arrangement is operationally similar to that of a body-powered elbow used with a
body-powered, voluntary-opening split hook, forces used to flex the Steeper elbow (with
interlock switch) do not alter the force of prehension of the Servo Hand. In a total body-
powered prosthesis, the force in the control cable that flexes the elbow is also transferred to
the split-hook prehensor and proportionally diminishes the prehension force exerted by the
rubber bands. As the elbow flexion force is increased because of the weight of an object
being actively lifted, a limit is eventually reached where the prehensor exerts no holding force.
In a prosthesis with the Steeper Interlock System, the Servo Hand is electrically disconnected
whenever the elbow is unlocked and free to move. The force of prehension remains constant
regardless of how much force is exerted on the control cable to flex the elbow.
The Steeper mechanical elbow and Interlock System can be used in combination with other
prehensors, such as the switch-controlled versions of the Bock System Electric Hand and
Greifer. In this configuration, a Bock Harness Pull Switch is sewn into the control strap (with a
shunt strap to protect the switch from high forces), and one of the battery leads for the Bock
prehensor is connected through the interlock switch. When the elbow is locked and the
interlock is in the "on" state, pulling on the harness extends the harness switch and operates
the prehensor. When the elbow is unlocked and the interlock is in the "off" state, the harness
switch extends during elbow flexion but has no effect on the prehensor.
It is important to note that the control configuration with the Steeper Interlock provides
sequential control of the elbow and prehensor. It is not possible to operate both devices in a
coordinated manner as is possible with independent-control hybrid configurations, such as a
body-powered elbow and myoelectrically controlled prehensor using biceps and triceps
muscles.
Steeper Electric Elbow Lock

The electric lock for the Steeper mechanical elbow is a straightforward alternative to the
body-actuated mechanical lock. Just as with the mechanical elbow lock, each operation of the
electric lock changes its state: from locked to unlocked or from unlocked to locked. The
electric lock, powered by a 6-V battery, is operated by an electromechanical switch or by a
single-site myo-switch control. Steeper offers a variety of switches, and any other
commercially available switch that provides a momentary switch closure can be used as well.
The variety of control arrangements possible with the electric lock is a major advantage for
persons who could benefit from a cable-actuated mechanical elbow but who have difficulty
producing the control motions or forces required by the mechanical lock.
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
degrees/sec. Therefore, one cannot expect to perform the same types of activities,
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 NY-
Hosmer 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
900 degrees/sec. Clearly the maximum speeds of adult electric elbows (see Table 6C-3)
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
degrees/sec/degrees x distance (degrees). For a movement over a 10-degree range, the
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
would appear that all of the electric elbows can approach functional physiologic speeds over
short distance movements but are significantly slower than the physiologic elbow over larger
angular movements.
Perhaps more important than an electric elbow's measured speed is how it is being controlled
in relation to its speed of response. To use an extreme example, it would be difficult to
position a fast elbow by using switch control that actuated the elbow at full speed in flexion
and in extension. The user would have a tendency to overshoot the target position and would
likely not be able to make small changes in position. Therefore, as electric elbows have
become faster, there has been greater utilization of proportional velocity control. In this type of
control, the magnitude of the input signal, which the user is presumed to be able to regulate,
determines in direct proportion the speed of motion. By creating a higher-amplitude signal,
the user directs the elbow to move faster (up to the limits of the mechanism), and by
producing lower-level signals, the user drives the elbow at slower speed.
The following sections elaborate on each of the adult electric-powered elbow systems.
Liberty Mutual Boston Elbow

The Boston Elbow had its origins in the 1960s in a cooperative research and development
venture involving the Liberty Mutual Insurance Company and its Research Center, the
Massachusetts Institute of Technology, the Harvard University Medical School, and
Massachusetts General Hospital. The first prototypes were encouraging, but considerable
development by the Liberty Mutual Research Center during the first 5 years of the 1970s was
necessary to produce a version that could be commercialized. Robert Jerard redesigned the
original prototype and proved that a commercial version was feasible, and T. Walley Williams
III carried out the commercialization and directed subsequent design alterations. Trials with
the commercial elbow were begun in 1975, and the elbow was made generally available in
1979.
In its present form (see Fig 6C-7.), the Boston Elbow is available in one size and is
configured with the motor and gearing within the elbow "cap" and the battery and electronics
supported in a metal forearm frame. A prefabricated plastic and foam forearm shell (not
shown in the figure) is custom-shaped and laminated to enclose and protect the forearm
componentry when the prosthesis is finished.
The elbow is typically controlled in one of two ways: by a two-site, two-function myoelectric
controller or by integrated or separate two-function electromechanical switches. The two-
site myoelectric controller offers control of speed and torque in proportion to the magnitude of
the myoelectric signal. Separate gain adjustments allow for tailoring the response of the
elbow with respect to the condition of the myoelectric sources. An Evaluation Meter is
available to monitor the myoelectric signals for evaluation and training and can be used with
or without the elbow in operation.
Control by electromechanical switches provides single-speed (or single-torque) operation in

flexion and in extension. The additional circuit board required for switch control includes
circuitry for limiting the flexion and extension speeds separately. Although the user cannot
vary the speed of motion when using switches, the speed can be set to an acceptable level.
These adjustments can be helpful during training, when the speeds might be reduced while
the client becomes familiar with the operation of the elbow. The speed adjustments are also
helpful in balancing the elbow's response to gravity, which (as with all elbow mechanisms)
assists the elbow during extension and retards it during flexion, especially if an electric
prehensor and electric wrist rotator are used.
In operation, the Boston Elbow can be positioned anywhere within its 135-degree range of
motion and is self-locking whenever the control signal ceases. A free-swing range of 30
degrees of flexion from the stopped position of the elbow can be engaged and disengaged by
manual operation of a mechanical slide bar.
The Boston Elbow can be used in conjunction with cable-actuated body-powered prehensors
and with other electric components in a configuration with separate control sources for each
component. Use of separate control sources is preferred, when feasible, because it can allow
for simultaneous and coordinated operation of more than one component. However, if control
sources are limited, Liberty Mutual offers a two-site, four-function proportional myoelectric
controller configured for sequential operation of the elbow and an electric prehension device.
A separate switch, such as a harness-type switch, is used to select the component to be
controlled. Although three control sources are needed-two myoelectric sites to control the
movement of the component and a source to actuate the selection switch-this arrangement
provides for proportional control of each of the two components. Other customized control
configurations have been developed by the Liberty Mutual Research Center, and circuit
diagrams for the elbow controller are readily available.
NY-Hosmer Electric Elbow

The NY-Hosmer Electric Elbow was designed by William Lembeck at New York University
under the direction of Sidney Fishman. The prototype of this mechanism was originally
conceived for use by children and was evaluated, as such, in the 1970s. Consequent
modification to that prototype design and the involvement of the Hosmer Dorrance
Corporation resulted in the commercialization of "large" and "medium"-sized versions
introduced in 1983. The two sizes are equivalent to the E-400 and E-200 Hosmer Dorrance
mechanical elbows, and the mechanical elbows can be alternatively fit to prostheses originally
configured with the electric elbow. Hosmer Dorrance also introduced versions of the elbows
for exoskeletal and endoskeletal applications (Fig 6C-8).
The same motor and drive mechanism, contained in the elbow cap, is used for all versions of
the elbow; therefore, mechanical performance characteristics are the same for all models.
External dimensions, the turntable, and the forearm saddle attachments vary from model to
model. The absence of fixed componentry in the forearm and the use of a forearm saddle
provides considerable freedom in the length and customized shaping of the forearm section.
The elbow is powered by a separate battery pack, available in four-and five-AA cell
configurations, that can be positioned within the prosthesis as appropriate. Placement within
the humeral section is preferable to placement in the forearm because additional weight in
the forearm will reduce the functional lift capacity- the maximum weight of a held object that
can be lifted by the elbow.
Two control options are available from Hosmer Dor-rance: switch control using two-function
electromechanical switches and two-site, two-function myoswitch control. A variety of
electromechanical switches are available from the manufacturer, including cable and harness
pull switches and one-site and two-site push switches. Other switch configurations are also
possible. Both the switch control and the myoswitch control operate the elbow at one speed,
which cannot be adjusted but which is determined by the battery voltage, the load on the
elbow, and the direction of movement.
The variable-speed controller manufactured by Universal Artificial Limb Co. has been adapted
to the NY-Hosmer Electric Elbow. This two-source controller can be set up to accept input
from force-sensitive pads, displacement transducers, or Otto Bock electrodes to provide
proportional control of the elbow's speed.
A pawl-type locking mechanism placed in an early stage of the drive train locks the elbow
virtually anywhere through its 130-degree range. Locking is automatic whenever the control
signal ceases. The elbow can also be made to swing freely by driving it to its fully extended
position, at which point the free swing automatically engages. Once engaged, the elbow can
be swung or pushed unpowered anywhere within its full range of motion. Free swing is
disengaged by activation of the flexion control. Elbows can be equipped with or without the
free-swing feature, and elbows without free swing can be retrofit to incorporate it.
Numerous configurations are possible when the electric elbow is used in conjunction with
wrist and prehension components having control sources separate from the source (or
sources) operating the elbow. Hosmer Dorrance does not offer methods for integrating control
of the elbow with other electric components, with the exception of the NY-Hosmer Prehension
Actuator (PA). In configuration with the PA (shown in Fig 6C-4.), the elbow can be operated
by a three-function cable pull switch. The first two functions operate the elbow in flexion and
extension, and the third function (with the switch control cable fully extended) operates the
opening of the PA.
Motion Control Utah Arm

The Utah Artificial Arm is manufactured and distributed by Motion Control, a division of
IOMED, Inc. The system was developed at the University of Utah in the latter half of the
1970s by a team directed by Stephen Jacobsen, Ph.D. The original Utah Arm, as first
clinically fit in 1980, included the electric elbow mechanism and control electronics developed
by the Utah team and a body-powered voluntary-opening split-hook prehensor. In 1982,

Motion Control introduced a proportional myoelectric controller that allowed the elbow to be
used in conjunction with an electric prehensor. As it is presently configured, the "arm"
includes a motorized elbow mechanism, a friction-type humeral turntable, a forearm shell, and
electronics for both the elbow and an optional electric prehension device (either an Otto Bock
System Electric Hand or Grei-fer).
The Utah Arm is available in one size and is shown in Fig 6C-9. The battery pack and elbow
electronics are contained within the stationary (with respect to the humeral section) enclosure
distal to the turntable. The motor, mechanical transmission, and prehensor electronics are
located in the forearm section. The forearm shell is a finished injection-molded plastic
enclosure that can be cut to shorter length or lengthened by the addition of an extension.
Elbow rotation occurs about an axis through the anterior aspect of the joint. This placement
allows flexion to approximately 150 degrees, thus bringing the prehensor nearer to the face
with less shoulder flexion than is possible with other elbow designs. Modularity of the
electrical and mechanical assemblies is a hallmark of the Utah Arm, and this facilitates
access for troubleshooting and replacement of subunits.
A single control technique is used to operate the elbow mechanism: two-site proportional
myoelectric control. Switch control is not feasible because of the relatively high speed of the
elbow, over 100 degrees/sec with an electric prehension device. Nonlinear filtering of the
myoelectric signals provides for quick response of the elbow to sudden high-amplitude
changes in the control signals to achieve fast movements, but smoother response for the
slower-changing lower-amplitude signals used in more precise movements. Motion Control
offers the MYOLAB II-EMG Tester/ Trainer, which incorporates meters and auditory feedback
of myoelectric signal amplitude for evaluation and training. The MYOLAB II can be used to
monitor the myoelectric signals simultaneously with operation of the Utah Arm.
Locking of the elbow is engaged whenever it is held stationary for a set period of time (the
length of which can be adjusted) or whenever a momentary switch is actuated. The elbow
has 22 locked positions throughout its range of motion. Unlocking can be effected in several
ways: by rapid cocontraction of the controlling muscles, or "rate" control; by a slower
contraction of at least one muscle, or "threshold" control; or by actuation of the same
momentary switch that can be used for locking. Lock control by the switch is always
available. "Rate" control and "threshold" control of unlocking are mutually exclusive and are
determined by an adjustment in the electronics.
When the elbow is unlocked and no myoelectric signals are present, the elbow is in a
powered free-swing mode. The free swing is powered (unlike the free-swing modes of the
Boston Elbow and the NY-Hosmer Electric Elbow) because the drive transmission of the Utah
elbow remains engaged during free swing. Therefore, to overcome the electromechanical
inertia of the drive mechanism, the motor actively flexes and extends the elbow, thus drawing
battery current, as the arm is swung. The action of the motor is controlled by the response of
a load cell transducer to the torque exerted on the forearm.
The Utah elbow can be used in conjunction with other body-powered and electric components
having separate control sources. In addition, options exist for integrated control. The
electronics added in the Utah Arm version with electric prehensor converts the system from a
two-site, two-function controller of elbow flexion and extension to a two-site, four-function
sequential controller of elbow and prehensor. In this configuration, the myoelectric sources
proportionally control the elbow when it is unlocked. Whenever the elbow is locked, the same
myoelectric sources are automatically channeled to proportionally control opening and closing
of the prehension device. Unlocking the elbow by "rate" control-rapid cocontraction of the
controlling muscles-returns control to the elbow without inadvertent operation of the
prehensor.
An electric wrist rotator (Otto Bock) can also be added to the Utah Arm system if there is
sufficient forearm length. The rotator can be controlled from a separate and independent
source, such as a two-function harness switch actuated by scapular abduction. Alternatively,
the movement of the rotator can be controlled by the same myoelectric sources as the elbow
and prehensor. In this arrangement, a switch is still needed, but actuation of the switch when
the elbow is locked channels the myoelectric signals to the wrist rotator. When the switch is
not actuated and the elbow is locked, the myoelectric signals control the prehensor.
Commentary on Electric Elbows
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
prosthetic elbow. In a related study using tracking experiments, it was also shown that
position control of a hypothetical prosthesis mechanism with nonlimited dynamic-response
characteristics had greater potential for effective control of prosthetic joints than did velocity-
control 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 upper-
limb 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
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
supinated forearm, in Medicine and Sport, vol 6, Biomechanics II, Basel, Switzerland, S
Karger AG, 1971.
16. 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.
17. 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 19.1-
19.5.
18. 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.
19. Mathiowetz V, Kashman N, Volland G, et al: Grip and pinch strength: Normative data
for adults. Arch Phys Med Rehahil 1985; 66:69-74.
20. Michael JW: Upper limb powered components and controls: Current concepts. Clin
Prosthet Orthot 1986; 10:66-77.
21. 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.
22. 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.
23. 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.
24. Nader, M: The artificial substitution of missing hands with myoelectrical prostheses.
Clin Orthop 1990; 258:9-17.
25. Palmer AK, Werner FW, Murphy D, et al: Functional wrist motion: A biomechanical
study. J Hand Surg [Am] 1985; 10:39-46.
26. Peizer E, Wright DW, Mason C, et al: Guidelines for standards for externally powered
hands. Bull Prosthet Res 1969; 10:118-155.
27. 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.
28. 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.
29. 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.
30. Safaee-Rad R, Shwedyk E, Quanbury AO, et al: Normal
31. functional range of motion of upper limb joints during performance of three feeding
activities. Arch Phys Med Rehabil 1990; 71:505-509.
32. Schlesinger G: Der Mechanische Aufbau der kanstlichen Glieder, in Ersatzglieder und
Arbeitshilfen, part 2. Berlin, Springer-Verlag, 1919.
33. 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.
34. 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.
35. Simpson DC: Functional requirements and systems of control for powered prostheses.
Biomed Eng 1966; 1:250-256.
36. Simpson DC: The functioning hand, the human advantage, J R Coll Surg Edinb 1976;
21:329-340.
37. Tanenbaum SJ: The Boston Elbow-Health Technology Case Study 29, Report OTA-
HCS-29. Washington, DC, U.S. Congress, Office of Technology Assessment, 1984.
38. 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.
39. 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.
40. Uellendahl J, Heckathorne CW, Krick H, et al: Four-function hybrid arm prosthesis
incorporating an electric wrist rotator and prototype electric prehensor, in Proceedings
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.
6D: Control of Limb Prostheses | O&P Virtual Library
Search
GO
Upper-Limb Prosthetics: Control of Limb Prostheses Reproduced with

permission from
Dudley S. Childress, Ph.D Bowker HK,
Michael JW (eds):
The material that follows in large part deals with control of externally powered prostheses. Atlas of Limb
Prosthetics:
Prostheses that are entirely cable actuated and body powered are dealt with in another
section of the Atlas (see Chapter 6A and Chapter 6B). The various control schemes of cable- Rehabilitation Principles.
operated prostheses are considered there. Nevertheless, cable-operated systems will also be Rosemont, IL, American Academy
considered in this discussion because they are an important form of prosthesis control, even of Orthopedic Surgeons, edition 2,
when electric-powered components are used. This is particularly the case for high-level 1992, reprinted 2002.
unilateral and bilateral amputees, where the systems of choice often use hybrid control (cable,
myoelectric, switch, or some combination of these or other methods) and hybrid power has been updated and published
(electric and body power). Also, powered systems that emulate cable systems will play, it is in Atlas of Amputations and Limb
believed, an important role in prosthesis control of the future. Consequently, any general Deficiencies: Surgical, Prosthetic,
discussion of control systems for arm amputees must include cable control from body and Rehabilitation Principles
movement inputs. (retitled third edition of Atlas of
It is interesting that when we talk about lower-limb prostheses, we seldom talk about control. Academy or Orthopedic Surgeons.
Instead, we talk more about interface loads, suspension, alignment, etc. This comes about Click for more information about
this text.
because the lower limb must bear significant body loads, because lower-limb activity is highly
repetitious and stylized (e.g., walking) and because the intact knee joint acts as the natural
controller for the transtibial prosthesis, the most commonly prescribed lower-limb prosthesis. Funding for digitization
The transradial prosthesis for the upper-limb (the most common upper-limb prosthesis) is of the Atlas of Limb
similar to the transtibial prosthesis in that it is an extension of the limb and because position Prosthetics was
and velocity are controlled by the elbow joint. However, with the transradial prosthesis, the provided by the
attached prehensor needs to be controlled (unless a passive hand is used), whereas the
artificial foot is a passive mechanism. Hence, discussion is more prevalent about control of Prosthetists
upper-limb prostheses than it is with lower-limb prostheses; only for persons with
amputations at the knee or higher do issues of control become apparent with lower-limb
prostheses.
PLACEMENT OF PROSTHESIS CONTROL IN THE GENERAL

CONTEXT OF CONTROL THEORY AND PRACTICE O&P Virtual Library with a
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.
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 human-
prosthesis 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
manipulator applications. Murphy points out that bilateral users of cable-actuated prosthetic
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
cable systems in the powered systems. This did not happen in prosthetics when power
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.
SOME COMMONLY EXPERIENCED CONTROL SYSTEMS

THAT RELATE TO PROSTHESIS CONTROL
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 voluntary-
closing 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 switch-
controlled 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 up-
and-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
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.
DESIRABLE ATTRIBUTES OF PROSTHESIS CONTROL

(GOALS FOR LIMB PROSTHESIS CONTROL)
There are several highly desirable attributes of control systems for limb prostheses. Some of
these attributes may be difficult, if not impossible to achieve in practice. Nevertheless, they
need to be stated as goals in order to stimulate continued control system improvement and
development. Systems that fall short of these goals may be serviceable and practical, but we
will know that they can be improved and made better. Some of the important attributes are as
follows:
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, body-
powered 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.
WHAT SHOULD BE DESIGNED/WHAT SHOULD BE

CONTROLLED?
The question of what should be controlled by prosthetics control systems depends importantly
upon the philosophy of artificial limb design. If the objective is to design an artificial arm that
emulates a human arm as much as possible, then one may want to control joint compliance
and other variables that may make the prosthetic limb have a number of characteristics of
a human arm. However, at this stage of arm prosthesis development these concepts are still
not clinically available. In any case, it is difficult to "replace" the human arm and/or hand
system and probably always will be. Hence, the clinical approach most often taken with arm
prostheses is to design them as "tools" that the amputee can effectively use in assistance
with activities of daily living. That is the direction taken by the author in this chapter. It is, of
course, desirable for the "tool" to look and function somewhat like a human arm. Practical
issues often support the "tool" development approach to arm prosthetics. For example, when
a person holds an object with the elbow bent at 90 degrees, muscular action and expenditure
of energy are required from the arm. Since the energy stored in a battery of an artificial arm
would be depleted rather quickly under this approach, optional, nonphysiologic control choices
like mechanically locking the elbow have to be made. In this document we have assumed
that the prostheses to be controlled are basically "assistive tools." In other words, prostheses
are the machine parts of a human-machine system and not a part of the human system-
even though we want as much integration as possible.
It is advantageous for a prosthesis to move freely so that it can easily be put into the desired
positions for operation. It may also be advantageous to control the rate of movement to the
desired positions (the velocity). Once in position, it is often desirable to be able to control
prehension force. Likewise, when a desirable position is reached, it may be advantageous to
lock specific joints. Therefore, the variables to be controlled in arm prostheses of the kind
under discussion are as follows:
1. Position
2. Velocity
3. Prehension force
4. The joint state (locked/unlocked)
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.
SOURCES OF BODY INPUTS TO PROSTHESIS

CONTROLLERS
The human body can generate a variety of control signals that potentially could be used to
operate prostheses. Childress has enumerated many of them. Practical inputs typically
come from muscular activity (1) directly, (2) indirectly through joints, and (3) indirectly from by-
products of muscular contraction (myo-electricity, myoacoustics, muscle bulge, and changes
in muscle mechanical/electrical impedance). Although signals can be obtained from brain
waves (electroencephalography [EEG]), voice, feet, eyes, tongue, and other places, these
sources of control have not been shown to be practical for artificial limb control. A partial list
of control options is included here, with concentration on options that are currently in common
or partial use and on those that appear to have some future potential for use with practical
limb prostheses. The options have been classified as two types: biomechanical and
bioelectric/acoustic.
I. Biomechanical
II. Bioelectric/acoustic
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.
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?
The Integrated Nature of Prosthetics Systems

Limb prosthetics systems suffer from the kind of "reductionist" approach being pursued in this
chapter. While it may be useful in one sense to break down upper-limb prosthetics systems
into powered components, control systems, transducers, etc., and to only talk about control in
this chapter, in another sense this may not be a good way to think about how to design a
well-functioning system. It is the author's opinion that the best operating system for a given
task needs to be built as an integrated whole and not through a "modular" approach where
different componentry is cobbled together to create a total system. The modular approach has
the advantage of providing great flexibility and novelty of system design. However, this
approach will probably never be able to attain the highest functional goals that may be
possible. Only systems that are designed from a more integrated standpoint may be able to
accomplish this.
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.
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 µV (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
Childress have prepared a comprehensive bibliography concerning myoelectric control of
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
scientists were instrumental in advancing the concepts of myoelectric control early on and
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
100 µV, 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
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
neurons, remains a control possibility that may have future applications. This method of
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 human-
machine 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
investigated in basic studies of animal preparations by Kuiken. The concept, for example,
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,
and the proceedings of that meeting is a landmark publication on prosthesis control
research.
THE ROLE OF SURGERY IN THE CREATION OF CONTROL

SITES/SOURCES
We know that amputation surgery is very important to the clinical outcome of prosthetics
fittings. Nevertheless, this area of prosthetics is perhaps not emphasized as much as it
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.
Bones and Joints

As a general rule, the surgeon should try to save joints and bone length, consistent with good
medical practice. This procedure, in general, leads to improved prosthesis control. With
transradial amputations it is usually desirable to make the limb as long as possible. Wrist
disarticulations are desirable since they conserve natural supination-pronation of the forearm,
provide contours for prosthesis suspension, and create a force-tolerant distal end for the limb.
The elbow joint should always be saved, if possible, since it greatly enhances prosthesis
control, just as saving the knee enhances lower-limb prosthesis control. Bone lengthening
might be considered for increasing the length of very short limbs, where it is practical.
Decisions concerning saving the wrist joint, if all fingers have been amputated, have to be
made on an individual basis. In the future, if advanced finger components are available for
the partial-hand amputee, it may be useful to save the wrist because of the highly desirable
movements it provides for positioning an artificial prehension component. At present, the
range of fitting options that can be achieved are limited at this amputation level (e.g.,
passive/cosmetic prosthesis, opposition post, HandiHook, Robin-Aids Hand) because of size
and length constraints. Some partial-hand amputees who have no fingers or thumb decide
that they want to have their limbs revised (shortened) to the wrist disarticulation level so that
they can easily be fitted with standard electric hands and myoelectric control.
From a control viewpoint, transhumeral amputations seem to follow guidelines similar to those
for the transradial amputation. Elbow disarticulations conserve humeral rotation, can be used
to aid prosthesis suspension, and provide a force-tolerant distal end. Long transhumeral limbs
often obtain good control of prosthetic elbow flexion by using glenohumeral flexion; however,
if a disarticulation is not possible, the length should usually be reduced enough to
accommodate elbow mechanisms without compromising function. Mar-quardt has used
angle osteotomies of the distal end of the humerus to improve mechanical coupling between
the humerus and the prosthesis so that the humeral rotation of the prosthesis is readily
controlled by natural humeral rotation.
A control viewpoint suggests that the surgeon should attempt to save a short humerus if it will
be voluntarily mobile because a mobile short humeral neck can be used to activate control
switches or to push against pressure-sensitive pads. Muscles attached to it may also be used
for myoelectric control purposes. If amputation above the elbow is performed after brachial
plexus injury, it is often helpful to have the flail humerus fused with the scapula at the
glenohumeral joint. In this way the humeral section can be controlled, to some extent, by
action of the scapula.
Soft-Tissue Conservation and Reconstruction

Surgeons should conserve residual muscles that might be used for myoelectric sources if the
conservation is consistent with good medical practice. Myoplasty procedures that connect
antagonist-agonist muscle groups at the distal end of the amputation site are often used in
order to keep the muscles in a dynamic, somewhat natural working relationship. It is felt that
this promotes the possibility of good two-site myoelectric control from these muscles.
Myodesis is sometimes performed. Single muscles that may have no functional purpose after
amputation but that can be voluntarily activated should be attached to a reaction point and
saved for possible use as a myoelectric control site. For example, if part of the deltoid muscle
can be conserved after arm disarticulation, its free end may be attached to the torso for
possible use as a myoelectric control source for an arm prosthesis.
Although tunnel cineplasties have not been used much in the United States since the 1950s,
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
electronic prosthesis technology. Beasley introduced a new cineplasty-like, "tendon
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.
CONTROL OF PROSTHESES FOR SINGLE (UNILATERAL)

LIMB LOSS
While fittings of unilateral amputees are technically much more simple than bilateral fittings,
evaluation of the results of unilateral fittings may be more difficult than for bilateral cases.
This is because the unilateral amputee has a physiologic arm and hand that, if normal, can
accomplish almost any task. Therefore, the prosthesis at best serves only in an assistive
mode. Some amputees may want it primarily for appearance purposes. Others may
incorporate it extensively into their activities and body image, while some may have only
specific functions (jobs or sports activities) for it. Many unilateral amputees decide not to
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.
Control of Unilateral Transradial Prostheses

Transradial prostheses may be controlled successfully in many ways. Cable-controlled
voluntary-opening and voluntary-closing prehensors (nonanthropomorphic) both work well
with transradial amputees, although cable-controlled mechanical hands are generally
inefficient. When myoelectric control first became available, the conventional wisdom was that
it might have more important usage with higher-level amputations and was not so important
for transradial prostheses. However, experience has shown that myoelectric control works
admirably at this level. In fact, it has its greatest application with the transradial amputee. A
myoelectrically controlled transradial prosthesis is shown in Fig 6D-3.. If possible, it is
preferable to use two myoelectric sites to control the two functions (closing/opening) of the
hand because this gives the operator direct control of each function. This kind of control can
become rather subconscious in nature for some amputees. Of course, the prehensor can be
various electric hands or various nonanthropomorphic electric prehensors as described in
Chapter 6C.
Single-site, two-function control is quite acceptable for amputees who do not have two good
myoelectric sites. It has been used effectively with youngsters (e.g., the New Brunswick
system) and with adults. In like manner, the single-site, single-function myocontroller of hand
opening with automatic powered closing (the St. Anthony control circuit, the so-called "cookie
crusher'' system) has been shown to be effective with very young children who are born with
limb absences. This is similar to the single-site, single-function myocontroller for voluntary-
opening prehensors (Hosmer's Prehension Actuator), which can be used to provide powered
operation to a variety of voluntary-opening devices that traditionally have been controlled
through cables and body power.
A pair of single-site, two-function controllers can be used to control four functions of powered
hand opening/closing and powered pronation/supination for the short transradial limb. In
general, supination/pronation is not necessary for most unilateral amputees unless a
particular vocation or avocation demands it. Powered supination/pronation adds weight
distally and also adds complexity. Sockets and apparatus that allow natural
supination/pronation (body powered) from residual movements of the amputated limb are
recommended, when possible.
Proportional control has been shown to be effective by Sears and Shaperman. This is
intuitively understood; however, if powered prostheses have slow dynamic responses (e.g.,
hands close or open at slow rates), then proportional control is not necessary for effective
control; on-off control is sufficient. Rapidly moving prostheses that have maximum angular
velocities greater than 2.0 to 3.0 radians/sec (-115 to 172 degrees/sec) normally will require
proportional control, although few devices with this speed are currently available. At some
operating velocity, accurate control of position becomes impossible for the human-operator
using on-off velocity control (as noted previously in the discussion on control of electric-
powered automobile windows).
Electric switches in series with Bowden cables can be used to control powered hand
prostheses. However, this kind of control probably should be avoided if possible because a
prosthesis controlled in this way by a transradial amputee has the disadvantages of cable
control (harness and limited work envelope) along with the disadvantages of powered hands
(weight, battery, mechanical complexity). A possible exception would be when the switch is
operated from a tunnel cineplasty; however, it seems likely that position control, as with the
Steeper hand controller (see Fig 6C-2) or with some other kind of position control
mechanism, would be preferred for hand control through a tunnel cineplasty. In this situation,
the muscle position would determine hand opening position. If muscle velocity could also be
related to prosthesis velocity and muscle force to prosthesis gripping force, then the muscle
might provide some proprioceptive sense to the user.
Evaluation of the Effectiveness of Control Approaches

As the reader can see from the transradial unilateral situation, there are many ways to fit
amputees from a control viewpoint and from a component viewpoint. Which way is best? Is
there a "best?" With higher-level amputations the question becomes even more important
because the fitting options are multiplied. Powered and nonpowered components at multiple
joints coupled with various control schemes yield many possible fitting combinations. How can
the various options be evaluated? Of course, everyone has his own opinions about what is
best, which may be subject to change or may not. (Note that although this question can be
raised in all areas of prosthetics, it just becomes very obvious in high-level fittings.)
Unfortunately, the question can only be answered quantitatively for particular criteria that are
arbitrarily selected and through large-sample studies. It can be answered subjectively by the
prosthesis users, but again a large-sample study would be required. Such studies are difficult
to fund and conduct, and the results may be equivocal. At present, a combination of "rules of
thumb" based on experience and clinical judgment usually determines the initial prosthetic
approach.
Surgeons have the same problem in evaluating many surgical procedures. Their use of case
studies and retrospective analysis of results suggests the need for studies of this kind to be
performed by professionals in prosthetics who have reasonable caseloads of upper-limb
amputees. It is a partial solution, at best, to the evaluation of effectiveness of control
techniques and methods. The author proposes that an alternative evaluation approach might
be to measure control methods against the "Desirable Attributes of Prosthesis Control"
presented in the first part of this chapter. If they have many of the attributes, they would rank
higher than if they do not. This may be difficult to quantify, and not everyone will agree upon
the desirable attributes, but it may be a viable first approach to the problem. Another option is
to base evaluation of control approaches on the basis of a theoretical construct. Fittings with
close correspondence to the theory would get higher ratings than other fittings. These ratings
would be incorrect if the theory was incorrect, but if the theory was correct, they would be
valid. A theoretical construct proposed by the author is discussed later in this chapter, and
simple examples of evaluations based on the construct are presented.
Control of Unilateral Transhumeral Prostheses

It seems appropriate to present the most common control approaches currently used in
prosthetics practice for powered transhumeral prostheses along with an emerging approach of
interest to the author. As with transradial amputees, transhumeral amputees with relatively
long limbs can function well with totally cable-operated, body-powered prostheses. Several
other approaches are common:
1. For transhumeral amputees with long residual limbs, the hybrid approach of a cable-
operated, body-powered elbow along with myoelectric control from the biceps (closing)
and triceps (opening) of a powered pre-hensor (hand or nonhand) is a very functional
fitting approach. This approach has been used effectively in Europe for almost 25
years. Billock has used this technique effectively with many people. It is a relatively
simple approach-technically comparable to a transradial myoelectric fitting. This kind of
fitting is shown in Fig 6D-4.,A. The hybrid control/power approach has reasonable
proprioceptive qualities and allows simultaneous coordinated control of elbow and
prehensor function. It avoids the problem of prehensor opening during forearm lifting
against a load, which is a problem with a cable-operated elbow if the cable is also
used to operate a voluntary-opening (spring return) prehensor. The author feels that
myoelectric control of prehension, in this case from the biceps and triceps, is
somewhat natural because gripping objects strongly often involves the contraction of
muscles quite distant from the hand. The relationship between prehension and
muscular contraction has been called the "myopre-hension" concept.
2. Hugh Steeper, Ltd., has a body-powered elbow that is designed for a hybrid control
approach to trans-humeral fittings. The mechanical elbow has an electrical switch in it
that is connected with the elbow locking mechanism. When the elbow is unlocked, the
electrical switch is open, and when locked, the switch is closed. This allows a single
cable to operate a servo-controlled hand and also the elbow, without interaction. When
the cable is pulled to operate the unlocked elbow, the electrical connection to the hand
is turned off. When the elbow is locked, the connection to the hand is on, and pulling
on the cable operates the hand through the position servo control system. Another
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 body-
powered 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 two-
site 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.
Control of Unilateral Shoulder Disarticulation Prostheses

Unilateral shoulder disarticulation amputees often choose not to wear a prosthesis. Some
prefer to wear a lightweight passive prosthesis that is free to swing comfortably during
walking and that can be easily positioned (passively) for placing its cosmetic hand in their lap
when they sit. Light, passive holding by the cosmetic hand may provide some utility. Body-
powered prostheses are marginally effective at this level of amputation-when the contralateral
limb is fully functional. The user often has somewhat limited force and excursion when
compared with amputees with mid to long transhumeral limbs, and a body-powered system
may be difficult to operate. A powered prosthesis (e.g., with electric elbow and electric hand
or other powered prehensor) may also not be desirable at this level of amputation because,
again, the functional gains provided are likely to be marginal when the opposite limb is fully
capable. Powered limbs also add undesirable weight, a detrimental factor in this kind of
fitting.
If a powered limb should be fitted for this amputation level, it would likely be used mainly as
an assist to the normal contralateral limb, primarily with its prehensor acting as a conveniently
located viselike holding mechanism (e.g., holding a bottle while the other hand takes off the
cap). An electric elbow and electric prehensor could be used in conjunction with friction or
manually locking wrist rotation, friction or manually locking humeral rotation, and friction or a
manually locking shoulder. The user would preset wrist rotation, humeral rotation, and
shoulder position with his capable limb and would use the control system to position the
elbow joint and operate the prehensor.
A convenient control scheme for this situation would be movement or force from the shoulder
on the amputated side. If support for the arm can come from the torso, then the structure can
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.
Control of Bilateral Arm Prostheses

The fitting problems become dramatically different when both arms are missing. We will not
address the fitting issues involved with all of the various combinations of bilateral limb loss. If
we only consider transradial and transhumeral amputation combinations, we have 4
combinations but only 3 different varieties (2 combinations are equivalent to each other, left
and right) of amputation conditions (bilateral transradial, bilateral transhumeral, and
transhumeral-transradial). If we add "long" and "short" to the classification of each amputation
level, we have 16 possible combinations, with 10 different varieties (12 combinations have
like equivalents, left and right) of amputation conditions. Therefore, the number of variations
can be large if several different amputation levels of each limb segment are considered and
much larger if associated movement limitations or pathologies of each limb segment are also
included. We will consider only a few conditions of the many varieties of amputation
conditions possible and will concentrate on general principles for the fittings rather than on
specific details.
Amputees with bilateral long transradial limbs can effectively control a wide range of
prostheses from cable-controlled voluntary-opening hooks to bilateral myoelectric hands.
Attempts should be made to maintain the physiologic pronation-supination remaining-on both
sides. Passive (friction or locking) wrist flexion will be useful, at least on the dominant side. It
might be useful to use two kinds of prehensors, one voluntary closing and one voluntary
opening, although the author has not seen this done. This would provide body power on both
sides, but the prehensors would be complementary in function. The voluntary-closing
prehensor would enable high prehension forces to be developed, and the voluntary-opening
prehensor would permit relaxed, unattended prehension. Another possibility is to use different
kinds of prehensors and different control schemes on each side. Body control with passive
wrist flexion could be fitted on the dominant side with a voluntary-opening or -closing
prehensor. A transradial myoelectric hand prosthesis (or nonanthro-pomorphic prehensor,
e.g., Greifer or Synergetic Prehensor) with socket provision to capture residual forearm
rotation could be fitted on the nondominant side. This would give the wearer the advantages
of both kinds of systems-the precision prehension capabilities of many hook prehensors along
with good proprioception from the cable-operated control system and the power prehension
of an electric prehensor along with the large work envelope that is possible with a myo-
electrically controlled prosthesis. The two systems should complement each other, and the
controls should be as independent as possible. There are many options, and the one chosen
will be highly dependent upon the needs and preferences of the user. Powered hand
prostheses may be used bilaterally with aesthetic advantage but often with functional
disadvantage because the hands are usually limited to one prehension pattern (palmar
prehension) and because their bulk makes it difficult to use them in constricted spaces (e.g.,
pockets).
If both arms have transradial amputations, one long and the other short, the long limb would
normally be fitted as the dominant limb. Again, as before, a wide range of fitting possibilities
are possible. An all cable-controlled system with hooks can be very effective, as
demonstrated by so many amputees who generally develop exceptional arm/prehensor skills.
A variant of the complementary body-powered, externally powered system discussed in the
previous paragraph may also be useful with this set of amputation levels. Powered
supination-pronation on the short, powered, nondominant side should be considered. Similar
control procedures are usable with the bilateral, short, transradial amputation condition.
However, passive rotation of the prehensor should be added (along with the wrist flexion) on
the body-powered, dominant side.
A person with a combination of transhumeral and transradial amputations can also be fitted
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 airplanes-
just 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 cable-
controlled, 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, cable-
controlled 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 myo-
electrically 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,
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 body-
controlled 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 flexion-
extension 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
based on the principles of Simpson and as adapted by Doubler and Childress for
positioning electric-powered joints in space. We also believe that electric-actuated, powered-
locking 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.
THEORETICAL FOUNDATIONS FOR PROSTHESIS

CONTROL
Childress has suggested that general principles for good control seem to come naturally
out of observations of the control of various kinds of aids in rehabilitation. He has suggested
that these principles may be useful in the formation of a theoretical foundation for control of
upper-limb prostheses and has proposed a preliminary theoretical framework. The utility of a
theoretical foundation is to give guidelines for control methods so that decisions do not all
have to be made only on the basis of experience or subjective feelings. This is one reason for
putting forth a set of principles of this kind. Another reason for suggesting an initial set of
principles is so that they can then be argued, tested, validated, refuted, altered, modified, or
added to. Not all the principles will be discussed in detail here, and the reader is referred to
the references for more extended discussion.
The first and perhaps the most important concept, which the author has called Simpsons
theory, is based on the following observations: (1) cable-controlled, body-powered arm
prostheses-when they can be used-often seem to be controlled well by amputees; (2)
Simpson was able to demonstrate good multifunctional control of powered prostheses,
without excessive "mental load," by children with high-level bilateral shortage; (3) prostheses
that are direct extensions of a limb (e.g., the patellar tendon-bearing [PTB] leg prosthesis) are
well controlled; (4) blind people are adept at understanding their physical environment with a
long cane; (5) persons with quadriplegia often control their environment well with a
mouthstick; and (6) humans in general are very capable when using extensions of their limbs
(e.g., stilts, racquets, hand tools, etc.). In all these observations the output is a position
variable that is controlled by positions of the body's own joints. These joints, plus the
sensation that comes back to the body through the instrument they are operating, seem to
provide a natural kind of control that is intuitive and effective. When Simpson implemented
this concept for the control of prosthetic arms, he called it extended physiologic
proprioception because the physiologic proprioception of the controlling body joints was, in a
sense, extended into the prosthesis, much as it is into a tennis racquet or into a hammer
when a person uses them. So behind the extended physiologic proprioception concept is the
notion that the prosthesis is a kind of "tool" that the body can control very well when it is
directly connected in some way to joints of the body. This kind of system has inherent
feedback. The output pathway and the input pathway for information flow are both embodied
in the tool. This concept for control is the same as the one alluded to in the beginning of this
chapter when powered steering of automobiles and cable control of remote manipulators and
airplane control surfaces were discussed. Doubler and Childress used tracking studies to
provide some objective evidence that this kind of control is superior to "on-ofl" and
"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
systems, Childress formulated Simpson's theory of control as follows:
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.
Carlson, Gow, and others have also worked on this kind of prosthesis control. This
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
through the years and that the body does not seem to interpret well. A corollary theory for
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).
Childress has speculated that direct muscle action can provide the same kind of control
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
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.
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.
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; 32:156-
161.
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.
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 two-
dimensional 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.
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, Can-
42. 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 Bio-
Engineering 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 Upper-
Extremity 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.
7A: Surgical Principles | O&P Virtual Library
Search
GO
Partial-Hand Amputations: Surgical Principles Reproduced with

permission from
Elizabeth Anne Ouellette, M.D. Bowker HK,
Michael JW (eds):
John A. McAuliffe, M.D.
Atlas of Limb
Ronaldo Carneiro, M.D. Prosthetics:
The primary goals of amputation surgery are preservation of length and useful sensibility, Rehabilitation Principles.
prevention of symptomatic neuromas and adjacent joint contracture, early prosthetic fitting Rosemont, IL, American Academy
where applicable, and prompt return of the patient to work or play. When the amputation is of Orthopedic Surgeons, edition 2,
for a malignant tumor, the primary goal is to restore the best function possible in the context 1992, reprinted 2002.
of preservation of life.
HAND FUNCTION in Atlas of Amputations and Limb
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 Limb Deficiencies), ©American
to repair or reconstruction. Academy or Orthopedic Surgeons.
There are a number of standard tests now used to assess hand function. These evaluate the this text.
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. Funding for digitization
The musculoskeletal components are evaluated by measuring muscle strength and joint range Prosthetics was
provided by the
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 American Academy of Orthotists &
joint ranges of motion are important in assessing function; the impairment as a result of lost Prosthetists
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
and, in the case of precision grips, by a movement profile as well. The hand grip
dynamometer provides the most consistent measure of power grip strength. It is assessed by You can help expand the
averaging three separate trials (Fig 7A-1.). There are three types of precision grip: tip, O&P Virtual Library with a
three-jaw chuck, and lateral-pinch grip. These involve the thumb and second and third fingers tax-deductible contribution.
(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,

vibration, and two-point discrimination. Normal static two-point discrimination at the
fingertips is approximately 6 mm. Moving two-point discrimination can also be used to test
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.).
Pressure sensitivity can be evaluated by Semmes-Weinstein monofilaments. These are a

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 two-
point discrimination.
Point localization, tactile object recognition, and su-domotor function are also important in
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.).
REPLANTATION: INDICATIONS AND RESULTS

Since the first report of successful reattachment of an amputated thumb by Komatsu and
Tamai in 1968, advances in microsurgical technique and increased experience have made
replantation routinely possible in microsurgical centers. At the level of the hand there is little
or no muscle tissue to sustain anoxic damage, and successful replantation following cold
ischemic times of over 30 hours has been reported. Virtually every individual in the
continental United States can therefore be considered to be within range of a microsurgical
center and thus a potential candidate for replantation. Although guidelines for consideration of
replantation can be discussed preoperatively, often the ultimate decision must be made in the
operating room. The referring physician must take care not to commit the replantation team to
too much or too little in his discussions with the patient and family.
Generally accepted indications for replantation include the thumb, amputations of multiple
digits, or those through the palm or near the wrist. In addition, virtually any amputation in a
child should be replanted. Although the technical aspects of vascular repair are more difficult
in children and success rates lower, the superior neurologic recovery exhibited, particularly by
the young child, makes this effort worthwhile. Most patients report excellent levels of
satisfaction with replanted thumbs. Significant stiffness at the interphalangeal and
metacarpophalangeal joints does not hamper the thumb with an intact carpometacarpal
articulation. Perhaps the most important reason for good function of the replanted thumb is
that no completely satisfactory substitute for its function is available. This fact not only
guarantees its use but also tends to maximize restoration of motion during the usual activities
of daily living.
The same considerations also apply in the case of multiple digital replantations. Although the
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
or no remaining normal digits available for substitution. Certainly each additional digit in
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
joint motion that averages approximately 35 degrees. Scott and associates found the total
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
children. Ring avulsion injuries are a specific subset of single-digit amputations whose care
has been subject to debate. Although complete amputations by this mechanism were not
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
most series, and the almost universal presence of cold intolerance. Urbaniak states that
this problem usually resolves spontaneously in the year or two following replantation, although
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
function of the hand and 36% loss of function of the entire upper limb. There is still
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
documented. This should be the first consideration when examining a thumb amputation.
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 of the Distal Phalanx of the Thumb

The functional impairment of amputation at this level is minimal. Primary goals are skeletal
stability and adequate pain-free skin coverage with good sensation. There are numerous
techniques that will maintain length and provide sensation.
For losses of soft tissue dorsally but minimal loss from the distal phalanx, healing by
secondary intention or skin graft is possible. If these do not provide adequate coverage, then
lateral triangular advancement flaps or pedicle flaps may be used to gain coverage.
When the soft-tissue loss is greater and there is digital nerve damage, other procedures may
be necessary to preserve length and maintain good sensation. These consist of palmar
advancement flaps, cross-finger flaps, and neurovascular island flaps.
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
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.
A free toe transfer satisfies all the requirements of reconstruction at this level. When this is
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.).
Disarticulation at the Metacarpophalangeal Joint of the Thumb

At this level, the thumb is unable to perform any of its normal functions. Restoration of length,
stability, sensation, and mobility are required. Lengthening the residuum by 2 cm may
improve function dramatically.
Procedures that have been used to gain length and sensibility at this level are pollicization,
transfer replantation of salvaged injured digits to the thumb position, toe-to-hand transfers,
metacarpal lengthening, bone grafting with tubed pedicle flaps, and composite radial forearm
island flaps.
Sensation must be achieved for these techniques to restore useful function. For this reason,
bone grafting with flap coverage is considered a less-satisfactory alternative. Two thirds of the
first metacarpal with good skin coverage must be present before contemplating metacarpal
lengthening. Pollicization and transfer of free tissue offer the best chances to restore thumb
function (Fig 7A-10.).
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
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.
Amputations Proximal to the Digital Tips

These amputations by definition involve bone of the fingers. Function can be preserved by
shortening or maintaining length, depending on the anatomic situation. Flap coverage similar
to those used in fingertip injuries may be used to preserve length. If this is unnecessary, then
bone trimming and primary wound closure can be performed (Fig 7A-16.).
It is not necessary to remove articular cartilage in amputations through the interphalangeal

joints. In fact, there is evidence that the inflammatory response to amputation is less when
the cartilage is left intact. The condyles should be trimmed so that they are not prominent.
Both the tendon and the digital nerves should be found and transected so that clean edges
may retract proximally. The flexor and extensor tendons should not be sewn to each other
because the excursion of these tendons would be limited, thus limiting range of motion of the
amputated finger and adjacent fingers. The most significant complication of amputation at the
distal interphalangeal joint is the lumbrical-plus finger. This is caused by the flexor digitorum
profundus retracting proximally after transection. As it retracts, the lumbrical muscle is pulled
into a more taut position. When flexion at the metacarpophalangeal and proximal
interphalangeal joints is attempted while making a fist, the involved finger's proximal
phalangeal joint is seen to paradoxically extend. Tension of the unrestrained flexor digitorum
profundus tendon is transmitted through the lumbrical to the dorsal hood mechanism to
produce this effect. This complication can be alleviated by releasing the lumbrical from its
origin on the flexor digitorium profundus tendon in the palm. It is unnecessary to perform this
at the time of the amputation since few fingers amputated at the distal interphalangeal joint
develop this complication.
An amputation through the middle phalanx distal to the flexor digitorum sublimis tendon
insertion is a functional one. When flexion control of the remaining middle phalanx is lost,
disarticulation at the proximal interphalangeal joint is recommended. The proximal
interphalangeal joint should be approached in a fashion similar to the distal interphalangeal
joint.
When amputation through the proximal phalanx occurs in the long and ring fingers, a ray
resection should be considered in an effort to improve function. The space left in the center
of the hand cannot be compensated for except by closing the gap with a ray resection or with
a prosthesis (see Chapter 7C).
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
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
curative, but an established painful neuroma often requires a surgical solution. Tupper and
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 well-
padded 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
provide the most consistent and significant long-term relief of pain. The most promising
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
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 61-
191.
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
sutured median nerves: Faulty sensory localizations after nerve regeneration and its
physiological correlates. Exp Neurol 1981; 73: 90-106.
21. Harvey FJ, Harvey PM: A critical review of the results of primary finger and thumb
amputations. Hand 1974; 6:157.
22. Herndon JH, Eaton RG, Littler JW: Management of painful neuromas in the hand. J
23. Jebsen RH, Taylor N, Trieschmann RB, et al: An objective and standardized test of
hand function. Arch Phys Med Rehabil 1969; 50:311-319.
24. Jones L: The assessment of hand function: A critical review of techniques. J Hand
Surg [Am] 1989; 14: 221-228.
25. Kay S, Werntz J, Wolff TW: Ring avulsion injuries: Classification and prognosis. J
Hand Surg [Am] 1989; 14:204.
26. 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.
27. Komatsu S, Tamai S: Successful replantation of a completely cut off thumb. Plast
Reconstr Surg 1968; 42:374.
28. Laborde KJ, Kalisman M, Tsai T: Results of surgical treatment of painful neuromas of
the hand. J Hand Surg [Am] 1982; 7:190.
29. Leung PC: An analysis of complications in digital replantations. Hand 1980; 12:25.
30. Louis D: Amputations, in Green DP (ed): Operative
31. Hand Surgery, ed 2. New York, Churchill Livingstone Inc, 1988, pp 61-119.
32. 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.
33. May JW: Digit replantation with full survival after 28 hours of cold ischemia. Plast
Reconstr Surg 1981; 67:566.
34. McPhee SD: Functional hand evaluation: A review. Am J Occup Ther 1987; 41:158-
163.
35. Moberg E: Objective methods for determining the functional value of sensitivity in the
hand. J Bone Joint Surg [Br] 1958; 40:454-476.
36. Morrison WA, O'Brien BM, Macleod AM: Evaluation of digital replantation-a review of
100 cases. Orthop Clin North Am 1977; 8:295.
37. 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.
38. Mutniowetz V, Hashman N, Volland G, et al: Grip and pinch strength: Normative data
for adults. Arch Phys Med Rehabil 1985; 66:69-74.
39. Neu BR, Murray JF, MacKenzie JK: Profundus tendon blockage: Quadriga in finger
amputations. J Hand Surg [Am] 1985; 10:878.
40. O'Brien BM, Franklin JD, Morrison WA, et al: Replantation and revascularization
surgery in children. Hand 1980; 12:12.
41. Omer GE: The painful neuroma, in Strickland JW, Stei-chen JB (eds): Difficult
Problems in Hand Surgery. St Louis, Mosby-Year Book, 1982.
42. Onne L: Recovery of sensitivity and sudomotor activity in the hand after nerve suture.
Acta Univ Scand Suppl 1962; 300:1-69.
43. O'Riain S: New and simple test of nerve function in the hand. Br Med J 1973; 3:615-
616.
44. Owen JE: Sensitivity testing, in Owen GE, Spinner M (eds): Management of Peripheral
Nerve Injuries. Philadelphia, WB Saunders Co, 1980, pp 3-80.
45. Poppen NK, McCarroll HR, Doyle JR, et al: Recovery of sensitivity after suture of
digital nerves. J Hand Surg 1979; 4:212-226.
46. Schmidt RT, Toews JV: Grip strength as measured by the
47. James dynamometer. Arch Phys Med Rehabil 1970; 52:321-327.
48. Scott FA: Complications following replantation and revascularization, in Boswick JA
(ed): Complications in Hand Surgery. Philadelphia, WB Saunders Co, 1986.
49. Scott FA, Howar JW, Boswick JA: Recovery of function following replantation and
revascularization of amputated hand parts. J Trauma 1981; 21:204.
50. 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.
51. Smith HB: Hand function evaluation. Am J Occup Ther 1973; 27:244-251.
52. Smith JR, Gomez NH: Local injection therapy of neuromata of the hand with
triamcinolone acetonide. J Bone Joint Surg [Am] 1970; 52:71.
53. Strickland J: Thumb reconstruction, in Green DP (ed): Operative Hand Surgery, ed 2.
New York, Churchill Livingstone Inc, 1988, pp 2175-2261.
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.
7B: Prosthetic and Orthotic Management | O&P Virtual Library
Search
GO
Partial-Hand Amputations: Prosthetic and Orthotic Reproduced with

Management permission from
Bowker HK,
Michael JW (eds):
John W, Michael, M.Ed., C.P.O. Atlas of Limb
Prosthetics:
Upper-limb loss can be far more catastrophic to the individual than the more common lower- Surgical, Prosthetic, and
limb loss. Beas-ley has noted that: Rehabilitation Principles.
Loss of a hand results in a major restriction of capabilities and the loss of a 1992, reprinted 2002.
prime sensory perceptor and imposes a serious disfigurement that can be only
incompletely disguised at very best. The loss of both hands creates a handicap Much of the material in this text
that is exceeded only by serious brain or spinal cord injury. has been updated and published
In 1944, Kirk aptly summarized the challenge that partial-hand amputation presents to the
prosthetist-or-thotist: "No hand is so badly crippled that, if it is painless, has sensation, and (retitled third edition of Atlas of
strong prehension, it is [not] far better than any prosthesis. Despite numerous advances in Limb Deficiencies), ©American
the state of prosthetic art for other levels, treatment for partial-hand amputation has not Academy or Orthopedic Surgeons.
changed significantly since those words were written. Wedder-burn et al. commented in 1986 Click for more information about
that "partial hand amputees are more likely to reject their prostheses than any other upper this text.
limb amputee. Rejection stems from lack of tactile sensation, poor appearance, lack of
ventilation in the prosthesis, and limited function." As a result, many partial-hand amputees Funding for digitization
choose to function without a prosthesis. of the Atlas of Limb
Prosthetics was
provided by the
PRESCRIPTION RATIONALE Northern Plains Chapter of the
The dilemma facing physicians and prosthetists is to determine when our admittedly limited Prosthetists
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
assessment of the amputee's expectations and needs. Although a variety of approaches
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 You can help expand the
dictated by the remnant hand, few devices can provide both a cosmetic appearance and O&P Virtual Library with a
strong prehension simultaneously. Thus, it may well be necessary to prescribe more than one tax-deductible contribution.
device to meet all of the amputee's needs.
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
are generally well accepted by the amputee. Although it is true that covering the remnant
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
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
facilitating grasp of more varied objects (Fig 7B-10.). It is sometimes useful to attach a
prosthetic hook mechanism to a hand remnant with no useful residual function (Fig 7B-
11.). Body power transmitted from biscapular abduction is generally used to open the device,
but wrist motion (Fig 7B-12.) or other body motions may sometimes be used (Fig 7B-
13.). 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
cosmetic glove (Fig 7B-15.). This approach has been difficult to replicate due to numerous
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 low-
temperature 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; 12:929-
952.
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.
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.
7C: Aesthetic Restoration | O&P Virtual Library
Search
GO
Partial-Hand Amputations: Aesthetic Restoration Reproduced with

permission from
Jean Pillet, M.D. Bowker HK,
Michael JW (eds):
Evelyn J. Mackin, P.T.
Atlas of Limb
Prosthetics:
The senior author's interest in aesthetic hand prostheses began in the 1950s with his
recognition of how even the loss of a single digit could have a profound effect upon the Rehabilitation Principles.
amputees body image, self-esteem, and psychological status. The common attitude at that Rosemont, IL, American Academy
time was that because the prosthesis was inert and insensitive, it must be nonfunctional. of Orthopedic Surgeons, edition 2,
However, the author's 39 years of experience in the fitting of over 6,000 amputees 1992, reprinted 2002.
demonstrates that restoring near-normal appearance often improves the patient's function in a
global sense by enabling him to better use what he has in the complex socioeconomic has been updated and published
environment of today's mobile society. In addition, by providing an opposition part for the in Atlas of Amputations and Limb
remaining digits or thumb, the prosthesis can also provide some prehensile capability that can Deficiencies: Surgical, Prosthetic,
be very useful. To more accurately reflect its dual benefits of aesthetics and function, we refer and Rehabilitation Principles
to it as a "passive functional prosthesis." (retitled third edition of Atlas of
It is often difficult to recognize that certain patients would benefit from an aesthetic device Academy or Orthopedic Surgeons.
because the recent amputee commonly assumes that electronic prostheses will restore all Click for more information about
this text.
previous functioning. Once the limitations of active prostheses are understood, many prefer an
aesthetic restoration.
ATTITUDE OF THE UNILATERAL AMPUTEE Prosthetics was
provided by the
After acquired amputation, the amputee experiences a major functional handicap. He believes Northern Plains Chapter of the
in the miracles of surgery and the possibilities of a prosthesis. It is a period of illusions, but American Academy of Orthotists &
progressively the amputee adjusts to reality during the period of fitting, re-education, and Prosthetists
vocational rehabilitation. It is a period mixed with hope and frustration, during which doctors,
therapists, prosthetists, and psychologists all have important roles to play.
Some amputees become invalids, never able to accept their amputations. They hide their
stumps and refuse to use them. They wear their functional prostheses but do not make use of
them, as if the mere presence of the prostheses justified their behavior. Others accept their You can help expand the
amputations only too well-they are delighted to be helped and to be treated as children, and O&P Virtual Library with a
their attitude reflects a psychological need. tax-deductible contribution.
Contrary to this small group, the majority of amputees get down to the business of leading a
normal life. They reintegrate with their families and society and are able to do so because
they have succeeded in making a realistic assessment of their disabilities. In conjunction with
the stump, the remaining hand becomes increasingly skillful to the amazement of not only
immediate family members but also the amputee himself.
Thus one may say that for certain amputees it is the unaesthetic aspect of the stump rather
than the functional loss per se that is the most significant disability. Most patients finally grow
accustomed to their physical impairments and learn to disregard them and even to forget
about the function that has been lost. However, even this group may feel for a long time, and
perhaps forever, aesthetic frustration about their altered appearance.
UNILATERAL CONGENITAL ABSENCE
Functional Needs
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.
AESTHETIC IMPORTANCE OF THE HAND

The aesthetic prosthesis fulfills a deep-rooted need: the wish to go unnoticed and have two
hands like everybody else. This nearly universal desire demonstrates the importance of the
beauty of the hand.
One must understand that for some patients the hand not only is a functional tool but also
possesses expressive beauty: the appearance of the stump may seriously inhibit adaptation.
For such patients the hand emphasizes the beauty of gesture, the gracefulness of a
movement.
The importance of aesthetics varies from one person to another and from one culture to
another. Many of our patients are of Latin origin, while very few come from Britain or
Germany, and even fewer from Scandinavia. With the intermingling of ethnic groups over
many generations, attitudes have become attenuated, but they have never quite disappeared.
There is a strong desire for an aesthetic prosthesis in the Middle East, where amputation is
sometimes used as punishment for criminals.
ESSENTIAL CHARACTERISTICS OF THE PROSTHESIS

To be of real and lasting benefit, the prosthesis must be of high quality, both technically and
aesthetically. It must be very similar to the digit or hand of the opposite limb. The skin must
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.
FUNCTIONAL POTENTIAL OF PROSTHESES

The first objective of the prosthesis is to eliminate the psychological consequences of
amputation. It should restore the appearance sufficiently close to normal to reduce the stigma
associated with disfigurement. Often the disfigurement is more pronounced in the mind of the
amputee than others. However, the man who finds himself unable to take his hand from his
pocket, even though it is very "functional," may be as handicapped as if it were lost. By
allowing the use of a stump that the amputee considers too repulsive to expose and use, the
prosthesis may well improve overall function (Plates 1 and 2).
Sometimes covering a surgically reconstructed part with a thin, flexible, high-quality

prosthesis may prove essential to realizing the most from the reconstruction by giving it a
socially acceptable appearance.
In the incompletely amputated hand the prosthesis can often provide an essential physical
part for remaining parts to oppose. It may lengthen a short thumb or become a stable thumb
post against which the remaining mobile digits can work. Since potential combinations are
innumerable, fitting such a hand with the optimal prosthesis is most difficult and demands the
greatest ingenuity but often is also the most rewarding. Fabrication of these prostheses is
made possible by the availability of tough, thin, strong, flexible new materials with which good
mobility and some skin sensibility can be preserved.
Occasionally, function will be improved just by the protective effect of covering a tender
stump to free the injured person from fear of using it. Often the prosthesis can be useful for
holding light objects that are placed in it, even though it is totally passive.
Obviously, both psychological improvements and improvements in physical capacity contribute

to a better rehabilitation potential for the amputee. When a professional activity involving
frequent contacts with the public has been interrupted, the prosthesis is often the key to
returning the patient to the employment for which he is already prepared. When retraining is
required, the prosthesis broadens the number of vocational possibilities that one can
realistically consider.
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
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.
Partial or Total Amputation of the Middle Phalanx

The partial or total loss of a digit at the middle phalanx level interferes with lateral or key
pinch. In multiple amputations of the digits, the prosthesis provides a buttress against which
the pulp of the remaining thumb can hold light objects. When a single amputation of the long
finger occurs, strength is lost in key pinch. Lack of support by a missing ring finger allows the
long finger to deviate ulnarly (Plate 3). Providing a prosthesis for the missing ring finger
prevents deviation, adds stability to the fingers during lateral pinch, and also prevents small
objects from falling out of the hand when the remaining fingers are brought together (Plate 4).
When amputation occurs at the middle phalanx or just distal to the proximal interphalangeal
joint, the prosthesis is extended to the proximal phalanx. It is made very flexible at the
proximal interphalangeal joint level to allow motion. With the juncture lying near the
metacarpophalangeal joint the use of an ornamental ring will disguise the transition perfectly.
Inside the prosthesis, the missing part of the digit is filled with some supple plastic material to
give the same pulp consistency.
Partial Amputation of the Proximal Phalanx

Amputation at the proximal phalanx level requires a minimum stump length of 1.5 cm
measured from the metacarpophalangeal crease for adequate fixation of a digital prosthesis.
The patient with a stump shorter than 1.5 cm requires surgical interdigital web recession. If
the patient refuses further surgery, prosthetic fitting of the middle or ring finger can sometimes
be achieved by suspension with ornamental rings worn on the involved digit and adjacent
digit; however, the result is complicated, and fixation is tenuous (Fig 7C-3.,A-C).
When the juncture lies over the proximal phalanx, use of an ordinary ornamental ring
perfectly disguises the juncture, except in the case of the thumb. In the latter case, if a
disguise of the juncture is desired, it is best achieved by wearing a small skin-colored plastic
strip bandage as if covering an ordinary minor scratch.
The firmness and flexibility of the prosthesis depends on the functional needs. If the proximal
interphalangeal joint of the fingers is present, the prosthesis is made flexible at this level to
allow motion. If amputation is through the proximal phalanx, the prosthesis is firm and
semicurved to oppose the thumb for purposes of prehension. Individual fitting of all four
fingers is feasible if the stumps are of adequate length for secure individual fixation.
Otherwise, a glove is required, usually with the thumb exposed if it is in good condition, so
that one of the opposing parts has good sensibility.
Partial or Total Amputation of the Thumb

The thumb is essential for precision and power grip. Less thumb length decreases opposition
proportionately. Loss of the necessary counterpressure to maintain a grip on objects
diminishes power grip.
When amputation occurs at the interphalangeal joint or distal to the metacarpophalangeal

joint, a thumb prosthesis will assist prehension. By lengthening the thumb, the prosthesis will
provide proper opposition to the fingers. It also provides a shaft and crotch so as to make it
possible to hold objects too large for the fingers themselves to encircle.
Disarticulation of the thumb at the carpometacarpal joint requires a hand prosthesis with the
fingers exposed.
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.
Amputation Through the Wrist

Patients with amputations through the wrist require a total-hand prosthesis, and the prosthetic
problems chiefly involve the best socket arrangement. When amputation is through the
carpus, the prosthesis is made thin over the palm area so that useful sensibility can be
readily transmitted (Fig 7C-4.,A). By extending the hand to its normal length, the prosthesis
increases the functional surface of the hand, thereby enabling the patient to use it to push
and as an assist in two-handed activities. The prosthesis is also useful for holding light
objects that are placed in it due to the elastic memory of its components (Fig 7C-4.,B).
Amputation at the Forearm
Long Stump
A long stump, with preservation of sensitivity and pronation/supination, is very functional for
the patient, who uses it to push. To preserve these qualities it is necessary to make a hand
prosthesis rather than a forearm prosthesis to avoid restricting forearm rotation.
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.
Upper-Arm Amputation
Long Stump
Amputation of the humerus at least 5 cm proximal to the normal elbow crease allows
incorporation of a mechanical elbow to provide flexion and extension. The fixation is similar to
the forearm prosthesis. New materials and techniques now allow fabrication of prosthetic
sockets that are light, soft, flexible, and secure. Those for amputation distal to the shoulder
usually require no harnessing whatsoever. These self-suspending sockets represent a major
step in the advancement of prosthetics.
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)
AESTHETIC PROSTHESES FOR CHILDREN

The majority of children seen in consultation for prostheses are seen as the result of
congenital abnormality. If the stump does not have a pinch mechanism, fitting of a prosthesis
may be carried out at a very early age-usually between 6 and 18 months. Fitting at this age
accustoms the child to the presence of the prosthesis and encourages bimanual activity.
If the stump has a useful pinch mechanism, the prosthesis will be functionally more
bothersome than useful in the daily activities of school and play. In these circumstances it is
preferable to postpone fitting until the child has attained adolescence, at which time his "self-
image" becomes preeminent and he will be more motivated to accept the inconveniences of a
prosthesis.
A child's physical appearance at birth is of primary importance to the parents, and it is

sometimes necessary to fit a child with a prosthesis if the parents are suffering from
psychological trauma. In such cases, it is the parents we are treating through the child.
AESTHETIC PROSTHESES FOR BILATERAL AMPUTEES

Physical impairment is so great for the bilateral amputee that it overshadows the aesthetic
concern, but such a concern is in fact not diminished in these patients. Benefits may be
derived in the bilateral amputee by fitting one side with an aesthetic prosthesis, but the need
for sensibility of a part on at least one side very often precludes useful bilateral fitting.
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
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.
DURABILITY OF THE PROSTHESIS

We believe that each patient should have two prostheses, particularly in areas of wide
variations in climate: one with the color adjusted to the average winter pigmentation and the
other to summer. This does not necessarily increase the total cost because two prostheses
will wear twice as long as one. Having a second prosthesis also ensures that one is always
available if the other needs repairs and/or adjustments if the morphology of the stump
changes.
It is generally recommended that the patient wear the initial prosthesis for approximately 6
months before beginning the second one. This allows time for any necessary adjustments
and to verify that the patient has become a good prosthetic wearer. The average life span of
an aesthetic prosthesis varies from 2 to 4 years and depends on how well the patient takes
care of it as well as whether it is worn everyday or just for special occasions.
CONTRAINDICATIONS TO AESTHETIC PROSTHESES

An absolute contraindication to the provision of an aesthetic prosthesis is a patient without
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.
ACCEPTANCE AND UTILIZATION OF AESTHETIC

PROSTHESES
Long-Term Results
In June 1990, 700 files of patients who had been wearing the passive functional prostheses
for between 10 years and 38 years and had spontaneously consulted during the last 30
months (January 1988 to June 1990) were reviewed. The patients, all unilateral amputees,
were divided into two categories: acquired and congenital amputees.
Each category was further subdivided into full-time and part-time wearers. The full-time group
included those who put on their prostheses each morning and removed them only for sleep,
thus making the device much a part of themselves. In the part-time group, the patients
treated their prostheses much as clothing and wore them regularly when out of the home or
on the job, but frequently omitting them within the confines of the family circle. Acquired
amputees generally fell into the group integrating the prosthesis as a part of their body, while
congenital patients mostly belonged to the second group who wore them as clothing.
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.
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 amputés 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; 87:3421-
3425.
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.
Search
GO
Surgical Principles Reproduced with

permission from
Elizabeth Anne Ouellette, M.D. Bowker HK,
Michael JW (eds):
In the upper limb, the etiology of 90% of amputations is trauma. This occurs predominantly in Atlas of Limb
Prosthetics:
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 Rehabilitation Principles.
common, including peripheral vascular disease, neurologic disorders, malignant tumors, Rosemont, IL, American Academy
infections, contractures, and congenital deformities. The most common congenital of Orthopedic Surgeons, edition 2,
amputation, however, is at the short transradial (below-elbow) level. 1992, reprinted 2002.
With the advent of limb salvage procedures, a malignant tumor no longer automatically leads Much of the material in this text
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 Deficiencies: Surgical, Prosthetic,
the final outcome. and Rehabilitation Principles
Amputation levels are now chosen not by the prosthesis, but by the level of injury or Limb Deficiencies), ©American
involvement by the disease process. If the cause is trauma, there must be adequate Academy or Orthopedic Surgeons.
debridement of nonviable tissue, but primary amputation closure is contraindicated to prevent Click for more information about
infection. Length of the amputation can be preserved by coverage with split grafts over this text.
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 Funding for digitization
functional. of the Atlas of Limb
Prosthetics was
provided by the
AMPUTATION THROUGH THE CARPUS Northern Plains Chapter of the
The ability to amputate through the carpus allows for the preservation of wrist flexion and Prosthetists
extension as well as forearm pronation and supination. The surgical technique is similar to
wrist disarticulation. Motor strength can be enhanced by attachment of the wrist flexors and
extensors to the remaining carpal bones. The palmar-to-dorsal skin flap ratio should be 2:1 in
order to provide coverage of the carpus with durable palmar skin. The movable, sensate,
well-padded carpal segment makes this amputation quite useful in "bimanual" activities, even
without a prosthesis. Grasp can be provided, however, by a specially designed wrist-driven You can help expand the
prosthesis. Although functional, this active prosthesis is not cosmetic. Passive restorations, O&P Virtual Library with a
however, can be quite aesthetic. 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
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.
POSTOPERATIVE IMMEDIATE PROSTHETIC FITTING

Rigid postoperative dressings were initially used in lower-limb amputees. The advantages of
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.
8B: Prosthetic Principles | O&P Virtual Library
Search
GO
Prosthetic Principles Reproduced with

permission from
Carl D. Brenner, C.P.O. Bowker HK,
Michael JW (eds):
Atlas of Limb
THE NEED FOR EARLY INTERVENTION Prosthetics:
Of all the new developments that have occurred in the past decade as regards upper-limb Rehabilitation Principles.
amputee management, nothing has made as singular an impact as recognition of the need for
early prosthetic intervention. In this context, early intervention means the application of some 1992, reprinted 2002.
form of upper-limb prosthesis within the first 30 days after amputation. Historically, the use
of traditional methods that would delay prosthetic fitting for 3 to 6 months, i.e., until full Much of the material in this text
healing had been achieved, had yielded a rejection rate of approximately 50%. However, has been updated and published
the application of a prosthesis within the first 4 weeks of amputation has dramatically
improved the long-range outcomes, with some centers reporting a success rate of prosthetic and Rehabilitation Principles
use and acceptance of 90% and higher. This improvement is believed to be due to the (retitled third edition of Atlas of
effective preservation of bimanual functional patterns resulting from early prosthetic training. Limb Deficiencies), ©American
The use of an immediate or early postoperative prosthesis has been demonstrated to be an Click for more information about
effective way to achieve the goals of early intervention. Although this procedure has been in this text.
widespread use for well over 20 years in lower-limb amputation, it has remained underutilized
in upper-limb applications despite the fact that it does not jeopardize wound healing, as is
sometimes the case in weight-bearing lower-limb situations. of the Atlas of Limb
Prosthetics was
provided by the
COMPREHENSIVE PROSTHETIC MANAGEMENT Northern Plains Chapter of the
A total of five distinctly different types of prostheses make up the armamentarium necessary Prosthetists
to provide optimum and comprehensive management for the upper-limb amputee. These five
procedures include (1) immediate/early postoperative prostheses, (2) preparatory/ training
mechanical prostheses, (3) definitive mechanical prostheses, (4) preparatory/training
electronic prostheses, and (5) definitive electronic prostheses. Listed in Table 8B-1. is the
ideal fitting timetable for the utilization of these five prosthetic procedures.
A discussion of comprehensive prosthetic management would not be complete without some
comment on the historical precedent to "save all length." Although the intrinsic advantages of tax-deductible contribution.
disarticulation surgery through the wrist have been understood for decades, the introduction
of new electronic componentry necessitates careful scrutiny on the part of the surgeon prior
to choosing the level of amputation. The two major issues are limb length and residual
pronation and supination. In those cases where amputation is carried out at the wrist, the use
of a prosthesis will frequently result in an overall prosthetic length that is cosmetically
unacceptable to the patient. This is particularly true in those instances where a quick-
disconnect wrist is employed in order to provide easy interchangeability between an electronic
hook terminal device and an electronic hand. In addition, the absence of residual pronation
and supination mitigates against disarticulation surgery if it is anticipated that the amputee will
derive greater benefit from an electronically controlled wrist rotation module. In the event that
skin grafting is necessary in order to preserve the viability of a disarticulation surgical level, a
higher-level amputation just proximal to the graft site may prove to be a better decision,
especially if the amputee will alternate between wearing an electronic prosthesis and a
mechanical body-powered prosthesis.
IMMEDIATE AND EARLY POSTSURGICAL PROSTHESES
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
inspection and management. However, the patient and the nursing staff should be advised
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
patient is alert enough to follow directions. The benefits of using immediate or early
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.
PREPARATORY/TRAINING MECHANICAL PROSTHESES

The second type of prosthesis utilized in the comprehensive management of upper-limb
amputees is the preparatory/training mechanical prosthesis. Ideally, this prosthesis is applied
at the time the sutures have been removed, generally 10 to 14 days after surgery. The major
differences between the preparatory/training prosthesis and the postoperative prosthesis are
that (1) the preparatory socket is made over a plaster model of the patient's residual limb, (2)
the prosthesis is fabricated from materials that are more durable than those in a
postoperative prosthesis, and (3) the design of a preparatory prosthesis allows for the easy
interchange-ability of various components during the evaluation process (Fig 8B-5.). It should
be understood that to be successful, a preparatory/training prosthesis should be designed and
fitted with the same care as a definitive system, even including the use of test sockets when
necessary. The primary purpose of the preparatory/ training prosthesis is threefold and
consists of preparation, evaluation, and training objectives. In terms of preparation, the
preparatory prosthesis provides (1) continued edema control, (2) a reduction of the pain and
anxiety that the patient experiences, and (3) help to condition tissues to accept the forces
exerted by a prosthetic socket. As an evaluation tool the preparatory prosthesis (1) helps the
clinic team and the patient determine which components may prove to be of the greatest
benefit, (2) assists the rehabilitation team in assessing the patient's level of motivation and
compliance, and (3) aids the patient in identifying the functional value and limitations of a
mechanical body-powered prosthesis. With regard to training, the preparatory prosthesis
helps the patient preserve two-handed function and allows the amputee to practice using a
mechanical prosthesis for the normal activities of daily living (ADL).
DEFINITIVE MECHANICAL PROSTHESES

Once the patient has worn a postoperative prosthesis for 1 to 2 weeks, followed by a
preparatory mechanical prosthesis for an additional 2 to 4 weeks, the formulation of definitive
prosthetic prescription specifications is a relatively academic matter. If the two previous
prostheses were used in the way intended, i.e., to provide a diligent evaluation of the socket
design and the harnessing system and also to determine which wrist and elbow components
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 below-
elbow (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
socket, while the Munster-style socket is the frequent choice for short transradial levels.
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 triple-
thickness 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 quick-
disconnect/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.
Advantages and Limitations

When evaluating the benefits and disadvantages of the mechanical prosthesis, several factors
emerge. Among the advantages are the freedom to operate in a carefree manner within most
physical environments and the ability to achieve a high level of accuracy and speed during
functional performance. The primary disadvantages of the mechanical prosthesis are the
discomfort caused by the shoulder harness and the cosmetic appearance of the hook terminal
device, which generates various degrees of negative attention.
PREPARATORY/TRAINING ELECTRONIC PROSTHESES

In the last decade, electronic technology has made significant strides in the field of
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
different design and component options before coming to a final conclusion. As such, the
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 cost-
effective 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
electronic touch controls. It is not uncommon for a prosthesis to have a combination of one
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.
Limb Banking and Lend-Leasing

In recent years, the formation of limb banks and corresponding lend-lease programs have
made a favorable impact on the cost and complexities of providing sophisticated electronic
limbs. The concept of a limb bank involves the collection, over a period of time, of a variety
of different kinds of electronic components, including electronic hands, electrodes and
electronic switching mechanisms, batteries, and battery chargers, all of which can be loaned
to the patient on a trial basis for a modest leasing charge. The advantage of this arrangement
is that for a fraction of the purchase cost of new electronic hardware it is possible to provide
the necessary electronics in a preparatory/training prosthesis on a very cost-effective basis. A
limb bank can generally have one of three origins for its initial development. The most
common type of limb bank is a private limb bank, generally organized and funded by an
individual prosthetic laboratory. The second type is a commercial limb bank sponsored by a
manufacturer of electronic limb components. The third type is an institutional limb bank, which
is generally organized and supported by either a hospital or a charitable organization.
Rationale For Use

As the fourth type of prosthesis used in the comprehensive management of the upper-limb
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.
DEFINITIVE ELECTRONIC PROSTHESES

After proceeding through the previous four types of prostheses, which not only exposes the
patient to the majority of prosthetic technology but also provides the opportunity to personally
evaluate both simple and sophisticated systems, the amputee and the clinic team are
positioned at a unique vantage point from which to determine the prosthetic specifications for
the long-term benefit of the patient. Since there has been a significant amount of controversy
over the past two decades regarding the respective advantages of mechanical and externally
powered prostheses, it has been found that by providing the amputee an opportunity to
personally experience the actual benefits and limitations of each of these systems, the final
choice can be made with some assurance that no major oversights have occurred. In today's
world where health care costs seem to run toward the infinite and health care resources and
funding most certainly have a finite nature, it is essential that effective methods for evaluating
high technology be utilized whenever possible. Since one of the prime sources of upper-limb
loss occurs secondary to work-related injuries, the ability of amputees to return to work or
their preinjury activities has proved to be a useful guide in measuring successful outcomes.
When the techniques described here are used, it has been documented that amputees
treated by means of the aggressive methods presented have returned to work in five out of
six cases reported.
Self-Suspended Socket Designs

An important decision to be made regarding the definitive electronic prosthesis is choice of
the socket design. Under ideal circumstances, the patient should have had the opportunity to
try more than one type of socket suspension at the time that the test sockets were being
evaluated. This is particularly true of those patients who are wrist disarticulation or long
transradial amputees. Socket designs for the transradial level fall into three basic categories:
(1) supracondylar brims that capture the humeral epicondyles and the posterior olecranon, (2)
sleeve suspensions that use either atmospheric pressure or skin traction to maintain
suspension, and (3) suprastyloid suspensions for wrist disarticulation amputees with
prominent styloids.
Among the supracondylar designs there are four basic types. These are (1) the Miinster
socket for short transradial amputations, (2) the Northwestern supracondylar socket for
midlength transradial amputations ( Fig 8B-9.), (3) the modified supracondylar brim with an
olecranon cutout for long transradial amputations, and (4) the floating-brim suspension for
long transradial and wrist disarticulation amputations (Fig 8B-10.). The sleeve suspension
techniques include (1) latex rubber sleeves, which provide atmospheric pressure suspension;
(2) neoprene sleeves, which provide a combination of atmospheric pressure and skin traction;
and (3) elastic sleeves, which provide skin traction/suspension. The third category of
suspension designs, i.e., those involving suprastyloid purchase, includes (1) silicone bladder
suspension, (2) window/door suspension with elasticized closure, and (3) soft removable
inserts that grip the styloids.
Funding, Maintenance, and Downtime

Among the concerns that come up when considering the viability of fitting electronic
prostheses are the questions of funding, maintenance, and downtime. The issue of funding
has long been one of the major obstacles in providing advanced technology to amputees.
However, in the past decade it has been found that the majority of amputees have sufficient
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
frequency as mechanical prostheses. However, the issue of downtime for maintenance can
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.
Benefits and Disadvantages

When evaluating the advantages and limitations of electronic prostheses, a mirrorlike image
of the contrast between a mechanical and an electronic prosthesis appears. For most adult
amputees, the advantages of an electronic prosthesis are in direct correlation to the
disadvantages of a mechanical prosthesis. For these amputees, the absence of a
control/suspension harness through the use of a self-suspended socket has proved to be the
biggest benefit and has provided them with a maximum degree of comfort. Other amputees
find the ability to function with a prosthesis that has a close resemblance to a normal human
hand to be of the highest level of importance.
On the converse side, these same adult amputees who wear electronic prostheses have also
come to realize that although the electronic terminal device generally provides a much
stronger grip force, it may still prove to be somewhat slower in operation than a mechanical
hook. Second, they generally find that the lack of freedom to use their electronic prosthesis
in hostile environments where dirt, water, dust, grease, and solvents are in frequent contact
with the prosthesis has proved to be a major drawback. However, this has been partially
remedied by the availability of electronic hook terminal devices such as the Otto Bock Greifer
and the Steeper electronic hook. As a result, many adult amputees have found that the best
solution is to have the freedom to choose between both a mechanical and an electronic
prosthesis at their discretion, depending on the situations in which they find themselves.
CONCLUSIONS
Each of the five prostheses described previously has proved to have a very specific role in
assisting the rehabilitation team in providing comprehensive care for upper-limb amputees.
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
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
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 Pros-
thetic-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.
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
Search
GO
Elbow Disarticulation and Transhumeral Amputation: Reproduced with

Surgical Principles permission from
Bowker HK,
Michael JW (eds):
John A. McAuliffe, M.D. Atlas of Limb
Prosthetics:
The vast majority of amputations through the humerus or elbow joint result from trauma. As Surgical, Prosthetic, and
with other types of injury, young males represent a major proportion of these amputees, Rehabilitation Principles.
which makes early functional rehabilitation critical. Tumor control remains the next most
important reason for amputation at these levels despite recent advances in oncologic surgery 1992, reprinted 2002.
favoring limb salvage procedures. Elbow disarticulation may be the level of choice for
lesions of the forearm requiring radical surgical margins if the resultant cosmetic limitations Much of the material in this text
are acceptable. Unlike the lower limb, vascular disorders account for fewer than 5% of upper has been updated and published
limb amputations and are equally likely to occur in children and young adults due to entities in Atlas of Amputations and Limb
such as fulminating purpura, the inflammatory vasculitides, and particularly Buerger's disease.
An important subset of trauma patients in whom secondary amputation is frequently a Limb Deficiencies), ©American
consideration are those with unreconstructable brachial plexus injuries. For a full discussion of Academy or Orthopedic Surgeons.
this problem, the reader is referred to Chapter 12A.
this text.
Replantation of traumatically amputated limbs is now a clinical reality. The superior potential
for neurologic recovery in children makes them candidates for these procedures with injury at Funding for digitization
almost any level. Reports of transhumeral replantation in adults are still relatively few in of the Atlas of Limb
number. Useful elbow control in these patients seems fairly predictable, while return of Prosthetics was
function to the wrist and hand is unusual and limited at best. While the functional gain of provided by the
converting these patients to transradial (below-elbow) prosthetic wearers is significant, the Northern Plains Chapter of the
potential psychological turmoil inherent in suggesting transradial amputation following
Prosthetists
successful transhumeral replantation is very real. Such "segmental replantation" is just one
example of unconventional use of portions of an amputated limb that would otherwise be
discarded in the form of microvascular free-tissue transfer. Major limb replantation entails
significant metabolic disturbance and risk and requires scrupulous medical management.
The caveat that such a procedure must result in a limb of more functional benefit than a
prosthesis must always be borne in mind.
Rigid postoperative dressings can be of value at these levels of amputation, with beneficial
effects on wound management, residual-limb shrinkage, and pain control, as well as making
immediate postoperative prosthetic fitting possible. Rigid dressings are, however, not of
such proven benefit for upper-limb amputees to have gained the level of acceptance that they
enjoy in the lower limb. Many feel them to be an unnecessary complication and expense and
cite frequently encountered difficulties with suspension. Early prosthetic fitting, within 30 days,
remains the single most important variable affecting the success of prosthetic rehabilitation
and seems to be as effective as immediate postsurgical fitting in producing this effect.
Training is usually begun by using a conventional body-powered prosthesis, with the decision
regarding final prosthetic prescription made later. The use of electrically powered prostheses,
although they are more costly and fragile, is associated with increased prosthetic acceptance
in the transhumeral (above-elbow) amputee, particularly those with shorter residual limbs.
Amputation should generally be performed at the most distal level compatible with the
disease process that will allow for adequate padding and wound closure with healthy skin.
Elbow disarticulation remains controversial even though it provides improved suspension
capabilities and rotational stability of the prosthesis because the adult amputee is limited to
cable controls and relatively weak external hinges. In addition, the full humeral length in the
case of disarticulation precludes the use of a myoelectric elbow. Disarticulation is clearly the
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
equivalent to a transhumeral level. Supracondylar amputations should take into account
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.
Muscle and Tendon

Myoplasty of the flexor and extensor musculotendinous units not only provides coverage and
control of the stump but is also an important adjunct to maintaining shoulder control inasmuch
as several of these motors cross this joint. Myodesis (suture of muscle to bone) is seldom
necessary, save for possible reinsertion of the deltoid at very proximal levels to enhance
myoelectric control. It has been suggested that a portion of the forearm extensor musculature
be reflected as a flap over the distal end of the humerus and affixed in the region of the
medial epicondyle in the case of disarticulation; however, this is not of proven benefit and is
to be avoided when attempting oncologic control of forearm lesions by radical margins.
Pectoralis cineplasty has in the past been performed to provide control of elbow locking
mechanisms; however, this technique has been made obsolete by the development of
practical myoelectric prostheses.
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.
Bone and Joints
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.
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.
Search
GO
Elbow Disarticulation and Transhumeral Amputation: Reproduced with

Prosthetic Principles permission from
Bowker HK,
Michael JW (eds):
J. Thomas Andrew, C.P. Atlas of Limb
Prosthetics:
PHYSICAL FACTORS Rehabilitation Principles.
There are several factors that are crucial when designing and optimizing transhumeral and of Orthopedic Surgeons, edition 2,
elbow disarticulation prostheses, including the following: 1992, reprinted 2002.

1. Length of the bony lever arm has been updated and published
2. Quality and nature of soft-tissue coverage in Atlas of Amputations and Limb
3. Shape and muscle tone of the residual limb Deficiencies: Surgical, Prosthetic,
4. Flexibility, range of motion, and stability of the proximal joints and Rehabilitation Principles
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 Click for more information about
minimizing the need for revision surgery. Consideration should be given to what prosthetic this text.
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, Funding for digitization
including external power.
Prosthetics was
provided by the
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 American Academy of Orthotists &
active rotary control and the possibility of a self-suspending socket, both component durability Prosthetists
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 O&P Virtual Library with a
tissue is functionally useless and serves only to complicate the prosthetic fitting. Myoplasty tax-deductible contribution.
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
to be the most common. Innervated pectoralis-to-biceps transfer has also resulted in a
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.
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
prosthetic fitting is most successful. When prosthetic rehabilitation is delayed for many
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. Soft insert with an integral supracondylar wedge

2. Fenestration with a cover plate (Fig 9B-5.)
3. Flexible bladder variants for the less bulbous remnants
4. "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.).
INFLUENCE OF HUMERAL LENGTH

Leverage for prosthetic control varies directly with the length of the humerus. Amputation
through the distal third of the humerus provides functional control very similar to the elbow
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
flexed position. Since the average adult transhumeral amputee can achieve no more than
2½ 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
precise yet powerful grip, this hybrid approach is particularly useful for hand users. If
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.
UTAH DYNAMIC SOCKET

Over the past decade, experience in fitting significant numbers of externally powered
transhumeral prostheses has led to refinements in socket design and harnessing techniques.
The author has previously described the "Utah Dynamic Socket technique" for transhumeral
socket design, which is an outgrowth of the previous work of Pentland and Wasilieff.
Mediolateral stability is enhanced by casting the remnant limb in a special fashion (Fig 9B-
12.). Careful shaping of the shoulder region adds rotational stability (Fig 9B-13.). The
properly fitted dynamic socket does not require socks for comfort or stability, although they
may be worn if desired. This socket design is suitable for either myoelec-trically controlled or
body-powered prostheses or for a hybrid prosthesis combining both options (Fig 9B-14.,A-
C).
This technique can also be adapted to provide suction suspension. With myoelectrically
controlled transhumeral fittings, suction suspension allows minimal harnessing, decreases
loading in the contralateral axilla (which may reduce deleterious effects on the sound-side
brachial plexus ), enhances proprioception, and improves EMG consistency. In selected fully
myoelectric prostheses, the harness may be totally eliminated. Contraindications to suction
socket transhumeral fittings are analogous to those for transfemoral cases and include
remnant limbs with excessively bulbous distal ends, painfully adherent distal scarring, and
fresh skin grafts. (Grafted amputations may eventually accept suction once they are well
healed and mature.) Although it is sometimes possible for the bilateral amputee to pull
himself into the socket with an appropriately designed pull sock, the difficulty of donning a
suction socket should be carefully considered (Fig 9B-15.).
While a thorough discussion of harnessing is included in Chapter 6B, one variant works
particularly well with the dynamic socket described above. The Utah inverted V harness (Fig
9B-16.) is a modification of the standard Northwestern figure-of-8 ring type. Since the socket
design enhances rotary stability, both the lateral suspensor and the anterior suspensor straps
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-Orthopädische 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.
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.
10A: Shoulder Disarticulation and Forequarter Amputation | O&P Virtual Library
Search
GO
Shoulder Disarticulation and Forequarter Amputation: Reproduced with

Surgical Principles permission from
Bowker HK,
Michael JW (eds):
John A. McAuliffe, M.D. Atlas of Limb
Prosthetics:
Amputations through the glenohumeral and scapulotho-racic articulations are uncommon. Surgical, Prosthetic, and
Tumor control remains the primary indication for amputation at this level despite efforts at Rehabilitation Principles.
limb salvage made possible by more accurate methods of preoperative localization, modern
adjuvant therapy, and advances in tissue banking. Serious injury is the next most common 1992, reprinted 2002.
cause for limb loss about the shoulder, although fewer than 3% of traumatic amputations of
the upper limb occur at these proximal levels. All other causative factors are decidedly rare. Much of the material in this text
Congenital limb deficiencies do occur this far proximally, but as at other levels, the need has been updated and published
for surgical revision is rare and usually best avoided. in Atlas of Amputations and Limb
Advances in vascular surgery have made re-establishment of blood flow to severely and Rehabilitation Principles
traumatized limbs commonplace, safe, and effective. Replantation of a limb amputated
through the shoulder girdle is, however, seldom feasible or indicated. The vast majority of Academy or Orthopedic Surgeons.
traumatic amputations about the shoulder are due to avulsion forces, and the re- Click for more information about
establishment of structural con-, tinuity is severely limited by the fact that most of these this text.
injuries occur through the scapulothoracic articulation rather than through the glenohumeral
joint with its greater ligamentous integrity. Replantation may occasionally be considered when
the skeletal and neural injuries allow repair or reconstruction, and probably then only in the
very young patient in whom some useful neurologic and functional recovery is possible. All Prosthetics was
of the caveats of major limb replantation concerning the patients overall injury status, duration provided by the
of ischemia, and the possibility of metabolic replantation toxemia must be carefully borne in Northern Plains Chapter of the
mind when such a decision is made. American Academy of Orthotists &
Prosthetists
The cosmetic deformity of forequarter amputation is significant (Fig 10A-1.). When sound
surgical judgement permits, retention of the scapula is far less disfiguring (Fig 10A-2.) and of
considerable psychological benefit to the patient. Although amputation through the surgical
neck of the humerus is functionally equivalent to shoulder disarticulation, maintenance of
shoulder width and axillary contour by the former procedure is a distinct cosmetic advantage.
This is particularly true for the female patient in whom sacrifice of the pec-toralis major You can help expand the
insertion disrupts breast contour and symmetry. Preservation of the deltoid musculature also O&P Virtual Library with a
facilitates myoelectric control of a prosthesis. tax-deductible contribution.
The amputation stump itself is of no inherent functional value at these levels because even
the ability to grasp or stabilize large objects between the residual limb and thorax will be
eliminated. The available function from a prosthetic replacement decreases as the level of
amputation progresses more proximally. Acceptance rates of conventional body-powered
prostheses therefore fall considerably for shoulder-level amputees. Electrically powered
prostheses, however, can provide important function and increase levels of acceptance, albeit
at higher cost. Rigid dressings are unnecessarily cumbersome and do not provide the
same beneficial effects on wound management and pain control as in amputees with longer
stumps. Nonetheless, early prosthetic fitting does encourage the retention of two-handed
patterns of activity and may result in significantly higher rates of long-term prosthetic use even
at these levels.
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.
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.
Muscle and Tendon

In the case of forequarter amputation, any remaining musculature, such as the pectoralis
major, latissimus dorsi, and trapezius, should be sutured together to form additional padding
and contour over the chest wall. Conventional technique for shoulder disarticulation suggests
that the rotator cuff tendons be sutured together over the glenoid, following which the deltoid
is attached to the inferior glenoid and lateral scapular border to fill the subacromial space.
Myodesis ensures consistent electromyographic localization that may improve functional
control and particularly proportional grasp for wearers of electric prostheses.
Nerves
Literally dozens of methods have been described in attempts to alleviate the problems of
amputation neuromas. As is usually the case when a plethora of techniques exist, none of
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.
Bone and Joints

During forequarter amputation, osteotomy of the clavicle should be performed at the lateral
margin of the sternocleidomastoid insertion whenever possible in order to preserve contour of
the neck. In shoulder disarticulation the articular cartilage on the face of the glenoid is left
undisturbed. Removal of acromial and cora-coid prominences is unnecessary and will further
disrupt form as well as reduce leverage for body-powered prostheses.
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..
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.
Littlewood's posterior approach is found by many to be technically easier and to involve

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.
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.
Joint Surg [Am] 1963; 45:1717.
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.
Search
GO
Shoulder Disarticulation and Forequarter Amputation: Reproduced with

Prosthetic Principles permission from
Bowker HK,
Michael JW (eds):
Robin Cooper, B.A., C.P., F.B.I.S.T. Atlas of Limb
Prosthetics:
OVERVIEW Rehabilitation Principles.
It is important in any description of the through-shoulder level of upper-limb absence to of Orthopedic Surgeons, edition 2,
distinguish between the appearance of an acquired amputation site and congenital absence 1992, reprinted 2002.
of the upper limb. Each of these groups present a separate and quite distinct clinical picture Much of the material in this text
that affects prosthetic management. has been updated and published
When considering the congenital group (Fig 10B-1.), it should be noted that the clavicle and Deficiencies: Surgical, Prosthetic,
scapula are often misshapen, may be fused, and are usually foreshortened with the lateral and Rehabilitation Principles
aspects swept upward. These features create a prominent and usually very mobile bony (retitled third edition of Atlas of
spur. The remainder of the shoulder area is often fleshy and has the potential for weight Limb Deficiencies), ©American
support, but the lack of bony structures tends to make stability a problem. The shoulder Academy or Orthopedic Surgeons.
profile drops away quite sharply from the bony point of the glenoid area, and the
this text.
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, Funding for digitization
with surfaces that are capable of bearing some weight unless they are scarred by the of the Atlas of Limb
trauma. It is unusual for the remnant shoulder musculature to be atrophied, although some Prosthetics was
muscle bulk may have been lost during the trauma or surgery. The major prosthetic problems provided by the
are therefore prosthesis stability and cosmetic appearance, in particular, retention of a natural Northern Plains Chapter of the
shoulder profile. In addition, when trying to provide for a functional device, it is sometimes
Prosthetists
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
individuals who have received surgery for ablation of a neoplasm or discuss the treatment
of the fragile stump in instances where the surface has been burned or grafted. In the You can help expand the
congenital group one might wish to include individuals with digits at the shoulder or with
similar longitudinal defi-cits.
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,
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
frame. Alternatively, a high-stiffness laminate (e.g., carbon fiber reinforcement) can be
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
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:
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.
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.
11: Adult Upper Limb Prosthetic Training | O&P Virtual Library
Search
GO
Adult Upper Limb Prosthetic Training Reproduced with

permission from
Diane Atkins, O.T.R. Bowker HK,
Michael JW (eds):
The impact of the sudden loss of a hand or arm upon a person cannot be overstated. The Atlas of Limb
Prosthetics:
loss of fine, coordinated movements of the hand, tactile sensation, proprioceptive feedback,
and aesthetic appearance can only be compensated for to a limited extent by three types of Rehabilitation Principles.
prostheses that are currently available. Rosemont, IL, American Academy
As outlined in previous chapters, the three prosthetic options include (1) a passive cosmetic 1992, reprinted 2002.
arm and hand; (2) a cable-controlled, body-powered prosthesis; and (3) an electrically
powered prosthesis controlled by myoelectric sensors or specialized switches. In reality there Much of the material in this text
are no perfect or ideal replacements that take the place of the exquisite mechanisms and
function of the human hand. Deficiencies: Surgical, Prosthetic,
An unusually high rejection rate of upper-limb prostheses can often be attributed to the (retitled third edition of Atlas of
following reasons: development of one-handedness, which removes the functional need for Limb Deficiencies), ©American
the prosthesis; lack of sufficient training or skill in using the prosthesis; poor comfort of the Academy or Orthopedic Surgeons.
prosthesis; a poorly made prosthesis; the unnatural look or profile of the prosthesis; and the Click for more information about
reactions that the wearer gets from other people. this text.
It is felt that successful outcomes in rehabilitation for the unilateral and bilateral amputee can
be attributed to the following reasons:
Prosthetics was
Early post-traumatic intervention provided by the
Experienced team approach Northern Plains Chapter of the
Patient-directed prosthetic training American Academy of Orthotists &
Patient education Prosthetists
Patient monitoring and follow-up
The focus of this chapter is to stress the importance of postoperative, preprosthetic, and
prosthetic training principles. Listening to and acknowledging the patient's psychological and
functional needs will be critically important in determining the success or lack of success with
prosthetic acceptance and function. You can help expand the
POSTOPERATIVE THERAPY PROGRAM
Awareness of postoperative and subsequent preprosthetic principles of care is crucial to
successful management of an individual who has just sustained traumatic limb loss. This
phase of care is one where the patient has little control over what is happening and must
depend upon the health care team to provide the best treatment possible.
Treatment goals of postoperative care can be addressed by any member of the rehabilitation
team, which may include the physician, nurse, and occupational or physical therapist. The
goals are as follows:
1. Promote wound healing.

2. Control incisional and phantom pain.
3. Maintain joint range of motion.
4. Explore the patient's and family's feelings about a change in body image.
5. Obtain adequate financial sponsorship for the prosthesis and training.
Promote Wound Healing

Wound healing is generally monitored by the surgeon who performed the amputation and by
the nurse. The role of the nurse cannot be overemphasized since she is the member of the
team having continuous contact with the patient during this stage of healing. The nurse will
need to be active in the patient's rehabilitation program so that those activities taught to the
patient by the occupational and physical therapists may be carried over successfully to the
nursing unit situation.
Control Incisional and Phantom Pain

Acute incisional pain is generally managed by narcotic agents given intravenously or
intramuscularly. This is necessary for the first 3 to 4 postoperative days. Transcutaneous
electrical nerve stimulation (TENS) has also been used to decrease incisional and phantom
pain in the amputated limb. This modality can be used alone or in conjunction with oral
analgesics.
The difference between a phantom limb and phantom pain should be clearly explained to the
amputee. A phantom limb is the feeling or sensation that the limb is still present, and
phantom pain is differentiated by the sensation of pain in the phantom limb. Significant
success in decreasing phantom pain has been achieved by using amitriptyline (Elavil) at
doses of 50 to 150 mg daily at bedtime. Elavil is involved in serotonin production and is
believed to modify pain perception.
Phantom limb pain may also be controlled by isometric exercise. These exercises can be
started within 5 to 7 days following surgery. Residual wrist extensors and flexors as well as
residual biceps and triceps are the muscles of choice to use in isometric exercise in
transradial and transhumeral amputees, respectively. These exercises should be performed
every other hour for 10 to 20 repetitions.
Maintain Joint Range of Motion

Maintaining adequate range of motion in all joints of the upper limb is critical. This is
particularly true in the burn patient. Full range of motion is frequently lost at the glenohumeral
and elbow joints. Additionally, scapulohumeral mobility must be maintained and strengthened.
Full flexion and extension at the elbow combined with maintaining maximum pronation and
supination of the forearm cannot be overemphasized. These motions are crucial for terminal
device placement and subsequent function.
An active exercise program should be initiated by the physical or occupational therapist. This
can begin as early as the second postoperative day. The program should be closely
supervised and include active and ac-tive-assistive joint range of motion. Gentle isometric
contractions can begin on the fifth postoperative day, and isotonic contractions can be
encouraged 7 to 10 days postoperatively. Active exercise practiced several times daily can
begin shortly thereafter and should be thoroughly reviewed with the patient.
Explore the Feelings of the Patient and Family

The emotional impact of limb loss on the patient and his family is overwhelming. Often there
is a period of depersonalization that may occur during this time when other limbs and body
systems may be involved following severe traumatic injury. Reassurance and support are
vitally necessary not only at this time but throughout the rehabilitation process. All members
of the team should respect the individual's dignity, support the patient and family throughout
the grief process, as well as offer encouragement and realistic optimism with respect to his
future generally. It is premature to discuss prosthetic component options at this time. Often
the patient and his family are not ready to hear about or see prostheses until the acute
postoperative phase has passed.
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.
PREPROSTHETIC THERAPY PROGRAM

From the time the sutures are removed to the time the prosthetic prescription is being
discussed there are many goals that are important to address. The occupational therapist is
the primary person who will be managing and monitoring this program for the upper-limb
amputee. Nursing is an important adjunct, however, and all shifts of the nursing staff should
be thoroughly familiar with each of these areas.
The goals of the preprosthetic program are as follows:
1. Residual limb shrinkage and shaping

2. Residual limb desensitization
3. Maintenance of normal joint range of motion
4. Increasing muscle strength
5. Instruction in proper hygiene of the limb
6. Maximizing independence
7. Myoelectric site testing (if myoelectric components are prescribed)
8. Orientation to prosthetic options
9. Exploration of patient goals regarding the future
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.
Residual Limb Shrinkage and Shaping

Shrinking and shaping of the residual limb is usually accomplished by compression from an
elastic bandage, intermittent positive-pressure compression, or a tubular elastic bandage. If
an elastic bandage is used, it is important that the proper technique be taught to the patient,
family, and nursing staff. A figure-of-8 wrap is one that applies more pressure distally than
proximally; elastic bandaging should never be done in a circumferential manner.
The wrapping process begins with the end of the bandage placed diagonally at the distal end
of the residual limb. The wrap should encircle the limb from behind and wrap diagonally
upward to cross over the end of the bandage. This figure-of-8 process should continue, with
each pattern overlapping the previous one by approximately two thirds the width of the
bandage (Fig 11-1.). The bandage is then secured with tape or special clasps.
No elastic bandage should be used for more than 48 hours without being washed with mild
soap and lukewarm water and thoroughly rinsed with clean water. Bandages should not be
twisted, but laid flat to dry. Washers and dryers decrease their longevity and ruin their
elasticity.
The wrap should be reapplied every few hours or more frequently if it slips or bunches. The
elastic bandage should be worn all day and all night except when bathing. A preparatory
prosthesis might also be applied early in the shaping process; however, a compression
bandage is generally preferred because it affords better monitoring of skin healing and points
of pressure.
Residual Limb Desensitization

An equally important yet often overlooked factor is desensitization of the residual limb. It can
be accomplished with gentle massage and tapping techniques (Fig 11-2.). Desensitization
can also be accomplished by vibration, constant touch pressure, or the input of various
textures applied to the sensitive areas of the limb. The patient should be encouraged to do
these techniques himself. He is aware of his tolerance and can become more "in touch" with
his body by practicing this regularly. When healing has occurred, aggressive massage will
prevent adhesions from occurring and provide additional sensory input. It should be explained
that this will improve the patient's tolerance to the pressure that will be placed on the residual
limb by the prosthetic socket.
Maintenance of Joint Range of Motion

When establishing an effective treatment program, the maintenance of joint range of motion is
essential. As stated earlier, scapular, glenohumeral, elbow, and forearm range of motions are
crucial to maintain in order to aid in the prosthetic control motions and to maximize the
functional potential of the prosthesis.
Increasing Muscle Strength

Increasing upper-limb muscle strength can be accomplished in conjunction with the range-of-
motion program. Active resistance applied by the therapist or cuff weights attached to the limb
can be utilized.
Instruction in Proper Hygiene of the Limb

Education in proper hygiene and care of the residual limb is equally important at this time.
The limb should be washed daily with mild soap and warm water. It should be rinsed
thoroughly and patted dry with a towel. This provides additional sensory input into the
residual limb as well as allows the patient to become more familiar with the changes in his
body.
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.
Myoelectric Site Testing

If a myoelectric prosthesis is being considered, this is an appropriate time to utilize a
myotester to gauge the electric potential generated by various muscles. The myotester results
should be discussed with a prosthe-tist, particularly for the proximal levels of amputation. The
occupational therapist, physician, and prosthetist should jointly determine the best positioning
for the electrodes and discuss the issues of prosthetic socket design.
Orientation to Prosthetic Options

This is an important time to orient the amputee patient and his family to prosthetic options
available to him. The unique differences between body-powered and electric components
should be comprehensively described, and examples of each should be shown and
demonstrated if possible. Photographs or slides may be reasonable substitutions, but being
able to touch the device and understand how it operates is extremely helpful and informative
for the amputee. An overview of the advantages and disadvantages of body-powered and
electric components should be clearly explained.
A careful inventory of the patient's life-style, support system, educational background, and
future goals should be explored and discussed. The amputee patient is an integral part of the
decision-making process of this prosthetic prescription. Involving the patient in decisions that
affect his own health care will help to restore a sense of control over his life.
DETERMINING THE PROSTHETIC PRESCRIPTION

The discussion of the prosthetic prescription is ideally accomplished in the presence of the
patient, physician, therapist, prosthetist, family, and third-party payer. Many amputees who
have sustained work-related injuries have the unique advantage of having a rehabilitation
insurance nurse or case manager assigned to their care. This individual is a valuable liaison
between the patient, insurance carrier, and medical providers. It is important to include these
insurance representatives in the discussion of the prosthetic prescription because they have a
direct influence on the financial approval of the prosthesis and the rehabilitation treatment
plan.
The prosthetic prescription is based on a number of criteria that should be comprehensively

addressed and recorded. These criteria frequently include the following:
1. Length of the residual limb

2. Amount of soft-tissue coverage
3. Presence of an adherent scar
4. Movement of proximal joints
5. Muscle strength in the residual limb
6. Muscle strength in the opposite limb
7. Adequate ability to learn and retain new information
8. Adequate sensation in the residual limb
9. Desire for function
10. Desire for cosmesis
11. Patient attitude and motivation
12. Vocational interests
13. Avocational interests
14. Third-party payer considerations
15. 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.
ADULT UPPER-LIMB PROSTHETIC TRAINING

Before initiating a program of upper-limb prosthetic training, one must realistically orient the
patient to what the prosthesis can and cannot do. If the individual has an unrealistic
expectation about the usefulness of the prosthesis as a replacement arm, he will be
dissatisfied with the ultimate functioning of the prosthesis and may reject it altogether. On the
other hand, if the expectations of the amputee are more realistic at the beginning of training,
then the ultimate acceptance will be based upon the ability of the prosthesis to improve the
individual's performance. It is imperative, then, that the therapist be honest and positive about
the function of the prosthesis. If he "believes in" and understands the functional potential of
the prosthesis, success can be more realistically achieved.
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.
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.
Orientation to Prosthetic Component Terminology

In view of the fact that the prosthesis has not become the patient's "arm," it is important that
the patient learn to identify the major components of the prosthesis appropriately. Any
orientation to identifying such basic aspects as the figure-of-8 harness, cable, elbow unit or
elbow hinge, wrist unit, terminal device, and hook or hand will suffice at this time.
Independence in Donning and Doffing the Prosthesis

It is important that independence be established early in donning and doffing the prosthesis
by the "pullover sweater" method. As an alternative, the "coat" method may also be used (Fig
11-3.). Bilateral amputees most often use the "sweater" method.
Prosthetic Wearing Schedule

Development of a wearing schedule is an extremely important aspect of this first visit. Initial
wearing periods should be no longer than 15 to 30 minutes, with frequent examination of the
skin for excess pressure or poor socket fit. This is particularly important for the amputee with
insensate areas and adherent scar tissue. If redness persists for more than 20 minutes after
the prosthesis is removed, the patient should return to the prosthetist for socket modifications.
If no skin problems are present, wearing periods may be increased in 30-minute increments
three times a day. By the end of a week, the upper-limb amputee should be wearing his
prosthesis all day.
Care of the Residual Limb and Prosthesis

Following amputation, the skin of the residual limb is subject to irritation and sometimes to
further injury and infection. Appropriate care of the skin is therefore a vital part of
rehabilitation. The residual limb should be bathed daily, preferably in the evening. It is
advisable to not wash the residual limb in the morning unless a stump sock is worn. Damp
skin may swell and stick to the prosthesis and may be irritated by rubbing. The limb should be
washed with mild soap and lukewarm water. It should be rinsed thoroughly with clean water.
If soap is left to dry on the skin, it may be irritating. After rinsing, the skin should be dried
thoroughly by using patting motions. Avoid brisk rubbing, which may irritate the skin. Lotions,
creams, and moisturizers should not be applied to the limb unless specific orders are given
by the physician or therapist.
The socket should be cleaned often, particularly if the individual perspires heavily. In warm
weather the socket may require cleaning at least once or twice daily. The socket should be
washed with warm water and mild soap. It should be thoroughly wiped out inside with a cloth
dampened in clean warm water. The socket can be left to dry through the night or dried
thoroughly with a towel inside if one plans to continue to wear the prosthesis immediately.
If stump socks are worn, several changes may be necessary during warm weather owing to
perspiration. If possible, the sock should be washed as soon as it is taken off, before the
perspiration dries on it. This will prolong the life of the stump socks. Mild soap and warm
water should be used, followed by the sock being thoroughly rinsed. Allow the sock to dry
slowly to avoid shrinkage.
The amputee should be encouraged to inspect his skin daily. If skin disorders develop, the
physician should be called promptly. A minor disorder may become disabling if incorrect
treatment is used. It will probably be necessary to adjust the prosthesis, and therefore the
prosthetist is generally involved at this time as well. Strong disinfectants such as iodine
should never be used on the skin of the stump.
Body Control Motions

Prior to allowing the upper-limb amputee to practice prosthetic controls training, several
motions need to be reviewed. This is best done before the prosthesis is actually applied.
1. Scapular abduction.-Spreading the shoulder blades apart in combination with humeral

flexion, or alone, will provide tension on the figure-of-8 harness in order to open the
terminal device.
2. Chest expansion.-This motion should be practiced by deeply inhaling, expanding the
chest as much as possible, and then relaxing slowly. Chest expansion may be utilized
in a variety of ways for the transhum-eral, shoulder disarticulation, or forequarter
amputee. Harnessing this motion with a cross-chest strap is determined by the
prosthetic design; in some instances of extensive axillary scarring, it may be preferred
to the figure-of-8 harness.
3. Shoulder depression, extension, and abduction.- This is the combined movement
necessary to operate the body-powered, internal-locking elbow of the trans-humeral
prosthesis. It is advisable to have the amputee practice this motion by cupping one's
hand under the residual limb and instructing the patient to press down into the palm.
This will simulate the motion required to lock and unlock the elbow in the individual
with transhum-eral amputation.
4. Humeral flexion.-The amputee is instructed to raise his residual limb forward to
shoulder level and to push his arm forward while sliding the shoulder blades apart as
far as possible. This motion applies pressure on the cable and allows the terminal
device to open. Scapular abduction and humeral flexion are the basic motions to
review with the transradial amputee.
5. Elbow flexion/extension.-It is critical to instruct the transradial amputee to maintain full
elbow range of motion. This range will enable him to reach many areas of his body
without undue strain or special modifications to the prosthesis.
6. Forearm pronation/supination.-In the long transradial amputee, it is equally important to
maintain as much forearm pronation and supination as possible. This will enable the
amputee to position the terminal device where he chooses without manually
preposition-ing the wrist unit. If the amputee has retained more than 50% of his
forearm, some degree of forearm pronation and supination is maintained.
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.
Prosthetic Controls Training

Manual controls are important to review after the prosthesis is applied. One control should be
taught at a time and then combined with others:
1. Positioning the terminal device in the wrist unit is accomplished by manual rotation
with the sound hand. In the bilateral upper-limb amputee, a force against an object in
the environment or between the individual's knees is necessary to accomplish this
positioning.
2. Rotation at the elbow turntable is manually adjusted or controlled by leaning the
prosthesis against an object.
3. The friction shoulder joint is manually adjusted with the sound hand or by applying
pressure against an object or the arm of a chair.
4. If the prosthesis has a wrist flexion unit, this can be manually controlled by applying
pressure on the button or, for the bilateral amputee, by applying pressure against a
stationary object.
Active controls are equally important to review prior to functional training. The upper-limb
amputee incorporates the body-control motions he learned previously while wearing the
prosthesis. It is essential that the harness be adjusted properly before initiating these
exercises:
1. In all proximal levels of upper-limb loss, body-powered elbow flexion is facilitated by a

forearm lift assist that counterbalances the weight of the forearm. Elbow extension is
accomplished by gravity if the elbow unit is unlocked.
2. Elbow lock/unlock is perhaps one of the most difficult tasks to learn in the operation of
a transhumeral prosthesis. The pattern of "down, back, and out" is often stated to the
amputee in an effort for him to repeat the shoulder depression, extension, and
abduction pattern. This pattern not only locks but unlocks the elbow in an audible "two-
click cycle." Practicing this task should occur in a quiet, nondistracting room where one
can hear the clicks without difficulty. This pattern may need to be exaggerated at first,
but soon it will be barely observable.
3. Before approaching terminal device operations, it is important for the amputee to
practice locking and unlocking the elbow in several positions.
4. In the shoulder disarticulation and forequarter amputee, the mechanism to lock and
unlock the elbow is often a nudge control "button" attached to the thoracic shell. By
depressing this button with the chin, one is able to position and lock the elbow where
desired.
5. It is important to clearly explain that the elbow must be locked first, in the proper
position, before one is able to operate the terminal device. As described previously,
biscapular abduction and/or humeral flexion causes the conventional terminal device to
open, while relaxing allows it to close (Fig 11-4.).
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.
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.
Functional Use Training

Functional use training is the most difficult and prolonged stage of the prosthetic training
process. The individua'ls acceptance and usage of the prosthesis is dependent upon (1) the
motivation of the patient, (2) the comprehensiveness and quality of the tasks and activities
practiced, and (3), of critical importance, the experience and enthusiasm of the occupational
therapist. The training experience is most effective if the same therapist remains with the
patient throughout the entire process.
It is extremely important to reinforce to the unilateral amputee that his prosthesis will play a
nondomi-nant functional role. The prosthetic terminal device is most useful for gross
prehension activities and to hold and stabilize objects, while the sound limb performs fine
motor prehension activities. It is unreasonable to expect the prosthesis to assume any more
than 30% of the total function of the task in unilateral upper-limb activities. The sound hand
will always be dominant for all activities performed. The therapist must be realistic and
convince the patient to view the prosthesis as a "helper."
Unilateral patterns of independence occur quickly in the amputee who has lost an arm or
hand. It is therefore essential, if possible, to fit the unilateral amputee within 1 to 2 months of
the amputation. These individuals definitely show a greater propensity for wearing and
successfully using their prostheses. This applies to all amputees fitted with body-powered or
electric components.
It is appropriate to practice activities of daily living that are useful and purposeful. Realistic
situations should be pursued so that the individual will automatically use the prosthesis when
he encounters the same activity in his daily routine. Examples include the following:
1. Cutting food
2. Using scissors
3. Dressing
4. Opening a jar or bottle
5. Washing dishes
6. Hammering a nail and using tools
7. Driving a car
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.
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.
Opening a Jar or Bottle

When opening a jar or bottle, the middle of the container is grasped by the terminal device,
and the sound hand unscrews the lid. All tension should be removed from the cable to ensure
maximum grasp on the container.
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.
Hammering a Nail and Using Tools

Hammering nails is accomplished by holding the nail in the hook fingers, rubber band guard,
or special attachment of the no. 3 or no. 7 Hosmer-Dorrance work hook. The hook should be
pronated to 90 degrees so that the nail is perpendicular to the wood. When correctly
positioned, the tip of the nail should just contact the wood.
As demonstrated (Fig 11-8.), the head of a large bolt may be secured in the hook terminal
device while the wrench is held in the sound hand to tighten or loosen the bolt. Again, the
amputee may need to be reminded that the prosthesis and terminal device are merely
"functional assists" to aid in stabilization. The sound limb always becomes the dominant and
active limb (Fig 11-9.).
An alternative design in terminal devices is illustrated by the voluntary-closing Grip II (Fig 11-
10.). This device is specifically designed by Therapeutic Recreation Systems, Inc. (TRS, 2860
Pennsylvania Ave, Boulder, CO 80803), to hold and manipulate objects by using body power
to close rather than to open the hook.
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.).
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.
Care and Maintenance of the Prosthesis

The following points are important to review with the amputee who has been fitted with a
body-powered upper-limb prosthesis. Several of these have been noted in the guide "Helpful
Hints for the Upper Extremity Amputee" from the Occupational Therapy Department at the
University of Florida.
1. The harness should be washed when soiled because perspiration stains permanently
mark the straps. A household cleaner with ammonia works well.
2. Do not iron the Velcro closures on straps.
3. The elbow lock should be cleaned frequently and kept free from abrasive materials.
4. The cable should be examined frequently for cut or worn areas.
5. The neoprene lining of the hook may need to be periodically relined for a firmer grip.
The neoprene is resistant to gasoline, oil, and other petroleum products. It should,
however, be protected from hot objects.
6. When a rubber band wears out from use, grease, or injury, cut it off with scissors, and
replace it with a new band. Rubber band applicators are obtained from the prosthetist.
Each rubber band is equivalent to approximately 1 lb of pinch force.
7. Take the prosthesis to the prosthetist as soon as damage occurs.
8. Never use the terminal device as a hammer, wedge, or lever.
9. The prosthesis should be hung up by the harness rather than by the cable or cable
strap.
10. Detergents should be avoided since they tend to dissolve the lubricating oils in the
hook and wrist unit mechanism. When an amputee washes dishes frequently, the stud
threads and bearings of the hook should be cleaned and oiled regularly.
11. Never reach for a moving object with the hook.
12. The cosmetic glove of a mechanical or myoelectric hand is easily stained. The
following substances cannot be removed unless immediately washed with water or
alcohol: ball point ink, shoe polish, egg yolk, carbon paper, colored lacquers, brightly
dyed fabric, fresh newsprint, tobacco tar, mustard/ketchup, and lipstick.
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
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. Maximize prosthetic function.

2. Maintain prosthetic components.
3. Decrease assistive devices.
4. Resume previous vocation or explore new vocational options.
5. Resume avocational interests.
6. Re-enter the family and community environment.
7. 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.
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.
Rehabilitation of Burns. Baltimore, Williams & Wilkins, 1984, p 280.
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; 16:33-
36.
12A: Brachial Plexus Injuries: Surgical Advances and Orthotic/Prosthetic Management | O&P Virtual Library
Search
GO
Special Considerations: Brachial Plexus Injuries: Reproduced with

Surgical Advances and Orthotic/Prosthetic Management permission from
Bowker HK,
Michael JW (eds):
John W. Michael, M.Ed., C.P.O. Atlas of Limb
James A. Nunley M.D. Prosthetics:
BASIC CONCEPTS Rosemont, IL, American Academy
Brachial plexus lesions can result from a variety of causes including birth injuries, gunshot 1992, reprinted 2002.
wounds, irradiation, and motor vehicle trauma. These injuries may be divided into open Much of the material in this text
penetrating trauma and closed injuries. Closed injuries produce the majority of cases and may has been updated and published
be the result of traction, compression, or traction and compression combined. Traction on the in Atlas of Amputations and Limb
brachial plexus occurs when the head and neck are moved in a lateral direction away from Deficiencies: Surgical, Prosthetic,
the shoulder. Because the brachial plexus is tethered by the clavicle and scalene muscles, and Rehabilitation Principles
forceful neck motion to the side frequently produces a traction injury to the upper brachial (retitled third edition of Atlas of
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 Click for more information about
(C8-T1). Compression injuries to the brachial plexus occur between the clavicle above and this text.
the first rib below.
Narakus' "law of seven seventies," based on experience with more than 1,000 patients over Funding for digitization
an 18-year span, estimates the current demographics: of the Atlas of Limb
Prosthetics was
provided by the
70% of traumatic brachial plexus injuries (BPIs) are due to motor vehicle accidents.
70% of the vehicle accidents involve motorcycles or bicycles. American Academy of Orthotists &
70% of the cycle riders have associated multiple injuries. Prosthetists
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 O&P Virtual Library with a
motorcycle riders while the proliferation of helmet laws increases the percentage who survive tax-deductible contribution.
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
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
transfer and the latissimus dorsi transfer are not possible with a C5-6 avulsion since
these muscles are paralyzed. Transfer of the triceps muscle to achieve elbow flexion, while
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
to the humeral shaft is certainly a possibility; however, this tendon transfer works best
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 subcutane-
ously 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
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
the serratus anterior and the trapezius muscles. Occupation is also a factor; employment
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
reported when a figure-of-8 harness and Bowden cable are used to provide body-powered
elbow flexion, sometimes with an elbow hinge that can be locked in several positions.
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
discard their prostheses over time. Leffert's excellent text notes that arthrodesis of the flail
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 body-
powered 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.).
With the widespread availability of externally powered components, limited body excursion
is now less problematic. Microswitch control requires only a few millimeters of motion and can
be utilized to operate an electric hand, an electric elbow, or both (Fig 12A-9.).
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
vascular complications. Prosthetic fitting is often complicated by residual weakness at the
shoulder or elbow. Dralle reported a case with good shoulder control and elbow flexors but no
triceps function. When the amputee attempted to operate a body-powered hook, the force
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;
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 12A-
14.).
FLAIL ARM ORTHOSES

In view of the substantial percentage of BPI amputees who reject prosthetic devices, it has
been argued that orthotic restoration is an equally plausible alternative. Wynn Parry has
reported his experience with a series of over 200 cases and states that 70% continue to use
a full-arm orthosis for work or hobby activities after 1 year.
Originally developed in London during the early 1960s, this device has recently become
available in the United States. It consists of a series of modules that can be interconnected to
provide any degree of control desired (Fig 12A-15.). For the completely flail arm, a body-
powered prosthetic hook mounted adjacent to the patient's hand is used to provide grasp (Fig
12A-16.). In essence, the patient has a prosthesis over his flail arm. Incomplete lesions
may require only the elbow or shoulder control modules.
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.
As a result of all these factors, a diagnostic prosthesis (see Chapter 8B) is strongly
recommended (Fig 12A-17.) and an interdisciplinary team approach encouraged. A
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
much less successful. Robinson has suggested 6 to 8 weeks postinjury as the optimal time
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
the device from displacing the arm downward at the shoulder. This is often a difficult task
since conventional prosthetic harnessing supports axial loads via pressure on the ipsilateral
trapezius or by encumbering the contralateral shoulder; neither approach is ideal in the
presence of BPI. One alternative is to unweight the arm with a strut along the axillary midline
attached to a waist belt or to a well-molded pelvic hemigirdle. Cool from the Netherlands
recently reported a clever approach using the weight of the paralyzed forearm acting across a
fulcrum at the radial head level to literally lever the humerus back into the glenoid fossa
(Fig 12A-18.). Although over 1,600 patients have been fitted in Europe, this approach is just
now reaching North America.
In general, any device should be as lightweight as possible to minimize inferior shoulder

subluxation. Since external power is often required, a trial with an appropriately weighted
socket can help determine tolerance for the added weight of powered components.
LIMB FUNCTION PREREQUISITES

David Simpson has summarized the prerequisites for upper-limb function as follows :
Proximal stability
Placement in space
Functional grasp
It is useful for both physician and prosthetist-orthotist to keep these principles in mind when
evaluating the patient with BPI.
Proximal stability is absolutely essential for successful fitting. The shoulder girdle and elbow
flexors must be strong enough to support the arm or arm remnant plus the orthotic/prosthetic
device. If body-powered control is anticipated, they must also be able to resist the forces
generated during cable actuation. This force typically varies between 2 kg (4.4 lb) and 10 kg
(22 lb), depending on the grip strength desired at the terminal device (Fig 12A-19.).
When shoulder stability is marginal, a trial with exercises to improve muscular control may be
warranted. Functional electric stimulation can also be helpful in strengthening residual
musculature. In the absence of intrinsic stability, the prosthetic or orthotic device must
stabilize the arm by extending well onto the torso. Many patients find this awkward or
uncomfortable, although some will tolerate it (Fig 12A-20.).
Although Rorabeck has suggested transhumeral amputation without shoulder arthrodesis,

an unstable shoulder will always compromise prosthetic function. Surgical stabilization is often
the most practical approach despite requiring several weeks' immobilization for the bony
fusion to occur. Malone et al. have suggested that postsurgical fitting with a prosthesis
immediately following arthrodesis may be useful (Fig 12A-21.).
Elbow stability can be provided by a variety of locking mechanisms. Unfortunately, many

orthoses require use of the uninvolved hand for unlocking. Wrist stability is readily achieved
since orthoses that fix the hand in slight wrist extension are well known and well tolerated.
Thumb and finger stabilization is determined individually by following accepted orthotic
principles.
Placement in space is closely related to stability and is imperative to provide a useful work
envelope and thereby allow the individual to reach above, below, in front of, and behind the
body. In cases where residual shoulder musculature can steady the arm but not support its
weight when reaching out, the utility of the prosthetic/orthotic device is severely compromised.
Orthotic control of the shoulder is cumbersome and requires extensions onto the torso, as
noted previously. Again, surgical stabilization via fusion may be preferable.
Elbow placement is more readily provided, usually by Bowden cable harnessing adapted from
transhum-eral prosthetic principles (see Chapter 6B). Because the weight of the
arm/orthosis/prosthesis provides a reliable extension moment, a locking mechanism is not
always required. A flexion moment generated by bicapular shoulder abduction, for example,
can be readily controlled by the patient to precisely counterbalance the extension forces due
to gravity. This is particularly effective when weak elbow flexors are present but shoulder
stability is good. Springs or elastics can also be used to help counterbalance the weight of
the forearm (Fig 12A-22.).
Functional grasp is readily restored in a variety of ways. Body-powered hooks of the
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
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; 70:388-
392.
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.
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
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.
12B: Fitting and Training the Bilateral Upper-Limb Amputee | O&P Virtual Library
Search
GO
Special Considerations: Fitting and Training the Bilateral Reproduced with

Upper-Limb Amputee permission from
Bowker HK,
Michael JW (eds):
H. Richard Lehneis, Ph.d., C.P.O. Atlas of Limb
Ruth Dickey, B.S., O.T.R. Prosthetics:
This chapter is concerned with the unique problems presented by the bilateral upper-limb Rehabilitation Principles.
amputee. Although it is generally recognized that the unilateral upper-limb amputee uses a
prosthesis as an assist and the sound limb for sensory feedback and fine manipulatory 1992, reprinted 2002.
activities, the bilateral amputee does not have such a choice. As such, the general principles,
preprosthetic training, prosthetic fitting and components, and prosthetic training for the Much of the material in this text
bilateral upper-limb amputee differ distinctly from those recognized in managing the unilateral has been updated and published
upper-limb amputee. in Atlas of Amputations and Limb
GENERAL PRINCIPLES (retitled third edition of Atlas of
The basic objective of prosthetic management of the bilateral upper-limb amputee is to Academy or Orthopedic Surgeons.
provide the patient with maximum function of the prostheses and residual limbs to be
this text.
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. Funding for digitization
To achieve these goals, independence in donning and doffing the prostheses is a necessity. Prosthetics was
This requires appropriate harnessing, preferably through interconnecting of the harness provided by the
systems of both prostheses, and a socket design that enhances ease of donning and doffing. Northern Plains Chapter of the
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 O&P Virtual Library with a
amputees rarely appreciate the functional advantages of a prosthetic hook over a prosthetic tax-deductible contribution.
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.
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.
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
fitting can usually be considered after 2 to 3 months. Elastic shrinkers and techniques
using elastic bandages have been found to be successful for shrinking and shaping. The
elastic shrinker provides the most consistent pressure; however, caution must be taken so
that the shrinker does not slide down the arm and produce a tourniquet effect. On short
transhumeral amputations, suspension systems are sometimes required for the shrinker to
remain in place. If supervision is inadequate, this is the safest method. The use of an elastic
bandage wrapping offers the therapist more control over both pressure and shaping.
Wrapping techniques for the short above-elbow limb frequently require use of the opposite
axilla. A conical shape is preferred for the transhumeral amputation and a screwdriver shape
for the transradial amputation. The latter preserves maximum use of residual rotation. Again,
care must be taken in wrapping so as not to produce proximal pressure, which would impair
desired shaping, increase edema, and reduce circulation. Residual limb shrinkage using a
plaster of paris bandage has also been reported effective when dealing with fatty or
edematous stumps. With this method the plaster bandage is applied and suspended from a
conventional harness. As shrinkage occurs, new bandages are applied.
Most amputees have phantom sensation, the sensation of the presence of their missing
limbs. The hands are usually felt more distinctly and over a longer period of time. Usually the
sensation diminishes within a year and generally does not interfere with training.
Phantom pain is felt as cramping, burning, or lancinating. Cramping is frequently relieved by

massage, vibration, or electrical stimulation. Burning pain, although uncommon, often requires
drug intervention. Much treatment has been unsuccessful. Lancinating pain is most frequently
caused by a neuroma and is sometimes treated by cold, vibration, or electrical stimulation.
Surgical removal of the neuroma may be required.
Immediate or Early Postoperative Fitting

Immediate postoperative fitting of the upper-limb amputee has come about as a result of the
success of this kind of fitting for the lower-limb amputee. Results of both immediate fitting
(application of a rigid surgical dressing with a terminal device at the time of surgery or in the
immediate postoperative period when the sutures are still in place) and early fitting
(application after suture removal) of the prosthetic equipment have been similar to those for
lower-limb amputees: (1) reduction in postoperative pain, (2) more rapid prosthetic use (and
thereby less dependency for some activities of daily living), (3) good psychological
adjustment, (4) reduced postsurgical edema, (5) more rapid limb desensi-tization, and (6)
rapid healing. Overall hospitalization time is often significantly reduced.
In both techniques, the amputee has the terminal device mounted in the plaster of paris
socket, and the harness system is adjustable for individual needs. As shrinkage occurs, a
new socket is fabricated. The difference between the fittings is that the immediate-fitting
socket is not removable whereas the early-fitting socket is. With these techniques the training
process precedes the fitting of permanent prosthetic equipment. Proponents of these
techniques believe that this facilitates the usual necessary adjustments in the harnessing
system and design of the trial prosthesis. Also, the amputee learns early the components of
the prosthesis and how to use them in activities of daily living rather than initially using
adapted devices and then having to change or modify the process when the permanent
equipment is delivered.
Another reason for using these early-fitting techniques is to counteract the high rejection rate
of prosthetic equipment use that is noted in the unilateral amputee. The longer he relies only
on the sound arm for accomplishing functional activities, the less likely is the amputee to
make good functional use of the prosthesis.
The most obvious candidates for immediate or early fitting are bilateral upper-limb amputees.
This group is the most profoundly dependent in all activities. The sooner some of this
dependency can be reduced, the sooner they are relieved of some of their frustration and fear
of uselessness. Even the fitting of one limb can be of significant help, especially in allowing
some independence for self-care such as eating and toilet care (Fig 12B-1.).
Early Performance of Activities of Daily Living

A program to give the bilateral amputee some degree of independence in activities of daily
living should always be initiated early. This can be done in two ways: (1) by beginning to do
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. Demographic
II. Diagnostic
III. Physical status
IV. Residual-limb descriptors
V. Sensory status
VI. Current status of activities of daily living
VII. Equipment expectations
VIII. Recommendations
PROSTHETIC FITTING AND COMPONENTS
The Bilateral Transradial Amputee

In general, all below-elbow sockets for bilateral amputees should be designed so as to
enhance easy donning and doffing, as well as to permit maximum range of residual motion.
For wrist disarticulation and the long and medium-length transradial amputation, a
conventional socket is indicated with a sufficiently low anterior trim line to permit full range of
elbow flexion. Particular attention should be paid to an intimate interface between the residual
limb and the socket to take full advantage of any residual pronation and supination. A
screwdriver-shaped cross section in the distal area will permit most efficient transmission of
residual pronation and supination to the prosthesis. Flexible elbow hinges attached to the
triceps pad are required for socket suspension and to permit pronation and supination.
For shorter amputation levels without residual pronation and supination, a socket that
encompasses the medial and lateral epicondyles is indicated so that any force applied
mediolaterally to the prosthesis will not cause displacement of the socket or at least minimize
displacement on the residual limb. Depending on the anticipated activity of the patient, the
socket is connected either to flexible hinges and a triceps pad or to metal elbow hinges, either
of the single or polycentric type, that are attached to a half cuff. This will reduce socket
displacement on the residual limb to a minimum when external loads are applied to the
prosthetic forearm. The choice of which elbow hinge to use depends on the residual limb level
and the activity of the patient and working environment. Functionally, the shorter the residual
limb, the greater the indication for a poly-centric elbow hinge so that prosthetic and anatomic
joint congruity can be approached as closely as possible. On the other hand, polycentric
hinges are more likely to require frequent maintenance, particularly in certain industrial
environments, whereas the single-pivot hinge is sturdier and requires less maintenance.
For the very short transradial amputation, a split socket with the elbow hinges attached to the
half cuff is indicated. Although this results in a reduction of force that can be transmitted to
the forearm, it is deemed far more important to provide full range of motion. It is, however,
possible to increase the forearm lift force by using a split housing so that shoulder flexion
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-de-
gree angle with the elbow flexion axis when placed on the prosthetic forearm in the medial-
volar quadrant. For high-level transradial amputations when there is no residual pronation or
supination, a separate Sierra wrist flexion unit should be installed on a constant-friction wrist.
This permits variable angulations of the wrist flexion unit in the constant-friction wrist. When
the patient's elbow flexion range is limited, the wrist flexion unit should be installed directly
distal to the end of the residual limb. This increases the radius of the flexion arc described by
the terminal device in the various flexion positions of the flexion unit, thus increasing the
effective range of operation of the terminal device in space. This is especially important for
activities near the body midline, such as personal hygiene.
In general, the forearm of all transradial prostheses, but especially those for the bilateral
amputee, should be aligned with regard to the socket in such a way that it favors an
alignment that brings the terminal device closer to the center of the body and forward and
upward. The forward-upward alignment may be as much as 30 degrees to simulate normal
elbow flexion alignment in the sagittal plane. The inward (toward the center) alignment should
be as much as cosmetically possible. Particular attention should be paid to the very short
below-elbow residual limbs because such limbs accentuate the normal carrying angle in the
frontal plane. Thus a forearm aligned coincident with the center of a very short residual limb
would fall way short in bringing the terminal device toward the center of the body and thus
would greatly diminish the function of the prosthesis, particularly with regard to personal
hygiene.
Harnessing for the bilateral transradial amputee is rather simple. Both prostheses are usually
interconnected by running the control attachment strap to the front support strap of the
opposite prosthesis. They are sewn together in the center line of the back, or they may run to
a center ring. Alternatively, some amputees prefer that each arm be harnessed independently
so that they have the option of wearing only one prosthesis on occasion.
The Bilateral Transhumeral Amputee

The medium-length or long above-elbow residual limb may be fitted best with a low lateral
socket wall such as developed by McLaurin. The anterior and posterior wings of the socket
should extend sufficiently to stabilize the prosthesis against axial rotation. Angulation
osteotomy of the humerus, as developed by Mar-quardt, gives the best rotational control.
Internal or external rotation of the humerus is thus transferred most effectively to the
prosthesis. In this case, the socket proximal trim line can be considerably shorter than in the
conventional design. The shorter the amputation level, the higher the socket trim line must
extend, particularly the posterior and anterior wings. This is necessary to provide adequate
control against longitudinal rotation as well as to provide suspension.
As previously discussed, if wrist flexion units are used, they should be of the Sierra type. The
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 friction-
controlled turntable for internal-external rotation are standard components to be used. A
humeral rotation lock may be indicated when positive locking of internal and external rotation
of the elbow and forearm on the humeral section is required for certain vocational and
avocational tasks. Although many levels of transhumeral amputations may be fitted with
prostheses with dual control cables, the short and very short levels generally do better with
some externally powered components to reduce the effort required to operate the prostheses.
Electric elbows, electric hooks or hands, or a combination of both are feasible. As previously
discussed, body-powered hooks (at least on one side) are preferred due to their versatile
grasp and reliability.
Normally, no deviation from standard alignment is necessary; however, when excursion is

limited, alignment of the forearm and wrist unit similar to that described for the transradial
amputee will enhance function. Another alignment consideration is for those amputees who
are wheelchair users. In this case, the length and alignment of the humeral section should be
such as to be compatible with the armrests of the wheelchair. In all other cases, whenever
the length of the residual limb permits, the humeral section should be lengthened and the
forearm section shortened while retaining the overall desired length. This shortens the distal
lever arm, thus bringing the center of gravity of the forearm closer to the elbow and reducing
the force required to flex the elbow. Such a differential in forearm length from the normal is
approximately 3 to 4 cm. Any further reduction of the forearm length would diminish the ability
of the patient to reach all facial and head areas.
The principle of harnessing the bilateral transhumeral amputee is similar to that described for
the bilateral transradial amputee, that is, the control attachment strap of one prosthesis is
connected to or serves as the front suspension strap of the contralateral prosthesis, thus
ensuring independence of control. The elbow control strap and the lateral suspension straps
are attached in the conventional manner.
Bilateral Shoulder Disarticulation

This amputation level is best served by the use of externally energized prostheses such as a
myoelectric or switch-controlled electric elbow or terminal device (Fig 12B-2.,A-D). It should
be noted that some clinicians and amputees are willing to sacrifice a certain amount of
function as a trade-off for the simplicity and lighter weight afforded by conventional
prostheses.
If the patient is to be fitted with functional prostheses bilaterally, the conventional shoulder
disarticulation socket configuration is indicated. If, however, only one side is to be fitted with a
functional prosthesis and the contralateral side is to be used as an anchor for harnessing, a
much smaller socket configuration on the control side may suffice.
Indications for the various components are the same as those described for the bilateral
transhumeral amputee. Various passive, free, or friction-controlled shoulder joints are
available. Those that provide motion about at least a shoulder abduction axis are indicated. If,
additionally, a shoulder flexion joint is used, it must have a 180-degree extension stop to
prevent shoulder hyperextension.
Others
Other than the shoulder joint, alignment of the bilateral shoulder disarticulation prosthesis is
identical to that described for the bilateral transhumeral amputee. Alignment of the shoulder
joint should be such that the flexion axis is skewed internally with respect to the frontal plane,
that is, it should form an angle of 30 degrees with respect to the sagittal plane.
Control harnessing for functional bilateral shoulder disarticulation amputees requires great
care. The control attachment straps should be attached somewhat superior to the
posteroinferior border of the socket so that they cross each other at an angle; otherwise they
may get caught on one another during operation. Furthermore, inadvertent operation may
result the closer the control attachment straps approach a horizontal matching alignment. An
elastic cross-back strap connecting the posteroinferior corners of the socket and a nonelas-tic
chest strap are required to stabilize the sockets against each other and to provide an intimate
interface between the socket and the patient. The front support straps are also attached to
the posteroinferior corners of the socket.
Bilateral forequarter amputees are best managed prosthetically through the use of external
power, although some function may be obtained through the fitting of conventionally
controlled prostheses through the use of perineal straps and nudge controls for the elbow
locks. Mixed bilateral upper-limb amputation levels must be treated by combining the fitting
principles described for the various levels of amputation.
PROSTHETIC TRAINING
As previously stated, the overall aim of prosthetic training for the adult bilateral upper-limb
amputee is to provide the maximum degree of independence in all activities of daily living,
both with and without prosthetic equipment. The bilateral upper-limb amputee depends
significantly more on prosthetic and other assistive/adaptive devices and the ability to skillfully
use residual body parts and motions. Therefore a framework for skill acquisition is
recommended. In following such a framework, there is no intent to force the amputee into a
rigid premeditated program. On the contrary, it has proved to be a highly successful means of
teaching the basic skills of prosthetic control, as well as providing a logical means of meeting
the specific needs of each amputee. Although a certain amount of trial and error is
necessary, a framework reduces unnecessary frustration, time, and energy. Both the amputee
and therapist have clear guidelines for monitoring progress and establishing ongoing goals.
The training period provides time for ongoing evaluation of prescribed prosthetic and assistive
devices from a mechanical and functional point of view. A sound liaison between the
prosthetist and occupational therapist permits an exchange of information about functional
performance with the prosthesis and allows time for revisions, if necesssary. Re-evaluation by
the entire team should occur periodically.
Mention should be made of the importance of a positive working relationship between the
amputee and the therapist. Training for the upper-limb amputee requires the best possible
collaboration of trainer skill and ingenuity and amputee motivation and ingenuity. The therapist
must identify those interests and needs that will create motivation to learn in the amputee.
The therapist's ability to motivate the amputee directly and to explain the importance of
training related to individual needs is crucial for building successful cooperation. For the
adult, motivation usually depends on one or more of the following: a desire for independence
in activities of daily living; cosmesis, especially that related to social and/or vocational
activities; securing or returning to employment; and participation in leisure time activities.
The therapist must have full knowledge of current prosthetic equipment, control motions of
operation, and mechanical and functional characteristics of components. This should be
combined with a sound background in upper-limb anatomy and kinesiology. Much of the
actual training is identical to that of the unilateral amputee, and the therapist should be
familiar with those principles and techniques. Also necessary are skills in practical problem
solving and a knowledge of factors that affect learning.
The amputee should continue a general conditioning program concurrent with any other
treatment and prosthetic training. The general conditioning program should continue until such
time as the use of prosthetic and other equipment and the use of residual body motions for
daily needs can maintain that same conditioning. If the amputee is largely accomplishing the
functional activities of dressing, grooming, personal hygiene, and eating, those needs are
probably being met.
Training Process
The process described includes four areas of training necessary for the transmission of basic
information, acquisition of the skills of prosthetics operation, and methods to deal with special
needs. Only the process itself will be defined and outlined; no attempt will be made to provide
step-by-step instruction in the techniques themselves. The four areas of training are
orientation and initial checkout, controls training, skills training, and functional activity.
Orientation and Initial Checkout

A clear explanation of the amputees training needs should be given, goals should be
identified and/or reviewed, cooperation elicited, and mutual goals set. As a result of the fitting
sessions during fabrication of the prostheses, the amputee is often somewhat familiar with the
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 maximum-
functioning 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
necessitated by mixed levels of amputations. Full concentration is given to teaching
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.
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
replicate normal limbs doing similar activity. The third phase of training incorporates the
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
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, psychological-
intellectual, 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.
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 voice-
actuated 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,
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.
12C: Upper-Limb Prosthetic Adaptations for Sports and Recreation | O&P Virtual Library
Search
GO
Special Considerations: Upper-Limb Prosthetic Reproduced with

Adaptations for Sports and Recreation permission from
Bowker HK,
Michael JW (eds):
Bob Radocy, B.S., M.S. Atlas of Limb
Prosthetics:
The concept of specialized adaptive prosthetic components to enable unilateral or bilateral Surgical, Prosthetic, and
handless persons to access sports and recreation activities is not new. Interest in sports and Rehabilitation Principles.
recreation has always existed for the physically challenged individual, but not until the late
1970s and early 1980s were consumer pressures sufficient to influence the direction of 1992, reprinted 2002.
commercial prosthetics. The interest in specialized prosthetic gear escalated throughout the
1980s and is expected to continue to increase in the 1990s. Much of the material in this text
Consumer groups (American Amputation Foundation, Little Rock, Ariz) and organizations such in Atlas of Amputations and Limb
as the National Handicapped Sports Association (Washington, DC) are fueling this interest Deficiencies: Surgical, Prosthetic,
and fostering an increased awareness of products and the newest technology by and Rehabilitation Principles
communicating to greater populations of the disabled public. Physically challenged persons'
expectations and attitudes have altered accordingly. The Olympics has incorporated Academy or Orthopedic Surgeons.
wheelchair racing, and special ski programs throughout the country have dramatically Click for more information about
improved the visibility of the disabled in the public eye. A consciousness of competition has this text.
been born. Mainstream participation in sports by the physically challenged is still a primary
goal. The disabled have proved that they can be competitive with the able-bodied in many
instances if they are equipped with the proper prosthetic technology.
Prosthetics was
Also encouraging this increased participation is the growth of the recreation industry itself.
provided by the
The rapid growth of recreation has affected all groups. Coupled with this is increased leisure Northern Plains Chapter of the
time for much of the population, which furthers interest in the pursuit of sports and recreation. American Academy of Orthotists &
Prosthetists
Prior to the 1980s, devices commercially available specifically for sports and recreation
activities were limited to the Hosmer-Dorrance prosthetic Baseball and Bowling Adapters
(Campbell, Calif). Prosthetists fabricated custom devices for other activities, or the patients
themselves designed adaptions for particular pursuits. Increasing demand, interest, and grass
roots product developments by consumers encouraged manufacturers to begin producing
commercial materials and componentry targeted for active physically challenged people with You can help expand the
the resultant emergence of a market. Details of developments available for specific activities O&P Virtual Library with a
will be dealt with later in this chapter. tax-deductible contribution.
Rehabilitation programs are beginning to consider the sports and recreation needs of the
patient. Rigorous activities for the unilateral or bilateral handless person cannot be considered
prior to a thorough, functional physical assessment and successful completion of a basic
rehabilitation program. A holistic approach to rehabilitation applied in a team environment is
most effective.
Traditional rehabilitation includes physical therapy, occupational therapy, and psychological

and prosthetic intervention. Recreation therapy is now also included in many progressive
rehabilitation programs. It has proved to be a functional motivator for many patients and is
especially effective in pediatrics.
Unfortunately, not all health professionals are aware of the importance and positive impact
that sports and recreation can have on a patient's overall rehabilitation progress. Federal,
state, and local rehabilitation agencies, workmen's compensation specialists, and private
insurance companies often need encouragement to ensure that a holistic therapy approach
that includes recreation considerations is provided to a hand amputee.
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. Harness-

suspended socket designs with triceps cuffs and the accompanying hardware are traditional.
Supracondylar, self-suspending sockets have experienced significant evolutionary progress
over the last decade and offer many benefits for the active individual. Partially padded or fully
lined sockets can enhance comfort. ISNY (Icelandic-Swedish-New York) sockets and other
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 body-
powered 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
improve the efficiency of power transmission. Rapid-adjust buckles allow quick cable
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
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
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.
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 Hosmer-
Dorrance 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
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
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.
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
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 ¼-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 custom-
fabricated 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.
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.

2. Billock JN: Northwestern University supracondylar suspension technique for below-
elbow 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.
12D: Trends in Upper-Extremity Prosthetics Development | O&P Virtual Library
Search
GO
Special Considerations: Trends in Upper-Extremity Reproduced with

Prosthetics Development permission from
Bowker HK,
Michael JW (eds):
Harold H. Sears, Ph.D. Atlas of Limb
Prosthetics:
INTRODUCTION AND BACKGROUND Rehabilitation Principles.
Research and development of arm prostheses has historically been spurred either by great of Orthopedic Surgeons, edition 2,
tragedies such as wars and birth defects or by the introduction of new technologies that allow 1992, reprinted 2002.
new solutions to persistent problems. One can only hope that new technologies, supported by Much of the material in this text
a more enlightened valuation of amputees' needs by society, will provide sufficient motivation has been updated and published
in the next decade. in Atlas of Amputations and Limb
The Post-World War II Era (retitled third edition of Atlas of
The late 1940s and early 1950s saw the application of new materials that had evolved from Academy or Orthopedic Surgeons.
the aircraft and other industries during the war. Steel cables applied in the classic Bowden Click for more information about
bicycle-type cable allowed the replacement of leather thongs and inefficient pulleys. this text.
Aluminum manufacturing made hook-type terminal devices more durable and light, and
neoprene linings made of improved rubber materials allowed better fric-tional surfaces.
Laminated sockets made of new resins with fiberglass and other materials allowed better- of the Atlas of Limb
fitting, lighter-weight, and cosmetic sockets to be made for arm prostheses without long hours Prosthetics was
of hand labor. Locking elbow joints made of aluminum and steel finally provided active provided by the
positioning with locking at the elbow for the transhumeral (above-elbow) amputee. Northern Plains Chapter of the
Prosthetists
External Power Beginnings
In the late 1960s and early 1970s, the first generation of portable batteries, electronic circuits
using transistors, and small electric motors allowed the first electric hands to be developed by
the Viennatone and Otto Bock Company in Europe and the Veterans
Administration/Northwestern University (VA/NU) electric hand in the United States. The Otto
Bock hand survives from that era, although much changed and improved since its earliest O&P Virtual Library with a
versions. tax-deductible contribution.
Early electric elbows were developed at Massachusetts Institute of Technology (MIT)

(sponsored by Liberty Mutual Insurance Company), as well as the Veteran's Administration,
Rancho Los Amigos Hospital, the INAIL (Officina Orthopedia per Invalidi del Lavoro) Center
in Italy, and several other centers.
Second-Generation Externally Powered Devices

Evolution of smaller, more powerful electric motors and better batteries allowed both hands
and elbows to evolve to a more natural-appearing prosthesis. As mentioned, the Otto Bock
hand became more efficient, with sufficient miniaturization so that a completely self-contained
transradial (below-elbow) prosthesis can be made for most amputees. Very ambitious
multiple-motion hands such as the Sven hand in Sweden as well as others in Yugoslavia,
Japan, and Canada were developed. These hands, with a much more anthropomorphic
design of multiply hinged fingers, have not yet proved to be commercially feasible.
The Utah Artificial Arm, a transhumeral prosthesis offering proportional control of both hand
and elbow, utilized advanced techniques for electromyographic (EMG) control applied in a
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.
Approaches Developed for EMG Control

Evolution of transistorized circuits finally allowed practical EMG amplifiers to be used in a
prosthesis. Computers allowed researchers to investigate more sophisticated control
methodologies in an effort to create a naturally performing arm with multiple degrees of
freedom. Simpson and others, faced with the challenge of hundreds of thalidomide-induced
birth defects, were the first to attempt a method of "natural" extension of remnant limb
function called extended physiologic proprioception (EPP) by using pneumatic actuators
without a great deal of electronic sophistication. Pattern recognition was an alternate
technique that attempted to recognize the intent of the amputee based on the pattern of
EMGs from several muscles in the remnant limb. Statistical analysis of the EMG from a
single muscle by using autoregressive moving average (ARMA) techniques was attempted at
the University of Illinois. Jacobsen's postulate control, pursued at the University of Utah, is
based on the ability of the EMG to linearly predict the force in a muscle and thus for the
muscles of the shoulder to predict the torques about the shoulder of the amputee. With the
estimated force information, the commands to the prosthesis are computed by using
kinematic equations of a normal arm linkage to produce a more or less "natural" control of the
limb. Although no arms with simultaneous multiple degrees of freedom are commercially
available, some of this work provided a theoretical basis and test bed for products that were
eventually commercially available, e.g., the Utah Arm, and may form the basis for other
developments in the future.
Sensory Feedback Systems

Several research groups have developed laboratory-tested systems and have even field-
tested prototype feedback systems extensively. The group at the University of New Brunswick
utilized an electrotactile display to the amputee, which represented the pinch force of the
thumb vs. the first finger of the hand. A nerve stimulation technique was utilized at Duke
University, with a telemetry system transmitting across the skin so that the stimulation of the
nerve would be proportional to the pinch force on the tips of a hook terminal device. Some
prototypes from the early field tests remain in place today. A vibrotactile skin interface was
utilized by Shannon in Australia, who sensed pinch force of the hand tips via strain gauges.
At the University of Utah, experiments were conducted with a mechanism that simply pushed
against the skin with a force proportional to the pinch force at the tips of a hook terminal
device. This method was dubbed extended physiologic taction (EPT). Laboratory tests
demonstrated that this simple feedback was capable of improving a subject's control over the
terminal device to near-normal levels.
None of the experimental systems described have achieved widespread commercial

application due to limitations such as size, cost, technical stumbling blocks, or the lack of
extended funding necessary to develop a practical system.
Terminal Device Development

Several new hook-type (or "nonhand") terminal devices have resulted from research in the
1970s. The Child Amputee Prosthetics Program (CAPP) terminal device, the work of the late
Carl Sumida of UCLA, introduced replaceable soft plastic covers and a center-pull cable
actuation, although some object to the "lobster claw" appearance. The Grip terminal device by
Therapeutic Recreation Systems was the first new voluntary-closing terminal device to be
offered since the American Prosthetic Research Laboratory (APRL) hook and hand
developments of the early 1950s. The Grip voluntary-closing approach has now been
expanded to child sizes as well as adult versions.
Other terminal device innovations have included the ACRU hook with classic Dorrance-type
finger shapes, plus a special adapter attached to the user's own tools, and the "Contour
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.
FEASIBLE DEVELOPMENTS WITHIN 10 YEARS
Body-Powered Arm Systems

Although the "sound and fury" over the last two decades of upper-limb prosthetics research
has been generated by externally powered arm and hand research, a resurgence of interest
in body-powered arm systems is beginning. It is apparent that externally powered systems
have limitations in distribution (primarily due to a lack of third-party funding) and in
applications in extremely rugged situations where environmental conditions would damage
electronic components. Also, the weight and maintenance of a precise socket fit remain
drawbacks to most myoelectric systems.
New materials have raised the possibility of more efficient actuation of body-powered
systems. Fibrous cables woven of extremely high strength polymers promise to make possible
a more efficient body-powered system of lighter weight. Better cosmesis may also be
possible due to internal routing of the more flexible fibrous cables.
The new body-powered elbow under development at the University of Utah seeks to
implement internally routed fibrous cables in a new mechanism that will allow cable recovery,
i.e., limited cable excursion can be "reused" by a rachet-type mechanism. Strong and
lightweight plastic shells are also in development, as well as plans for a multidirectional wrist.
Children's Hospital at Stanford has experimented with hydraulic actuation in which hydraulic
pressure generated by a harness pull (usually between the amputee's scapulae), allows a
hydraulic "slave" to drive the terminal device and/or other motions. A flexible tube containing
hydraulic fluid connects the cylinder in the harness with the terminal device. At this time,
however, hydraulic actuation is not considered to be practical by the Stanford group.
An alternative harnessing technique for transradial prostheses evolved from a student design
project at Stanford. Triceps power capture (TPC) harnessing utilizes a latch that harnesses
elbow extension directly to terminal device opening, but when unlatched allows the elbow to
swing freely. The evaluation reports the expected benefit of freedom from shoulder
harnessing, although accompanied by the awkwardness of the operation of the latch. Work
at Delft University also seeks to harness elbow extension to operate a children's-sized
hand that could be more comfortable and cosmetic by eliminating the shoulder harness.
Novel pulley-routing methods to eliminate the external cable housing (which adds weight and
interferes with clothing) have been the topic of private investigations by arm amputee Joe
Ivco. He too seeks a more efficient and lighter-weight cable actuation mechanism (see Fig
12D-1.).
The "lift pulley" by Carlson (see Fig 12D-2.) is another simple device that could increase
the efficiency and lifetime of a body-powered control cable by eliminating the sharp bend of
the traditional lift tab. Preliminary results by Carlson indicate from 20 to 100 times longer
cable life over this particular wear point.
Terminal Device Designs

New materials and new designs hold the promise for improved terminal devices. Much current
work continues to focus on nonhand approaches. A Stanford design (see Fig 12D-3.) allows
both voluntary-closing and voluntary-opening actuation in a nonhook, nonhand pre-hensor
shape. The CAPP terminal device is currently being developed in an adult size to allow a
continuous utilization of this same terminal device shape by those amputees who started with
the CAPP children's device. The Utah Terminal Device, developed by the author and
others at the University of Utah (Fig 12D-4.), was designed to offer more efficient gripping
shapes without sacrificing the advantages that have been proved in the Dorrance-type hooks.
New terminal device designs have several features in common, notably the application of
modern materials to improve the weight, durability, and appearance of traditional hook-type
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 voluntary-
opening 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 body-
powered 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.
Socket Designs for Transhumeral and Shoulder Disarticulation

Modern materials for sockets may allow improvements in the comfort and weight required to
be suspended on the amputees remnant limb. Flexible materials either molded (such as
room-temperature vulcanization [RTV] silicone materials) or vacuum-formed (such as Surlyn
and others) are being used regularly in lower-limb prosthetic sockets and are beginning to be
applied to upper-limb sockets as well. Greater flexibility reduces hard edges and surfaces
and allows the prosthetist to experiment with more intimately fitting techniques that promise
better comfort, just as a snug-fitting ski boot provides better comfort and control than a loose
one. New fibers such as Kev-lar, Spectra, and improved fiberglasses should allow
prosthetists to make lighter-weight and stronger sockets since fewer layers of material will be
required. Breathability, i.e., allowing amputees greater transpiration of heat and perspiration,
may be possible eventually. Variations on the traditional double-wall socket are being
explored currently by incorporating a flexible inner socket with a "skeletal" outer suspension.
Much of the medial surface of the socket can be single walled, which proves to be somewhat
cooler. New transhumeral socket shapes are also being developed with the more flexible
materials mentioned above. Sockets narrow in the mediolateral dimension for transhumeral
amputees apply techniques evolved for the new-style "ischial containment" sockets for
transfemoral (above-knee) amputees. Such intimate-fitting sockets can often be self-
suspending as well. Self-suspending suction sockets, routinely fitted to transfemoral
amputees, have also proved feasible for some longer transhumeral amputees. Shoulder
disarticulation designs are evolving to utilize newer, lightweight vacuum-formable materials
and techniques that transfer the weight of the prosthesis over the load-bearing areas of the
shoulder, with stabilizing "wings" around the lower part of the rib cage. Computer-aided
design/computer-aided manufacturing (CAD/CAM) techniques being developed for the lower
limb may soon be applied in upper-limb sockets. Sensing shapes for a transhumeral socket
may be awkward since a circumferential apparatus will not be possible with the remnant limb
in an anatomic position. Transradial sockets, however, should be feasible. The other promise
of CAD/CAM techniques is easy modification of the shape by using the digitized image. Part
of the challenge of using CAD/CAM techniques will be the intimate fittings being sought in the
upper limb, especially for myoelectric prostheses.
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 upper-
limb 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 agonist-
antagonist 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
skin-electrode interface. Some work in this area continues at the University of New
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 fore-
quarter amputee. Locking shoulder joints designed, with the other components, at the
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.
Externally Powered Hands

Progress is likely in externally powered hands because in this area (more than others)
developments may be "market driven." Since amputees have a strong desire for
improvements and since all prostheses require some type of terminal device, the market is
large enough that manufacturers may realize a return on their investment. This area is also
promising because several technical improvements are feasible.
Electric motors continue to improve each year. Innovations such as brushless dc motors and
cobalt samarium magnets are lowering the size and weight required to deliver a specific
torque output. Improved motors will allow not only smaller and lighter hands but also more
efficient energy consumption for longer battery life.
Composite/plastic structural materials also offer promise for lowering the weight of artificial
hands when used to replace metal structural elements and gearing. Heretofore, plastic
materials have not had equivalent strength-weight ratios to metals, but the gap is narrowing.
New design approaches in hands should provide a greater range of gripping modes.
Examples include the hand under development at Princess Margaret Rose Hospital in
Scotland, as well as other hands under development that promise a compliant grip, (i.e.,
fingers that curl around an object). A modular system of knuckle and thumb drives is
planned so that as many as six sizes could be produced from symmetrical structural
components. A wrist-driven child's hand is also being produced (Fig 12D-8). Silicone
production gloves are under development also, with the goal of more cosmetic and cleanable
gloves (Fig 12D-9.). It is also likely that hands with tip prehension between the thumb and
first finger will be developed so that two fingers may have a key-grip-type prehension that
has not been available in electric hands.
Variations of currently available hands will be seen, likely with added improvements in
reliability and lighter weight. The Otto Bock hand in 1990 has been introduced in a child's size
with a direct drive from a two-motor, synergetic drive in the palm that eliminates some
gearing used in previous adult hands (see Fig 12D-10.). A similar drive will also be made for
the adult-sized Otto Bock hand.
Reviving the pneumatic drive approach used in previous decades, work at Delft University in
The Netherlands is seeking to develop a child-sized hand powered by small gas canisters.
Since greater energy storage is possible in such a canister than in an equivalent-weight
battery, a lighter, faster, and smaller hand for children may be possible.
Gloves for externally powered hands should see the use of reinforced silicone materials that
are more easily cleaned and more natural looking. A need exists for gloves that are more
readily custom-colored to the skin tone of the amputee, as well as gloves that are more easily
replaced by the users themselves.
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
potentials of a nerve over a long period of time. Efficient telemetry electronics will also be
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.
Some more recent work at MIT uses a prosthesis control emulator to compare control
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.
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 2½ 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.
COMMENTS ON THE RESEARCH AND DEVELOPMENT

ENVIRONMENT IN UPPER-LIMB PROSTHETICS
Those interested in the development of new upper-limb prosthetic devices face a
predicament: great possibilities without the availability of sufficient resources to achieve them.
This shortage of resources can be traced directly to the small size of the patient population.
Research funding, usually distributed according to the size of the population of need,
allocates but a sliver of total medical research funds for the development of prosthetic
devices. Also, industry cannot expect a high-volume return from their development efforts for
the small upper-limb amputee population.
Development is also hindered by the fact that traditional reimbursement levels in prosthetics
are based on devices made with older technologies, usually with lower manufacturing costs.
New devices invariably cost more than the older devices they replace because of the capital
costs of starting new products in addition to development costs. This situation is inherently
frustrating for both the amputee and the developer, who can see the technology developed for
other industries, e.g., aircraft, robotics, consumer electronics, etc., that still awaits application
in artificial limbs. For example, an artificial hand with compliant gripping modes, sensory
feedback, lifelike cleanable gloves, and a reasonable weight is now technically feasible with
presently available technology. However, the price tag necessary to deliver such a prosthesis
would probably not be reimbursed by any present funding sources, either private or
governmental.
Another effect of the meager funding available for prosthetics research is that very little basic
research can be pursued in this area. Rather, prosthetics must adapt technologies from other
industries, e.g., electronics, composite plastics, batteries, etc., to problems in prosthetics.
Research centers as well as industrial research also have difficulty gaining and maintaining
momentum because of limited funding in prosthetics research. A team with experience and a
track record takes several years of continuous work to establish, and discontinuities in funding
break up a development team so that the advantage of continuous experience in the field is
lost along with the momentum.
However, one positive aspect of prosthetics research is that when new technologies become
available, prosthetics is an area where significant progress can be made rapidly. Also, such
improvements affect not just the performance of a mechanical device, but have a profound
impact on an amputee's life and livelihood. Studies have shown the cost-effectiveness of
successful rehabilitation. Potentially this can be used to influence both funding sources and
reimbursement sources to value the improvements of research and development for their life-
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:
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
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.
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; 17:51-
62.
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.
13: Normal Gait | O&P Virtual Library
Search
GO
Normal Gait Reproduced with

permission from
Jacquelin Perry, M.D. Bowker HK,
Michael JW (eds):
Walking depends on the repeated performance by the lower limbs of a sequence of motions Atlas of Limb
Prosthetics:
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 Rehabilitation Principles.
muscle action that is selective in both timing and intensity. Normal function is also optimally Rosemont, IL, American Academy
conservative of physiologic energy. Pathologic conditions alter the mode and efficiency of of Orthopedic Surgeons, edition 2,
walking. The loss of some actions necessitates substitution of others if forward progression 1992, reprinted 2002.
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 has been updated and published
becomes able to define the significant deficits and plan appropriate corrective measures. in Atlas of Amputations and Limb
NORMAL GAIT (retitled third edition of Atlas of
Gait Cycle Click for more information about
this text.
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 Funding for digitization
these intervals varies with the walking speed. There also are minor differences among of the Atlas of Limb
individuals. Prosthetics was
provided by the
The reciprocal action of the two limbs is timed to trade their weight-bearing responsibility Northern Plains Chapter of the
during a period of double stance (i.e., when both feet are in contact with the ground) and
Prosthetists
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.
Functional Elements
The three components of walking-progression, standing stability, and energy conservation- You can help expand the
involve distinct functional patterns. These need to be understood for an appropriate O&P Virtual Library with a
interpretation of some of the limitations displayed by patients. Although for this description tax-deductible contribution.
they will be separated, during walking all three action patterns are intertwined throughout
each stride.
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,
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 weight-
bearing 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
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.
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
joint. The point of heel contact is lateral to the middle of the ankle joint (Fig 13-10.). This
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.
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
response. Persistence of the biceps femoris (long head) probably relates to its external
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.
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
and fifth metatarsal heads is 28 degrees anterior to the coronal plane. Inversion of the
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
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.).
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 less-
demanding 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
human locomotion. Proceedings of the 2nd IEA Conference, Dortmund, W Germany,

1964. Ergonomics 1965; (suppl):53.
8. Ralston HJ: Energy-speed relation and optimal speed during level walking. Int Z
Angew Physiol 1958; 17:277.
9. Saunders JBCM, Inman VT, Eberhart HD: The major determinants in normal and
pathological gait. J Bone Joint Surg [Am] 1953; 35:543.
10. 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.
11. 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.
12. Perry J: Gait Analysis of Normal and Pathological Function. Slack Inc, 1992.
14: Analysis of Amputee Gait | O&P Virtual Library
Search
GO
Analysis of Amputee Gait Reproduced with

permission from
Norman Berger, M.S. Bowker HK,
Michael JW (eds):
Atlas of Limb
*Much of the material in this chapter is taken from the manual Lower-Limb Prosthetics:
Prosthetics, 1990 Revision, Prosthetics and Orthotics, New York University Surgical, Prosthetic, and
Post-Graduate Medical School. Permission to reprint is gratefully acknowledged. Rehabilitation Principles.
With equipment such as force plates, electrogoniome-ters, and electromyographs, a number of Orthopedic Surgeons, edition 2,
of research studies have presented objective, quantified analyses of amputee gait. Clinicians, 1992, reprinted 2002.
however, tend to rely on observational gait analysis to provide information about prosthetic fit, Much of the material in this text
alignment, and function for the individual patient. This simpler, more immediately available has been updated and published
procedure requires only the eye, the brain, and sufficient expertise to produce clinically useful in Atlas of Amputations and Limb
insights and understanding. Although the future may see sophisticated measurement Deficiencies: Surgical, Prosthetic,
equipment efficient and inexpensive enough to be used routinely in daily treatment programs, and Rehabilitation Principles
observational gait analysis remains the procedure of choice for the present and is therefore
the focus of this chapter. Academy or Orthopedic Surgeons.
Basically, observational gait analysis involves the identification of gait deviations and this text.
determination of the causes associated with each deviation. With this accomplished, the
treatment team can then plan and recommend corrective actions to improve the situation.
This process works well so long as the clinic team understands normal gait, biomechanics, Funding for digitization
and prosthetic fit and alignment. The component parts of the gait analysis procedure are as of the Atlas of Limb
Prosthetics was
follows:
provided by the
1. Observation.-It is essential to observe from at least two vantage points. Sagittal-plane American Academy of Orthotists &
motions are best seen from the side, while frontal-plane motions are best seen from Prosthetists
the front or rear.
2. Identification of gait deviations.-The phrase "gait deviation" is defined as any gait
characteristic that differs from the normal pattern. While all our detailed knowledge of
normal locomotion will be useful, keep in mind that the single most outstanding
characteristic of the normal pattern is symmetry. Thus, for the unilateral amputee
deviations are often identified by observing asymmetry, that is, differences in the You can help expand the
patterns of the prosthetic and normal sides. O&P Virtual Library with a
3. Determination of causes.-The obvious place to look is at the prosthesis, and it is tax-deductible contribution.
certainly true that there are many prosthetic causes for gait deviations. However, it is
equally true that there are many non-prosthetic causes. A particular patient may have
restricted range of motion at one or more joints, muscular weakness, concomitant
medical conditions, excessive fear, or old habit patterns, any of which may cause
deviant gait. Analyze the prosthesis, but do not ignore the patient.
ANALYSIS OF TRANSTIBIAL (BELOW-KNEE) AMPUTEE

GAIT
A number of important deviations that may appear in the gait of transtibial amputees are
discussed below. To assist in observing these sometimes subtle characteristics and in
understanding their causes, the phase of the walking cycle in which each deviation occurs is
identified.
I. Between heel strike and midstance

A. Excessive knee flexion
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
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
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.
ANALYSIS OF TRANSFEMORAL (ABOVE-KNEE) AMPUTEE

GAIT
Eleven common transfemoral deviations and their usual causes are presented. The sequence
of presentation is based on the preferred vantage point for observation, with the first 6
deviations best viewed from the rear or the front and the remaining 5 best seen from the
side.
LATERAL TRUNK BENDING

Description: The amputee leans toward the amputated side when the prosthesis is in stance
phase (Fig 14-4.).
When to observe: From just after heel strike to mid-stance.
How to observe: From behind the patient.
Causes:
1. Weak hip abductors. By shifting the center of gravity toward the prosthesis, lateral
bending counteracts the tendency toward pelvic drop on the sound side.
2. Abducted socket. This alignment fault reduces the effectiveness of the hip abductors in
stabilizing the pelvis. The resulting tendency of the pelvis to drop on the sound side is
counteracted by lateral trunk bending.
3. Insufficient support by the lateral socket wall. If the lateral wall does not block lateral
movement of the femur, the pelvis will tend to drop on the sound side when the
prosthesis is in stance phase. To check this tendency, the amputee leans toward the
prosthesis.
4. Pain or discomfort, particularly on the lateral distal aspect of the femur. By bending to
the prosthetic side, the amputee relieves pressure on the lateral aspect.
5. Lateral trunk bending. This is usually present when an amputee walks with an
abducted gait. Most of the causes of abducted gait can be responsible for lateral
bending.
6. Short prosthesis.
WIDE WALKING BASE (ABDUCTED GAIT)

Description: Throughout the gait cycle, the width of the walking base is significantly greater
than the normal range of 5 to 10 cm (2 to 4 in.). There is exaggerated displacement of the
pelvis and trunk (Fig 14-5.).
When to observe: During the period of double support.
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.
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
Description: Medial whip-At toe-off the heel moves medially (Fig 14-8.). Lateral whip-At toe-
off the heel moves laterally (Fig 14-8.).
When to observe: At and just after toe-off.
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 ROTATION AT HEEL STRIKE

Description: As the heel contacts the ground, the foot rotates laterally, sometimes with a
vibratory motion (Fig 14-9.).
When to observe: At heel strike. How to observe: From in front of the patient.
Cause: Too hard a heel cushion or plantar-flexion bumper.
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.
UNEVEN HEEL RISE

Description: Usually the prosthetic heel rises higher than the sound heel. However, the
reverse may also be seen, that is, the prosthetic heel rises less than the sound heel (Fig 14-
11.).
When to observe: During first part of swing phase.
How to observe: From the side.
Causes: Excessive heel rise results when the following are present:
1. Insufficient friction at the prosthetic knee.

2. Insufficient tension or absence of an extension aid.
3. Forceful hip flexion to ensure that the prosthetic knee will be extended fully at heel
strike.
Insufficient heel rise results when the following are present:
1. Excessive friction at the prosthetic knee.
2. Too tight an extension aid.
3. Fear and insecurity. The amputee walks with little or no knee flexion.
4. Manual knee lock.
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.
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.
UNEVEN STEP LENGTH

Description: The length of the step [*The term step refers to the distance between successive
positions of the sound foot and prosthetic foot. The total length of the stride taken with each
foot will be the same ("stride" signifies the distance between successive positions of the same
foot.) taken with the prosthesis differs from the length of the step taken with the sound leg.
When to observe: During successive periods of double support.
Causes:
1. Pain or insecurity causing the amputee to transfer his weight quickly from the
prosthesis to his sound leg. To do this he takes a short, rapid step with his sound foot.
2. Hip flexion contracture or insufficient socket flexion. Any restriction of the hip extension
range must be reflected by a shorter step length on the sound side.
3. Insufficient friction at the prosthetic knee or too loose an extension aid. The pendular
swing of the shank produces a prosthetic step length that is longer than the step
length on the sound side.
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.
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.
15: The Energy Expenditure of Amputee Gait | O&P Virtual Library
Search
GO
The Energy Expenditure of Amputee Gait Reproduced with

permission from
Robert L. Waters, M.D. Bowker HK,
Michael JW (eds):
Although there is a considerable body of literature on the physiologic energy expenditure of Atlas of Limb
Prosthetics:
amputee gait, a direct comparison of the results of the different studies is difficult for the
following reasons. First, young (usually traumatic) amputees are not consistently distinguished Rehabilitation Principles.
from older (usually vascular) amputees, and there are significant differences between these Rosemont, IL, American Academy
two groups with respect to gait performance. Second, there is often no distinction between of Orthopedic Surgeons, edition 2,
amputees who use upper-limb assistive devices and those who do not. Third, the adequacy 1992, reprinted 2002.
of prosthetic fit and prosthetic gait experience is not always specified. Therefore the majority
of the data presented in this review are based on investigations that utilized consistent has been updated and published
procedures conducted in the Pathokinesiology Laboratory of Rancho Los Amigos Medical in Atlas of Amputations and Limb
Center. Deficiencies: Surgical, Prosthetic,
ENERGY SOURCES Limb Deficiencies), ©American
After several minutes of exercise at a constant sub-maximal work load, the rate of oxygen Click for more information about
consumption reaches a level sufficient to meet the energy demands of the tissues, and a this text.
"steady-state" condition is achieved that reflects the energy expended during the activity.
Aerobic Oxidation of the Atlas of Limb
Prosthetics was
The functional unit of energy for muscle contraction is adenosine triphosphate (ATP). In provided by the
aerobic oxidation (citric acid cycle), carbohydrates and fats are oxidized through a series of Northern Plains Chapter of the
enzymatic reactions leading to the production of ATP. The net equation for the aerobic
Prosthetists
metabolism of glucose is as follows:
Glucose + 36ADP + 36P i + 36H+ + 60 2 —> 6C02 + 36ATP + 42H2 0,
where ADP is adenosine diphosphate.

Anaerobic Oxidation tax-deductible contribution.
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).
Aerobic vs. Anaerobic Metabolism

During continuous exercise there is an interplay between the aerobic and anaerobic metabolic
pathways that depends on the exercise work load. During mild or moderate exercise the
oxygen supply to the cell and the capacity of aerobic energy-producing mechanisms are
usually sufficient to satisfy ATP requirements. During more strenuous exercise both anaerobic
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.
Walking, Power and Work Units

The terms power and work are utilized to describe energy expenditure. The power
requirement (rate of 0 2 consumption) is the milliliters of 0 2 consumed per kilogram body
weight per minute (mL/kg-min).
Physiologic work is the amount of energy required to perform a task. Physiologic work (02
cost) during level walking is the amount of oxygen consumed per kilogram body weight per
unit distance traveled (mL/ kg-m). The 0 2 cost is determined by dividing the power
requirement (rate of energy expenditure) by the speed of walking. By comparing the energy
cost of pathologic gait to the corresponding value for normal walking, it is possible to
determine the gait efficiency.
The rate of 0 2 consumption relates to the level of physical effort, and the 0 2 cost determines
the total energy required to perform the task of walking. In the interpretation of data, it is
extremely important to recognize that the velocity is in the denominator and the rate of 0 2
consumption is in the numerator of the energy cost calculation. Commonly there is a
misinterpretation of the clinical data concerning the 0 2 cost and 0 2 rate. The 0 2 cost may be
elevated, thus indicating a physiologically inefficient gait, but the rate of 0 2 uptake may be
normal, and the subject will therefore not experience fatigue during customary walking
activities but, however, will be limited by the slow speed.
Maximal Aerobic Capacity

The maximal aerobic capacity (V0 2 max) is the highest oxygen uptake an individual can attain
during physical work while breathing air at sea level. It is the single best indicator of
physical fitness. Generally an individual is able to reach his V02 max within 2 to 3 minutes
of exhausting work.
Age influences the V02 max. Up to approximately 20 years of age, the maximum oxygen
uptake increases. Thereafter, the maximum oxygen uptake declines primarily due to a
decrease in both maximum heart rate and stroke volume and generally due to a more
sedentary life-style. Differences in body composition and hemoglobin content are factors
that account for a difference in the V02 max between the sexes.
The maximal aerobic capacity also depends on the type of exercise performed. The oxygen
demand is directly related to the muscle mass involved; therefore, the V02 max during upper-
limb exercise is lower than with the lower limbs. For any given work load, however, heart rate
and intra-arterial blood pressure are higher in upper-limb exercise than lower-limb exercise.
Oxygen Pulse
In the absence of cardiac disease, there is a linear relation between the rate of 0 2 uptake
and heart rate.
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.
A sedentary life-style has the opposite effect on maximum oxygen consumption. Not only
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.
Energy Expenditure During Normal Walking

At the chosen walking speed (CWS), the rate of oxygen consumption for young adults aged
20 to 59 years and senior subjects between 60 and 80 years of age does not significantly
differ and averages 12.1 and 12.0 mL/ kg-min. Expressed as a percentage of the V02 max,
the rate of oxygen consumption at the CWS requires approximately 32% of the V02 max of an
untrained normal subject 20 to 30 years of age and nearly 48% of the V02 max of a senior
subject 75 years of age. The RER is less than 0.85 for normal subjects of all ages at their
CWS, thus indicating anaerobic metabolism is not required.
Senior subjects have a slightly lower rate of oxygen consumption and average CWS than do
young adults, and this may be a purposeful effort to keep the exercise within the aerobic
range. The fact that walking taxes less than 50% of the V02 max in normal subjects in all
age groups and does not require anaerobic activity accounts for the perception that walking
requires little effort in healthy individuals. It is significant that with advancing years older
persons progressively have smaller aerobic reserves to accommodate to the added
physiologic penalties imposed by amputation.
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
Prosthesis vs. Crutches

Lower-limb amputation with or without prosthetic replacement imposes energy penalties for
ambulation. The patient must choose between walking without a prosthesis and using
crutches or walking with a prosthesis and utilizing the remaining muscles to substitute for lost
function and control the additional mass of the prosthesis.
Crutch walking without a prosthesis with a three-point gait pattern in unilateral amputees may
be a primary or secondary means of transportation when an adequate prosthesis is
unavailable or inadequate. Swing-through crutch locomotion requires a high rate of physical
effort in comparison to normal walking. The arms and shoulder girdle musculature must lift
and then swing the entire body weight forward with each step. Swing-through crutch-assisted
gait is required in amputees walking without a prosthesis.
A direct comparison of walking in unilateral amputees with and without a prosthesis utilizing a
three-point crutch-assisted gait pattern revealed that all, with the single exception of vascular
transfemoral amputees, had a lower rate of energy expenditure, heart rate, and 0 2 cost when
using a prosthesis. This difference was insignificant in the vascular transfemoral
amputation group and probably relates to the fact that even with a prosthesis, most of these
patients relied on crutches for some support, thus increasing the energy demand and heart
rate.
It may be concluded that a well-fitted prosthesis that results in a satisfactory gait not requiring
crutches significantly reduces the physiologic energy demand. Since crutch walking requires
more exertion than walking with a prosthesis does, crutch walking without a prosthesis should
not be considered an absolute requirement for prosthetic prescription and training.
Unilateral Prosthetic Ambulation

The combined results of two studies in which patients were tested at their CWSs under
similar conditions illustrate the importance of the level of amputation. In the first study, energy
expenditure in unilateral amputees was measured at the transtibial, knee disarticulation, and
transfemoral levels following amputation secondary to trauma. Patients had also worn their
prostheses at least 6 months and did not use upper-limb aids (with the exception of some
transfemoral amputees in the vascular group). In the second study, healthy hip disarticulation
and transpelvic (hemipel-vectomy) amputees were tested at their CWS by utilizing a similar
methodology. These surgical amputees met the following criteria: were young and healthy at
the time of testing, had not received radiation or chemotherapy for at least 6 months prior to
testing, had no evidence of tumor recurrence, had worn their prosthesis for at least 6 months,
and did not utilize crutches.
In the groups of traumatic and surgical amputees described above, the 0 2 cost progressively
increased at each higher amputation level ranging from the transtibial to the transpelvic levels
(Fig 15-1.). Patients with higher-level amputations had a less efficent gait and higher 0 2 cost
than did those with lower-level amputations.
The average rate of oxygen consumption for different-level amputees was not dependent on
level and was approximately the same as the value for normal subjects (Fig 15-2.) (Table
15-1.).
The CWS depended on the level of amputation and declined at each higher amputation level,
progressing from the transtibial, knee disarticulation, transfemoral, hip disarticulation, and
transpelvic levels in the traumatic and surgical amputee groups. These values averaged 71,
61, 52, 47, and 40 m/min (Fig 15-3.). These findings indicate that amputees slow their CWS
to keep the rate of 0 2 consumption from rising above normal limits. The reduced speeds at
higher amputation levels are inversely proportional to the increased 0 2 cost.
Other investigators who have tested amputees at their CWS have also reported that the rate
of 0 2 uptake was approximately the same as for normal subjects at their CWS. Clearly as
more joints and muscles of the leg are lost due to higher-level amputations, the greater the
loss of the normal locomotor mechanisms; therefore, the greater energy cost and slower
speed.
Relationship of Mechanical and Physiologic Energy Expenditure
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
heart rate if crutch assistance is required. In contrast, traumatic transfemoral amputees
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.
Length of the Residual Limb

Gonzales et al. evaluated transtibial amputees with stumps ranging from 14 to 19 cm in
length. Patients wore a patellar tendon-bearing prosthesis except for one who had a
prosthesis with a thigh corset. No significant differences were noted in speed or energy
expenditure between groups. Of particular clinical importance, a stump as short as 9 cm will
result in acceptable transtibial performance that is superior to performance at reported values
at the knee disarticulation and transfemoral levels.
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
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
with a walker. The patient walked faster at a slightly greater rate of oxygen consumption
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 amputees-
Influence 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.
16A: Partial-Foot Amputations | O&P Virtual Library
Search
GO
Partial-Foot Amputations: Surgical Procedures Reproduced with

permission from
F. William Wagner, Jr., M.D. Bowker HK,
Michael JW (eds):
Vascular disease and trauma are the major causes of lower-limb amputation. Atlas of Limb
Prosthetics:
Atherosclerosis with or without diabetes mellitus accounts for nearly 80% of the problems
severe enough to require amputation. Congenital and acquired deformities, neoplasms, and Rehabilitation Principles.
infections account for fewer cases. Trauma from industrial, motor vehicle, and sporting Rosemont, IL, American Academy
activities has increased in incidence and severity. The treatment of neoplasms has of Orthopedic Surgeons, edition 2,
undergone marked changes. Amputations should be performed by surgeons familiar with 1992, reprinted 2002.
staging techniques, perfusion techniques, local resection, and endoprosthetic replacements.
The casual surgeon should not embark upon the care of a patient with malignancy of the has been updated and published
lower limbs. in Atlas of Amputations and Limb
The ultimate surgical treatment for traumatic amputation is replantation of the severed part. It and Rehabilitation Principles
is now just over a quarter of a century since a successful replantation of an arm was (retitled third edition of Atlas of
performed. Several hundred major limb replantations have been performed at the Sixth Limb Deficiencies), ©American
Peoples Hospital in Shanghai, China. Many replacement teams have been formed in the Academy or Orthopedic Surgeons.
United States. The most suitable levels for replantation are in the distal levels of both the Click for more information about
this text.
upper and lower limbs. Microvascular techniques are used below the ankle and standard
vascular techniques above the ankle. These procedures are appropriate only for the trained
surgical team in a replantation center. Before transfer of any patient and the severed part, the Funding for digitization
center must be called for instructions on handling of the residual limb and the severed part. of the Atlas of Limb
Prosthetics was
Prevention of major amputation in patients with diabetic foot problems has aided in increasing provided by the
quality of life. Multispecialty clinics and the "team approach" are proving superior. Northern Plains Chapter of the
Prosthetists
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 You can help expand the
and appearance, skin temperature with differences from level to level and from side to side, O&P Virtual Library with a
palpation of pulses, rapidity of onset of the problem, temperature curves, white blood cell tax-deductible contribution.
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

foot that would have required a higher amputation (Fig 16A-1.). A severe
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
envelope, necrotic or absent bone, soft-tissue infection, but still a viable foot. A transtibial
amputation is indicated, but will be quite short.
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
sufficient length. Thus, saving all tissue possible from the injured foot can result in a more
functional amputation. With few exceptions, the most functional residual foot is at the trans-
metatarsal 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.
TRANSCUTANEOUS DOPPLER ULTRASOUND

This instrument provides a sensitive stethoscope or flow detector that is able to measure the
pulse when it cannot be palpated or heard with an ordinary stethoscope and can be used for
determining blood pressure at that point (Fig 16A-5.). For this purpose, the instrument
does not need to be directional, and several relatively inexpensive portable machines are
available. A unit with an audible response is valuable in allowing the patient, family, and
doctor to hear the difference between the diseased vessels and a normal one. The smaller
the vessel to be measured, the higher the frequency of the signal. Frequencies of 9 to 10
MHz are recommended for the foot and toes. As recommended by the American Heart
Association, the cuff width should be 120% of the diameter of the limb at the level being
measured. Thus, four different-sized cuffs are usual for a satisfactory complete
examination of the lower limb. The major vascular tree can be mapped with the instrument
and areas of lessened flow and zero flow determined and marked on a chart (Fig 16A-6.).
Collateral circulation is also mapped. Pulsation of the flow can be determined. Systolic
pressures are measured from the groin to the toes at various levels. An ischemic index is
calculated for each level by dividing the systolic pressure measured in the limb by the
brachial artery pressure. For example, the systolic pressure may be 120 mm at the arm and
at the thigh, 90 mm at the calf, 60 mm at the ankle, and 20 mm at midfoot. The ischemic
index would be 1 at the arm and thigh, 0.75 at the calf, 0.50 at the ankle, and 0.17 at the
midfoot. In this case, an ankle disarticulation is indicated if the skin of the heel is intact.
A triphasic full pulse is one similar to that heard at the brachial artery. A variation can be
heard that is represented by the dicrotic notch. This indicates a virtually normal flow. A drop
of 30 mm of pressure from one level to the next lower indicates a very definite decrease in
circulation. When the flow becomes markedly decreased, a wind tunnel effect is heard with
marked broadening of the width of the wave (Fig 16A-6.).. If there is a virtual block, there
may be just background noise and various indications of nonpulsatile flow or complete
silence. If there is a sudden acute blockage just below a relatively normal flow, there will be
increasing sharpness of the sound until a "water hammer" effect will be heard just before the
blockage. Immediately afterward, there will be silence until collateral flow begins to come into
the distal vessel. With relatively little experience, a very complete vascular examination can
be performed at the bedside with a portable transcutaneous Doppler ultrasound flowmeter.
If the ischemic index is insufficient for local healing at a functional level, a consultation is
obtained from the vascular surgery service. Successful revascularization procedures such as
endarterectomy, balloon dilatation, or bypass procedures can aid in local healing of the lesion,
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.
OPEN VS. CLOSED TECHNIQUES

All open wounds are eventually infected or colonized even with nonpathogenic bacteria. A
paradox is thus created in leaving an amputation open when performed for severe infection.
There is evidence in the literature that closed incisions do better than open incisions.
These, of course, may be done with secondary closures, as indicated. Removal of the major
amount of infected or gangrenous tissue by amputation usually leaves a number of bacteria
behind in the surrounding cellulitis and lymphangitis. These usually can be controlled by the
body's own defense mechanisms with the aid of appropriate antibiotics. Kritter has developed
a technique for irrigating wounds of this sort with closure. His technique has virtually done
away with open amputations in foot patients at Rancho Los Amigos Medical Center. A small
plastic catheter is drawn into the wound through a separate stab incision (see Fig 16A-11.).
The wound is closed relatively loosely and slowly irrigated with an appropriate antibiotic
solution for 72 to 96 hours. The fluid dilutes the hematoma and aids in the removal of blood
clots and debris between the sutures. Care must be taken with nephrotoxic and ototoxic
antibiotics so that total amounts given do not exceed allowable limits. In a recent personal
communication, Kritter states that he is now irrigating the wounds of similar patients without
antibiotics and believes that the irrigating effect is the more important.
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.
SPECIFIC SURGICAL TECHNIQUES
Guillotine Amputation
This method of amputation has had a resurgence as a preliminary procedure to remove a
severely infected part of the foot. In some cases sepsis can be controlled by amputation or
leg drainage to be followed by a definitive procedure. Guillotine amputation as the primary
operation is now archaic because the residual limb has a scarred closure that is rarely
suitable for use of a prosthesis.
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.
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.
Metatarsal Ray Resection

Third-, fourth-, and fifth-metatarsal ray resections have been quite successful and leave a
functional partial foot. With the use of the ischemic index obtained by transcutaneous
Doppler ultrasound, the success rate has improved markedly. Complete removal of infected
and necrotic tissue is important. Enough bone must be removed so that flaps may be closed
without tension. For a single second, third, or fourth toe and ray, a V-shaped wedge is
removed. This closes well and leaves a symmetrical foot. On occasion, all of the lateral rays
have been removed with the great toe and first metatarsal left (Fig 16A-8.). The residual foot
is quite functional and produces a better gait than with a trans-metatarsal amputation. The
wounds in such procedures are irrigated with antibiotic solutions when the removal has been
for major infection. Irrigation is performed with a physiologic solution when the wound has
been noninfected. We have left none open to granulate. Ecker and Jacobs reported that only
2 of 18 closed wounds failed whereas 16 of 36 open wounds failed.
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,
rheumatoid arthritis, and similar conditions. McKittrick et al. outlined the indications for
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.
Postoperative Treatment and Function
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.).
Lisfranc and Chopart Amputations

Lisfranc and Chopart amputations were introduced before blood transfusions, antibiotics, and
anesthesia were available. They had been planned as disarticulations, to be performed as
rapidly as possible, with soft-tissue instruments alone, without the need for cutting bone.
Except in special circumstances, there is much less indication for their use at present.
There are late complications associated with equinus deformity and resulting increased
plantar pressure (Fig 16A-13.). Some of the later problems may be prevented by transfer of
the peroneus brevis to the cuboid and transfer of the anterior tibial tendon to the neck of the
talus. Lengthening of the Achilles tendon will lessen some of the equinus deformity. If these
amputations are performed for an infected gangrenous foot, it is not wise to attempt tendon
transfers at the time of the initial surgery. Stabilization can be performed at a later date in
most cases. We have also had success at these levels by adding subcutaneous tenotomy of
the Achilles tendon and subsequent use of a polypropylene ankle-foot orthosis to the basic
technique (Fig 16A-14.).
At Rancho Los Amigos Medical Center, a further technique has been developed for the
Lisfranc amputation in which the bases of the fourth and fifth metatarsals are divided from the
distal metatarsal shafts and thus save the function of the peroneus brevis tendon. In the
Chopart amputation, the anterior tibial tendon and extensor digitorum longus tendons are
drawn down and incorporated in the skin closure so that they are attached to the plantar
fascia and aid in dorsiflexion.
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 16A-
20.). 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
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.
SURVIVAL OF THE CONTRALATERAL LIMB

A high percentage of dysvascular patients will have an amputation on the opposite side within
3 to 5 years. Many will not have survived. Elderly bilateral amputees do poorly with any
level that does not save the knee. For this reason, all efforts should be directed toward
partial-foot amputations if preventive measures are not successful. Revascularization
procedures should be considered to allow lower amputations to be performed.
References:
1. Anderson JA, Klaborg KE: Forefoot amputation in rheumatoid arthritis. Acta Orthop
Scand 1987; 58:394-397.
2. Anderson L, Weston GW, Oppenheim LL: Syme amputation in children: Indications,
results and long-term follow-up. J Pediatr Orthop 1984; 4:550.
3. Bottely KC, Burgess EM: Contralateral limb and patient survival after leg amputation.
Am J Surg 1983; 146:280-282.
4. Buchbinder D, Pasch AR, Rollins BF, et al: Results of arterial reconstruction of the
foot. Arch Surg 1986; 121:673.
5. Calhoun JH, Cantrell J, Cobos MD, et al: Treatment of diabetic foot infections: Wagner
classification, therapy and outcome. Foot Ankle 1988; 9:101-106.
6. Carter SA: The relationship of distal systolic pressure to healing of skin lesions with
arterial occlusive disease, with special reference to diabetes mellitus. Scand J Clin Lab
Invest 1973; 31(suppl 128):239.
7. Clifford EJ, Frye RE, Claggett GP, et al: Results of in situ vein bypass to the foot. Am
J Surg 1989; 158:502-505.
8. Collins WS, Vlahose JG, Dobkin GB, et al: Conservative management of gangrene in
the diabetic patient. JAMA 1962; 181:692.
9. Dickhaut SC, DeLee JC, Page CP: Nutritional status: Importance in predicting wound
healing after amputation. J Bone Joint Surg [Am] 1984; 66:71-75.
10. Donovon DL, File TM: Team approach in the management of diabetic foot infections. J
Foot Surg 1987; 26(suppl):12-16.
11. Doucette MM, Filling C, Knighton DR: Amputation prevention in a high-risk population
through comprehensive wound healing protocol. Arch Phys Med Rehabil 1989; 70:780-
785.
12. Ecker MD, Jacobs BS: Lower extremity amputations in diabetic patients. Diabetes
1970; 19:189.
13. Edmunds ME, Blundell MP, Morris ME, et al: Improved survival of the diabetic foot:
The role of a specialist foot clinic. Q J Med 1986; 60:763-771.
14. Gaenslen FJ: Split heel approach and osteomyelitis of the os calis. J Bone Joint Surg
1931; 13:759.
15. Ger R: Muscle transposition in the management of perforating ulcers of the forefoot.
Clin Orthop 1983; 175:186.
16. Ger R: Prevention of major amputations in the diabetic patient. Arch Surg 1985;
120:1317-1320.
17. Gibbons GW: The diabetic foot: Amputation and drainage of infection. J Vasc Surg
1987; 5:791-793.
18. Goodman J, Bessman AM, Teget B, et al: Risk factors in local surgical procedures for
diabetic gangrene. Surg Gynecol Obstet 1976; 143:587.
19. Gustillo RB, Mendoza RM, Williams DM: Problems in the management of type III
(severe) open fractures: A new classification of type III open fractures. J Trauma 1984;
24:742-746.
20. Hodge MJ, Peters PG, Efird WG: Amputations of the distal portion of the foot. South
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
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; 4:511-
516.
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 non-
salvagable 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
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.
Search
GO
Partial-Foot Amputations: Prosthetic and Orthotic Reproduced with

Bowker HK,
Michael JW (eds):
David N. Condie, B.Sc, C. Eng. Atlas of Limb
Melvin L. Stills, CO. Prosthetics:
NORMAL FOOT FUNCTION Rosemont, IL, American Academy
The successful management of partial-foot amputation requires a clear understanding of the 1992, reprinted 2002.
functions of the normal foot and the consequences of surgical ablation. Much of the material in this text
The normal foot is an extremely complex structure, the detailed function of which is still only in Atlas of Amputations and Limb
partially understood. This discussion of the mechanics of normal foot function will be restricted Deficiencies: Surgical, Prosthetic,
to a brief consideration of load-bearing structure and the function of the foot joints during and Rehabilitation Principles
normal walking. (retitled third edition of Atlas of
Load-Bearing Structure Click for more information about
this text.
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 Funding for digitization
the absorption of the high forces generated at impact and during the subsequent loading of
Prosthetics was
the limb. Once the foot is flat and until the heel leaves the ground as push-off is initiated, the provided by the
supporting forces are shared between the heel and the ball of the foot, with only a small Northern Plains Chapter of the
contribution from the lateral aspect of the midfoot. American Academy of Orthotists &
Prosthetists
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 O&P Virtual Library with a
plantar surface of the hallux. tax-deductible contribution.
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
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.
THE DESIGN OF PARTIAL-FOOT PROSTHESES/ORTHOSES

Devices used in the management of partial-foot amputations may be called orthoses or
prostheses. This ambiguity arises from the design of the various systems used. Traditional
prosthetic solutions used for these patients were in general heavy and bulky, and this led to
the widespread adoption of modified orthotic systems based on the ankle-foot orthosis
commonly used to control ankle function (Muilenburg Prosthetics, Inc., Houston) (Fig 16B-2.
and Fig 16B-3.).
Today the availability of moldable flexible materials permits the fabrication of partial-foot
prostheses that are both functionally and cosmetically acceptable (Life-Like Laboratory,
Dallas) (Fig 16B-4.).
There are many factors to take into consideration in the management of the partial-foot
amputee, perhaps most importantly the condition of the soft tissue in the weight-bearing
areas of the residuum. Can these tissues withstand both the direct and shear pressures that
will occur during normal activity, or does the load need to be transferred to a more proximal
normal tissue? What will be the functional consequences of the loss of the foot joints, and
how can the prosthesis be constructed to provide some degree of compensation?
These issues and the associated biomechanical considerations will be discussed in the
following description of the prostheses/orthoses currently in use for each amputation level.
AMPUTATION OF THE TOES

The functional requirement for this type of amputation is largely cosmetic; however, if the
hallux is absent, some consideration should be given to providing resistance to
hyperextension of the first metatarsophalangeal joint area both to reduce the effect of the loss
of the final element of push-off and to prevent uncomfortable shoe deformation. In addition, it
is desirable to resist deviation of the remaining toes toward the amputation site.
Patients may elect simply to use soft foam or cloth to fill voids left in the shoe. A preferable
solution consists of a simple insole to which toe fillers on spacers formed from orthopedic felt
or foam are bonded (Muilenburg Prosthetics) (Fig 16B-5.).
An alternative approach is the use of custom silicone rubber toes attached to the residuum
with medical ad-hesives and held in place with a sheer nylon stocking; however, this
technique is available at only a few specialized centers (Life-Like Laboratory) (Fig 16B-6. and
Fig 16B-7.).
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-
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 load-
bearing 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.).
TARSOMETATARSAL AND TRANSTARSAL AMPUTATIONS

With these more proximal amputations the prosthetic requirements become considerably more
demanding. Basically, the requirement to replace the anterior support area of the foot remains
the same; however, whereas for the more distal amputation levels the prostheses can be
effectively interfaced with the stump by using suitable footwear, a more extensive socket is
now indicated if relative motion between prosthesis and residuum is to be prevented when
weight is applied to the forefoot.
Two basic biomechanical solutions are available. In the more traditional designs of prostheses
(and some of the more recent ankle-foot orthotic solutions), the device is constructed to
encompass the entire residuum and extend some distance above the ankle. In these designs
the dorsiflexing moment created by forefoot loading is easily resisted by counterforces
generated on the heel and at the anterior brim of the device (Fig 16B-13.).
This design may also be constructed so as to provide axial load relief in the event that full
plantar weight bearing is contraindicated.
More modern designs of prostheses of the slipper type enclose only the residuum and
terminate around the ankle joint. In these designs resistance to the dorsi-flexion moment is
provided by the accurate fit of the socket on either side of the calcaneus (Fig 16B-14. and
Fig 16B-15.). Obviously some means must be provided for permitting entry and removal of
the residuum. For this, a variety of techniques are employed. (Jack Collins, C.P.O., Collins
Orthopedic Service, Inc., Fayetteville, Ark).
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 16B-
3.).
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.
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. Rigid
2. Semirigid
3. Semiflexible
4. 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:
Slipper-Type Elastomer Prosthesis

The slipper-type elastomer prosthesis (STEP) (Fig 16B-16.) manufacturing processing is
somewhat complex. Permanent tooling is developed for each individual amputee and consists
of a permanent polyester resin positive model and a negative mold of the finished artificial
foot. The device is fabricated by using semi-flexible urethane elastomers.
The Collins Orthopaedic Service Partial-Foot Prosthesis

The socket for this prosthesis (see Fig 16B-15.) is fabricated over a modified positive plaster
model of the stump. Silicone is laminated into a cloth material and reinforced with woven
glass if needed for increased durability. A spring steel is attached to the plantar surface of the
socket and extends to within 1 in. of the toe (distal end of the finished prosthesis). The
contours of the foot are filled out by using prosthetic foam that is foamed in place by using a
plaster toe mold.
The Imler Partial-Foot Orthosis-Chicago Boot

The socket for this prosthesis is vacuum formed over a modified plaster model in the manner
of a University of California Berkeley shoe insert (see Fig 16B-17.). The resulting
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.
Lange Silicone Partial-Foot Prosthesis

The socket for this prosthesis (Lawrence R. Lange, C.P.O., Wheeling, WV) (Fig 16B-18.) is
laminated over a modified plaster model in the usual manner by using a nylon-tricot cosmetic
stockinette and Otto Bock silicone (Otto Bock Orthopedic Industry, Inc., Minneapolis). The
socket is then bonded to a modified "Quantum" (Quantum Foot, Hossmer-Dorrance Corp.,
Campbell, Calif) or similar prosthetic foot shell. A zipper is added posteriorly, and a final
silicone lamination is performed to finish the prosthesis. This prosthesis extends just above
the ankle and uses a zipper closure for retention.
These four systems have all been used successfully in the management of the short partial-
foot amputee. The degree of flexibility is determined by the amount of reinforcement utilized
in the socket walls. Extensions above the malleoli are used to provide improved suspension
of the prosthesis on the limb. Flexible (see Fig 16B-4., Fig 16B-7., Fig 16B-9., Fig 16B-11.,
and Fig 16B-12.) partial-foot prostheses constructed from reinforced silicone were originally
introduced to provide cosmetic restoration only. Subsequent experience has demonstrated
that this design of prosthesis, in addition, permits the successful restoration of balance and a
more normal gait.
A lost wax method is used to create a negative impression of the foot to be formed. Pure
reinforced silicone is used to form the socket and the foot simultaneously. Pigment is added
to the silicone to closely match the basic tissue color of the individual. Detailed coloring is
done at the time of fitting to match the natural skin tones.
These flexible partial-foot prostheses have worked particularly well on patients with adherent
and fragile scar tissue, probably because silicone does not have the abrasive nature of the
other materials traditionally used for socket construction (see Fig 16B-4., Fig 16B-8., and Fig
16B-12.).
Normal ankle and subtalar movements are theoretically possible for patients wearing below-
ankle designs of prostheses. Since this is the case, then the provision of some alternative
means of achieving forefoot rotation would appear to be indicated. In the absence of such a
design a simple measure adopted by some prosthetists is to wedge the forefoot of the
prosthesis laterally, thus ensuring that full forefoot contact is achieved when the foot is flat.
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;
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.
17A: The Syme Ankle Disarticulation | O&P Virtual Library
Search
GO
The Syme Ankle Disarticulation: Surgical Procedures Reproduced with

permission from
F. William Wagner, Jr., M.D. Bowker HK,
Michael JW (eds):
James Syme was a clinical professor of surgery at the University of Edinburgh from 1843 to Atlas of Limb
Prosthetics:
1869. He pioneered many innovative procedures in general surgery and was regarded as one
of the premier surgeons of Europe and the United Kingdom. He is remembered today mainly Rehabilitation Principles.
for his disarticulation at the ankle joint. In 1842, he first performed the procedure on a 16- Rosemont, IL, American Academy
year-old boy for probable tuberculous caries of the talus and calcaneus. He reported the of Orthopedic Surgeons, edition 2,
procedure in 1843. He performed approximately 60 to 70 more amputations of this sort in 1992, reprinted 2002.
his lifetime. If one recognizes the many almost miraculous aids we now have in performing
surgery, it is hard to realize that he did most of his work before the development of the has been updated and published
science of bacteriology, antisepsis and antibiosis, blood transfusion, anesthesia, and all of the in Atlas of Amputations and Limb
modern mechanical adjuncts to the actual surgical procedures. He listed three advantages Deficiencies: Surgical, Prosthetic,
over the transtibial level: "One, the risk to life will be smaller; Two, a more comfortable stump and Rehabilitation Principles
will be afforded; Three, the limb will be more seemly and useful for progressive motion." The (retitled third edition of Atlas of
final statement of his article cannot be said better today: ". . . on these grounds, I think Limb Deficiencies), ©American
amputation of the ankle joint may be advantageously introduced into the practice of surgery. I
regret having cut off many limbs that might have been saved by it, and shall be glad if what this text.
has been here said in its favour encourages others to its performance."
Experience with many hundreds of cases at Los Angeles County University of Southern Funding for digitization
California (USC) Medical Center and Rancho Los Amigos Medical Center and in private of the Atlas of Limb
practice has gone far to prove the value of his procedure. However, a review of the literature Prosthetics was
shows mixed acceptance by various authors in various centers. Alldredge and Thompson provided by the
stated that it should never be performed in patients with diabetes, peripheral vascular
disease, or neuropathic foot problems. Prosthetists
They believed that good results could be obtained in other patients with proper selection of
cases and proper surgical techniques. Sarmiento and Warren reported 50% revision to a
higher level in Syme ankle disarticulations in diabetic and dysvascular patients. McKeever
related satisfactory experience in a large series of military amputees. "For a male, the Syme
amputation is the best possible amputation stump in the lower limb." Many authors report
satisfactory experiences with the procedure and conclude that the residual limb is ideally
suited for weight-bearing and lasts virtually the life of the patient when the procedure has tax-deductible contribution.
been performed properly. There has been an occasional mention of aversion to the
prosthesis in women. This has not been the major experience at Rancho Los Amigos Medical
Center nor in private practice. Shel-swell concluded that the Syme ankle disarticulation
should not be performed in a pulseless foot. There are a few references to its use in the
dysvascular patient, but most of these are small series. Increased experience with
revascularization procedures now permits its performance in previously nonoperable patients.
Srinivasan reported 20 cases performed for Hansen's disease and pointed out that a
Syme residual limb could last with proper care even in an insensitive foot. Level selection
depends on vascular supply, condition of the heel pad, ability of the patient to use a
prosthesis, and the absence of active infection at the operative site.
THE CLASSIC SYME ANKLE DISARTICULATION

Harris of Toronto has published two articles that describe the history, development, and
technique of the Syme ankle disarticulation. Following trauma or in the case of congenital
defects, some deviation in the flap may be indicated by the altered anatomy. Otherwise, no
deviations are recommended.
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
Chopart levels are best treated at the Syme level. Since the modern Syme prostheses are
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.
THE TWO-STAGE PROCEDURE

The classic Syme ankle disarticulation frequently failed in dysvascular and infected patients.
The superior function at the Syme level pushed the search for a method to allow its use in
infected patients. Spittler et al. related their experience with Hulnick's two-stage procedure at
Walter Reed Hospital. These patients had massively infected forefoot wounds from
sharpened bamboo slivers that had been smeared with human excrement and placed in the
ground during the Korean episode. These wounds were almost impossible to heal. Single-
stage Syme ablations became infected in almost all cases. In the two-stage procedure, the
infected forefoot was removed through disarticulation at the ankle. Virtually 100% of these
patients healed, and the definitive amputation was performed 6 to 8 weeks later. Antibiotic
prophylaxis is used preoperatively depending on bacterial cultures and sensitivity testing.
This technique was first adapted to the diabetic foot at the Los Angeles County General
Hospital in 1954 and at Rancho Los Amigos Hospital in 1969. Experience, improvement in
technique, and refinement of clinical indications gradually led to a 70% success rate. In
1970, a post-tourniquet reaction time was added. If the distal skin bled within 3 minutes, the
healing rate was around 80%. In 1975, Doppler ultrasound was used to map blood flow,
describe waveforms, and contrast the distal flow with the brachial artery flow. This led to the
ischemic index, which was the distal pressure at several places in the lower limb divided by
the brachial artery pressure. If the index was over 0.45, the success rate could approximate
90%.
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 17A-
8.,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
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.
Second-Stage Surgical Technique

Two elliptical incisions are made over the malleoli to remove the dog-ears (Fig 17A-14.). The
amount of tissue removed should be equal to the volume of the malleolus. Care must be
taken on the posteromedial aspect not to damage the posterior tibial nerve and artery. Close
dissection around the medial malleolus will protect the neurovascular bundle. After
subperiosteal dissection, the malleoli are cut flush with the joint surface (Fig 17A-15.). The
fat pad is usually adherent to the central cartilage, which is left intact.
The malleoli are dissected subperiosteally to approximately 3 cm above the joint line. The
medial and lateral flares of tibia and fibula are then removed parallel with the shaft (Fig 17A-
16.). This leaves the anterior and posterior flares of the tibia and fibula for suspension and a
moderate narrowing and flattening of the sides of the stump (Fig 17A-17.). Closure is
adapted to anchor the pad to bone. The deep fascia of the sole is clamped with a towel clip
to the periosteum of tibia, and the pad is tested. If it is too loose, soft tissue must be removed
from the ellipses until the pad is tight. It is then sutured through two drill holes in the tibia and
fibula, as well as to the periosteum. A few subcutaneous sutures level the skin. The skin is
closed with nonabsorbable sutures. Soft dressings are used for a few days and then replaced
with plaster (Fig 17A-18.).
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
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
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 twenty-
one 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
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
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
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.
17B: Prosthetic Management | O&P Virtual Library
Search
GO
The Syme Ankle Disarticulation: Prosthetic Management Reproduced with

permission from
Richard Voner, C.P.O. Bowker HK,
Michael JW (eds):
John W. Michael, M.Ed., C.P.O.
Atlas of Limb
Prosthetics:
Disarticulation at the ankle has challenged the prosthe-tist since the procedure was first
introduced by Syme in 1842. Surgical modifications have been introduced to make the stump Rehabilitation Principles.
neater and less bulky, allow more room for the ankle joint, and produce a more cosmetic Rosemont, IL, American Academy
prosthesis. of Orthopedic Surgeons, edition 2,
A satisfactory end-bearing Syme limb demands a prosthesis with the following characteristics:
1. Transmission of body loads
2. Light enough to wear comfortably Deficiencies: Surgical, Prosthetic,
3. Ability to supply the equivalent of foot and ankle function and Rehabilitation Principles
4. Lengthening of the limb to adjust for loss of the talus and os calcis (retitled third edition of Atlas of
5. Distribution of the high forces developed in the ankle area Limb Deficiencies), ©American
6. Provision of rotary stability about the long axis Academy or Orthopedic Surgeons.
7. Provision of shock absorption Click for more information about
this text.
8. Suspension during swing phase
9. Readily donned without requiring multiple non-cosmetic, difficult fasteners
10. Adjustability to relieve pressure along a sensitive scar line Funding for digitization
11. Cosmesis of the Atlas of Limb
Prosthetics was
Despite the advantages provided by the long lever arm of the essentially intact tibia and provided by the
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 Prosthetists
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).
SOLUTIONS TO PROBLEMS INHERENT IN THE DESIGN AND O&P Virtual Library with a
MANUFACTURE OF SYME PROSTHESES
Weight and Bulkiness

Until 1940, the usual prosthesis was a leather socket reinforced with steel straps and with an
anterior tongue and lacer. The ankle was frequently a single-axis joint with bumpers. Early
use of polyester-fiberglass laminate with an opening for entry of the residual limb materially
reduced bulkiness. However, to increase the strength of the socket, it was necessary to
substitute ep-oxy resins for the polyesters before adequate strength was obtained. A
prosthesis of this type was developed and is being used by the Canadian Department of
Veteran Affairs. It is commonly called the "Canadian Syme prosthesis" (Fig 17B-1.).
Reproduction of Ankle Joint Motion

The limited space available between the distal portion of the residual limb and the floor
severely constrains the design of foot mechanisms for the Syme prosthesis. Although
articulated joints have been used in the past, they were plagued by chronic wear and tear
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
option. Although clinically successful, the rigidity of the wooden keel added significant
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
residual limb. More recently, several dynamic-response feet have become available in a
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.
Provision for Donning

Provision for donning is necessary to allow the bulbous distal end to pass the narrow shank
portion of the prosthesis.
The following are some of the methods of providing the different diameters:
1. Older prostheses had an anteriorly opening corset that could be laced.

2. Plastic prostheses have windows either medially, posteriorly, or posteromedially (Fig
17B-2.).
3. Closed double-wall prostheses with flexible inner walls allow expansion so that the
bulbous end is inserted past the expandable portion. The elasticity is sufficient to
close about the end and provide suspension (Fig 17B-3.,A and C). A double wall with
an elastic panel also provides enough expansion (Fig 17B-3.,B).
4. A flexible inner socket of Kemblo rubber, Silastic foam, or similar material bridges the
narrow portion of the stump above the heel pad and maintains a total-contact, stump-
socket wall relationship (Fig 17B-4.).
Distribution and Absorption of Stresses Developed During Stance

Phase
Uniform distribution of loads along the tibia is necessary during push-off or rollover. Careful
molding is necessary along the tibial crest. High forces in the ankle area require sufficient
material to absorb the stress. Because of the bulbous form, there will be a certain bulky
appearance to any prosthesis design. There is a constant problem then between thickness
requirements for strength and thinness required for appearance. Strength is most easily
obtained by using high strength-to-weight ratio plastics that can be molded easily over a
plaster positive model.
Provision of Rotary Stability About the Long Axis

A patellar tendon-bearing shape of the proximal part of the brim will stabilize against the
mediolateral flares of the tibia. Flattening of the posterior portion of the brim adds to a
triangulation effect.
Provision of Pressure Relief Along a Sensitive Scar Line

Direct end bearing can be reduced by proximal loading of the prosthesis along the tibial
flares.
Provision of Suspension During Swing Phase

The bulbous distal end and the flare of the tibia and fibula provide sufficient surface. The
contour of the distal part of the socket must be in intimate contact with the residual limb in its
most bulbous portion. If the distal end is especially narrow and has minimal flare, a
suprapatellar suspension strap may be added.
Provision of Shock Absorption

The cushioned heel of the SACH foot is smaller than in a transfemoral or transtibial
prosthesis. A good share of the impact force is dissipated in the heel, but some load must be
assumed by the knee, which flexes just after heel contact.
Sweating in a Plastic Prosthesis

Porous plastic laminates have been introduced but have not proved completely satisfactory to
date. Substitution of several layers of prosthetic socks may provide better moisture
distribution.
Cosmesis
Plastic laminates provide a thinner wall. Air-cushion types that require no window and double-
walled 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).
Correction of Limb Length Discrepancy

A thinner SACH foot must be used for the Syme ankle disarticulation than that used for
transtibial or trans-femoral amputations. Because of this, it is not always possible to use as
thick a heel cushion as desired for shock absorption. In bilateral amputees, this is not a
problem, and such improvements as a five-way ankle may be used.
Comfortable Transmission of Stump-Socket Forces Through a

Satisfactory Socket
Socket design must provide the following:
1. Stabilization against rotary forces about the long axis. Three-point or triangular
stabilization against the flares of the tibia plus a flattening across the posterior portion
of the gastrocnemius will provide a good share of stability. In the two-stage method,
the distal portion of the stump is squared slightly. This possibly aids in preventing
rotation about the long axis.
2. Weight support can be distributed between the end of the prosthesis and the proximal
portion of the socket brim. Dispersion of forces against the proximal surface of the leg
at push-off can be accomplished through careful fitting against the mediolateral
surfaces of the tibia.
3. Dispersion of force encountered at heel contact is accomplished through contact from
the heel to the upper gastrocnemius. The cuplike contour for the stump end must
extend superiorly enough to prevent motion between the socket and the stump in an
anteroposterior direction.
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
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.
18A: Surgical Procedures and Immediate Postsurgical Management | O&P Virtual Library
Search
GO
Transtibial Amputation: Surgical Procedures and Reproduced with

Immediate Postsurgical Management permission from
Bowker HK,
Michael JW (eds):
Bertram Goldberg, M.D. Prosthetics:
Pradip D. Poonekar, M.B.B.S., M.S. (Gen Surg)
Among major amputations in the lower limb, the transtibial (below-knee) amputation is the
most common. Many series report a ratio of at least two transtibial amputations to every 1992, reprinted 2002.
transfemoral (above-knee) one. It is important to note that it is the most proximal level in
the lower limb at which near-normal function is available to a wide spectrum of lower-limb Much of the material in this text
amputees. This is because energy consumption for the transtibial amputee, due to has been updated and published
preservation of the knee joint, is far less than for amputees with a transfemoral level. The in Atlas of Amputations and Limb
relative ease of transtibial vs. transfemoral gait is borne out by several studies of prosthesis
usage. Combined data from 13 studies from 1943 through 1983 showed an average (retitled third edition of Atlas of
transtibial prosthesis usage rate of 73.5%. In contrast, analysis of four studies covering the Limb Deficiencies), ©American
same period disclosed that transfemoral prosthesis usage averaged only 26.5%. Most of Academy or Orthopedic Surgeons.
the patients in these studies had peripheral vascular disease. Another detailed study was Click for more information about
made of 25 unilateral transtibial amputees who were all under the age of 45 years at the time this text.
of amputation for trauma. They were reviewed 2½ years following surgery as regards their
function and life-style. Eighty-four percent wore their prostheses more than 13 hours a day, Funding for digitization
72% could walk a mile if necessary, and 84% drove automobiles. Sports were played by of the Atlas of Limb
72%. The most notable finding was that 84% of these unilateral transtibial amputees regarded Prosthetics was
themselves as minimally or nondisabled. provided by the
Another singular advantage of transtibial over transfemoral amputation is markedly reduced American Academy of Orthotists &
perioperative mortality. The combined mortality of three studies for transtibial amputation was Prosthetists
9.5% as compared with 29.7% for transfemoral amputation. Virtually the same findings
were reported by Sarmiento and Warren, who noted a fall in mortality rate from 24% to 10%
that was directly related to the reversal of their transtibial-to-transfemoral ratio from 1:2 to 2:1.
For many years, transfemoral amputations were preferred to transtibial ones because it was
felt that primary healing is easier to obtain at the thigh level. Healing at that level, however, is O&P Virtual Library with a
far from certain. Boontje, in a series of 171 amputations, noted a 28% failure of transfemoral tax-deductible contribution.
healing as compared with 35% for transtibial cases. By pooling the data from eight
reported series totaling 942 cases, each with at least 50 patients, it was found that 70% of
transtibial amputations healed primarily and 16% secondarily for a total healing rate of 86%.
These series did not separate diabetics with or without ischemia from those with ischemic
disease alone.
It was long taught that diabetics should have a primary amputation at the transfemoral level
because of their supposed inability to heal at more distal levels. Data were combined from
four series that compared the healing rate of transtibial amputations in diabetics with that in
patients with purely ischemic disease. Of 194 diabetic patients, 92% healed their wounds. In
contrast, only 75% of 188 patients with purely ischemic disease healed. Two additional
series of 100 diabetics each reported transtibial healing rates of 99% and 90%, respectively.
These studies strongly suggest that the notion that diabetics do best with a primary
transfemoral amputation for foot lesions should be discarded.
In ischemic conditions, unilateral transtibial amputation may be followed by loss of the

opposite limb with progression of vascular disease. One study of 80 patients noted an interval
of 23 months, on average, between transtibial amputations. The risk of contralateral limb
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
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
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
the amputated limb, and teach safe ambulation with a walker or crutches (see Chapter 23).
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
discouraging smoking preoperatively and postoperatively. A Danish study showed a 50%
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
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%
healed at the transtibial level. These findings point out the difficulty in evaluation of
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
amputations, on a par with reliance on palpable pulses. Arteriography is now used chiefly
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
and thigh corsets that were available at that time. Moore stated that the greatest length
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
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 sciatic-
femoral 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
been developed in an attempt to enhance function at that level. To achieve optimal
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
Closed Amputations
Long Posterior Myofasciocutaneous Flap

In 1943, Bickel reported on the use of a long posterior myofasciocutaneous flap in 110
transtibial amputations. The major impetus for the acceptance of this concept, however,
may be attributed to the educational efforts of Burgess. The senior author's technique,
adapted from Wagner, follows: reference points are marked medially and laterally on the
leg at the junction of the anterior two thirds and posterior third of the leg diameter at the level
selected for bone section. The two points are joined to form an anterior flap that is convex
distally and no more than 0.5 cm in length. The posterior flap is then drawn with its length
equal to the distance from the original reference point to the anterior third of the tibia. This
line passes slightly anterior and then gradually posterior to pass around the posterior aspect
of the leg and is completed in a similar fashion on the opposite side (Fig 18A-9.). The
anterior and posterior flaps meet in a small half circle that will eliminate the "dog ear."
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.
Equal Anterior and Posterior Flaps

In this technique, the length of each flap is equal to half the diameter of the leg at the level of
bone transection (Fig 18A-18.). Starting from a midlateral apex on either side, the skin is cut
to form equal anterior and posterior flaps. The anterior investing fascia and the muscle of the
anterolateral compartment are then cut down to the anterior tibial neurovascular bundle. This
and the superficial peroneal nerve and the neurovascular bundle are managed as described
in the previous section. The tibia and fibula are cut as noted before. The long amputation
knife is used to create a posterior myofasciocutaneous flap. The vessels and nerves are dealt
with as described. The tibia is beveled and contoured with a bone file. The wound is irrigated,
and myoplasty is carried out by suturing the investing fascia and myofascia of the posterior
and anterior flaps together over the end of the bone. The absolute indication for equal
anterior and posterior flaps is to conserve bone length when relatively little bone remains (Fig
18A-19.,A-C).
Equal Medial and Lateral (Sagittal) Flaps

The advantages of this approach were outlined by Persson. The flaps are less apt to
become necrotic in dysvascular cases for two reasons. The first is that the placement of flaps
medially and laterally automatically reduces the amount of poorly vascularized anterior skin
that is left. The second reason is that the resultant flaps are widely based and very short, thus
enhancing their viability (Fig 18A-20.,A-C). Persson also stated that a side-to-side myoplasty
covers the bone better and provides good spontaneous drainage. In trauma cases, another
advantage is that the sagittal flap configuration allows the skin to be more easily cut proximal
to any anterior or posterior damaged skin, thus helping to preserve bony length (Fig 18A-
21.,A and B and Fig 18A-22.,A and B).
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).
End Weight-Bearing Transtibial Amputations
Osteomyoplasty (Ertl Procedure)

This procedure was designed for revision of transtibial residual limbs in the war wounded.
The resultant amputation has end weight-bearing capability. Two osteoperiosteal flaps are
elevated from the anteromedial and lateral aspects of the tibia beginning approximately 10 cm
distal to the proposed level of bone transection. The proximal attachment of these
osteoperiosteal flaps is preserved as the remainder of the amputation is performed. Once the
amputation has been completed, the lateral flap is sewn to the medial aspect of the fibula,
and the anteromedial flap is sewn to its lateral aspect. They are then sewn to each other to
create an osteoperiosteal tube joining the ends of the bones, which will ossify to form a
sturdy weight-bearing bone bridge (Fig 18A-24.). This method has been employed in the
American military, but to a much lesser extent in the civilian population. It has been
recommended as a useful technique in young traumatic amputees, both initially and in
revision surgery. Its chief disadvantage is the sacrifice of 10 cm of bone length, particularly
in cases where there is sufficient mobile soft tissue present to cover a greater length of tibia.
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
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).
In cases of severe foot infection, an open ankle disarticulation is useful. If tissue planes
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).
SPECIAL CONSIDERATIONS DURING TRANSTIBIAL

AMPUTATION
Treatment of Skin
In order to have a successful amputation, the one tissue structure that must heal is the skin.
The skin-subcutaneous incision should be made at 90 degrees to the surface to avoid having
portions of skin unsupported by subcutaneous tissue and, hence, more difficult to accurately
oppose and more prone to necrosis. At no time should the skin be traumatized by grasping
with forceps. Instead, skin edges can be everted for closure by the suturing needle, skin
hooks, or gloved fingers. The skin must be precisely approximated without closure tension.
Simple interrupted sutures are widely spaced and alternated with adhesive paper strips to
contain subcutaneous fat. In dysvascular cases, the sutures are kept in place for 3 weeks to
allow for the slower healing that is common in these cases. There should be no separation
of layers in the creation of myofasciocutaneous flaps because this may interfere with the
blood supply to the skin. The residual limb should not be left with inverted scars, redundant
skin, or "dog ears" that will not promptly atrophy.
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
removal of necrotic muscles so long as the skin remains viable.
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
sharp division following mild traction on the nerve. The cut proximal end retracts into the
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
cutting with a power saw should be done with saline cooling to prevent thermal necrosis. If
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
distal residual limb with a prominent distal end of the tibia is to be avoided. To prevent
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.
IMMEDIATE POSTOPERATIVE MANAGEMENT

A rigid dressing from the end of the residual limb to midthigh with the knee in full extension
meets a number of worthwhile goals. Knee flexion contracture is prevented during the first
few painful postoperative days, the wound is protected from bed trauma, and edema
formation is limited. The patient is generally comfortable and, if the rigid dressing is light
enough, can move about in bed quite easily. Another advantage of the rigid dressing is that it
protects against falls onto the residual limb while the patient is learning to manage a walker
or crutches. If necessary, it can be secured with a waist belt. The only disadvantage is that
the wound cannot be readily inspected. Careful attention to the patient's general status,
however, will inform the surgeon of any indication for removal of the cast such as an
otherwise unexplained fever or evidence of excessive drainage. The cast is worn for 3 weeks
with weekly changes for wound inspection and full range of motion of the knee.
A soft dressing, on the other hand, allows easy access to the wound for inspection and for
motion of the knee with or without the guidance of a therapist. It does not, however, offer any
protection to the wound from trauma, nor does it prevent knee flexion contracture if the
patient does not move the knee on a regular basis. One randomized study comparing soft
and rigid dressings showed that rigid dressings resulted in less pain, improved sense of well-
being, and enhanced prosthetic fitting progress. In another series, hospital stay was
reduced from 14 to 7 days. A posterior plaster splint will keep the knee straight so long as
the splint is not broken and the wrapping is firm. If it is necessary to look at the wound,
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
anesthetic for the first 72 hours postoperatively. Avoidance of wound dependency will also
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 deep-
breathing 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
cast. If an immediate postoperative prosthesis has been applied, limited weight bearing on
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
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 below-
knee 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 wound-
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.
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; 1:72-
83.
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
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; 73:155-
157.
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.
Search
GO
Transtibial Amputation: Prosthetic Management Reproduced with

permission from
Susan Kapp, C.P. Bowker HK,
Michael JW (eds):
Donald Cummings, C.P.
Atlas of Limb
Prosthetics:
Once the patient has completed the postoperative phase of treatment and adequate wound
healing is established, the goals of rehabilitation become limb maturation and return to normal Rehabilitation Principles.
activity. These goals are often accomplished with the help of an intermediate (or preparatory) Rosemont, IL, American Academy
prosthesis coupled with gait training, a residual limb shrinkage program, and close of Orthopedic Surgeons, edition 2,
supervision by the clinic team. 1992, reprinted 2002.
An intermediate prosthesis consists of a socket, a pylon, a foot, and a method of suspension. Much of the material in this text
It is usually applied when edema is diminished and the patient's residual limb has atrophied
sufficiently to allow independent donning and doffing of a prosthetic socket. To accomplish Deficiencies: Surgical, Prosthetic,
this, the intermediate prosthesis is often preceded by rigid dressings or immediate and Rehabilitation Principles
postsurgical fittings. The intermediate may be worn for a few months or as long as a year, (retitled third edition of Atlas of
depending upon the pace of residual limb atrophy, before it is replaced with a definitive Limb Deficiencies), ©American
prosthesis. Academy or Orthopedic Surgeons.
Even after initial prosthetic fitting, elastic bandages and residual limb shrinkers still play an this text.
important role in the conditioning of an amputated limb. For patients with wound
complications, delayed healing, or other circumstances that delay prosthetic fitting, an elastic Funding for digitization
bandage or shrinker may be the most practical and economical form of residual limb of the Atlas of Limb
conditioning. Bandaging is beneficial whenever the new amputee is not wearing the Prosthetics was
prosthesis. It aids in residual limb shrinkage through pressure atrophy of subcutaneous fat provided by the
and by externally supporting veins and lymphatic channels to allow blood return through Northern Plains Chapter of the
muscular contractions. Residual limb shrinkers, which are composed of a series of elastic American Academy of Orthotists &
Prosthetists
bands sewn together to form a cylinder with a padded distal end, may be used in place of
elastic bandages. For the recent amputee, shrinkers or elastic bandages should be worn
whenever the patient is not wearing a prosthesis, rigid dressing, or some other compressive
device.
An intermediate prosthesis is generally constructed on an endoskeletal pylon, which ensures

that alignment changes can be made as needed throughout the intermediate period. This is a You can help expand the
considerable advantage since the needs of the patient can be constantly reassessed and O&P Virtual Library with a
accommodated as his ability to use the prosthesis improves.
Once fitted with an intermediate prosthesis, the patient may progress in physical therapy to
full weight bearing. In addition to gait training, it is recommended that the patient be instructed
in the use of prosthetic socks, the application of shrinkers or elastic wraps, residual-limb
hygiene, and regular inspection of the limb for any sign of excessive pressure. Alignment and
socket fit are adjusted by the prosthetist as needed. It is not unusual for the patient to
progress through several intermediate sockets within the first year following amputation.
A patient's readiness for a definitive fitting varies depending on his activity level, weight-
bearing tolerance, and limb shrinkage. Atrophic changes may stabilize after only 4 months.
More likely, however, the process continues for 12 months or more.
The decision to proceed with definitive fitting, largely subjective, is based on the overall
perception that the patient has reached a plateau in activity level, prosthetic wearing time,
and residual-limb volume. For example, a young active amputee who has worn an
intermediate prosthesis is probably ready for definitive fitting when he can tolerate full weight
bearing, wears the prosthesis all day, and for a period of perhaps 1 month has not had to
add prosthetic socks to accommodate limb shrinkage. In contrast, an elderly patient with other
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.
THE PATELLAR TENDON-BEARING SOCKET

The patellar tendon-bearing (PTB) socket (Fig 18B-1.) consists of a laminated or molded
plastic socket. To make a PTB socket, an impression taken of the patient's residual limb is
modified to achieve an intimate, total-contact fit over the entire surface of the residual limb. It
can be suspended in multiple ways, which are discussed later.
The anterior wall of the socket usually extends proxi-mally to encapsulate the distal third of
the patella. Just below the patella located at the middle of the patellar ligament is an inward
contour or "bar" that utilizes the patellar ligament of the residual limb as a major weight-
bearing surface. The term patellar tendon bearing can be misleading, however, because the
patellar ligament is not the only major weight-bearing surface utilized by the PTB socket.
The medial and lateral socket walls extend proximally to about the level of the adductor
tubercle of the femur. Together they control rotation, contain soft tissue, and may provide
some mediolateral knee stability. The medial wall is modified with a slight undercut in the
area of the pes anserinus on the medial flare of the tibia, thus utilizing another major
pressure-tolerant surface. The lateral wall provides a relief for the head of the fibula and
supports the fibular shaft. This wall also acts as a counterpressure to the medial wall.
The posterior wall is usually designed to apply an anteriorly directed force to maintain the
patellar ligament on the bar. The posterior wall is flared proximally to allow comfortable knee
flexion and to prevent excessive pressure on the hamstring tendons.
The distal portion of the PTB socket may incorporate a soft pad that in theory prevents distal
edema by aiding venous and lymphatic return from the distal part of the residual limb. A soft
socket liner may be used for added protection or comfort.
The PTB total-contact socket is appropriate for virtually all transtibial (below-knee)
amputations, except in some postoperative prostheses or when pathologic conditions require
an alternative socket.
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. Perspiration does not corrode the socket.

2. Less bulky at the knee than with an insert.
3. Easy to keep clean.
4. Contours within the socket do not compress or pack down with use.
5. Reliefs or modifications can be located with exactness.
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. Materials may deteriorate over time.

2. Not as sanitary as a hard socket because liners tend to absorb fluids.
3. Increases bulk around the knee and proximal circumference of the prosthesis.
4. The liner may compress over time with resultant loss of intimate fit.
5. 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.
Flexible Sockets With Rigid External Fra

New plastics and materials have enabled prosthetists to offer patients the benefits of a
flexible inner socket that is inserted into a rigid frame (Fig 18B-4.). The inner socket is
fabricated from polyethylene or a similar material and the frame from laminated plastic or
thermoplastic material. The frame provides coverage only over the primary weight-bearing
areas, while the more pressure-sensitive areas, i.e., bony prominences and soft tissues not
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. Decreased weight.
2. Increased comfort.
3. Improved heat dissipation.
4. 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. Adjustability.
2. Ease of donning and doffing by the patient.
3. Adequate suspension for the majority of transtibial amputees.
4. Provides moderate control of knee extension.
5. 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.
PTB Supracondylar Suprapatellar Suspension

The PTB supracondylar, suprapatellar (PTB-SCSP) socket (Fig 18B-6.) was designed
originally as an alternative suspension and as a means of providing increased mediolateral
and anteroposterior stability of the residual limb. This socket differs from the standard PTB
socket in that the medial, lateral, and anterior walls extend higher and fully encompass the
femoral condyles and the patella. The posterior wall is unchanged.
During casting and modification, the proximal mediolateral dimension just superior to the
femoral condyles is reduced to provide purchase over the femoral condyles, particularly the
medial condyle. The area just proximal to the patella may also be contoured inward to create
a "quadriceps bar," which provides added suspension over the patella and resists
recurvatum.
This type of suspension is particularly recommended for patients with short residual limbs
since it encompasses more surface area to share weight bearing and resist torsional forces.
Patients with mild mediolateral knee instability or those who cannot tolerate a supracondylar
cuff can also benefit from PTB-SCSP suspension. This socket style generally cannot provide
adequate purchase over the femoral condyles for obese or very muscular patients. Patients
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. Suspension is an inherent part of the socket.

2. Is less restrictive to circulation than a cuff or thigh corset.
3. Aids in knee stability, rotational control, and pressure distribution.
4. 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.
PTB Supracondylar Suspension

The major difference between this and the PTB-SCSP socket is that the patella is not
enclosed (Fig 18B-7.). The medial and lateral brims purchase over the femoral condyles, but
anteriorly they dip downward to form a more traditional trim line near the distal end of the
patella. The quadriceps bar and its knee extension control are thus eliminated.
This suspension may be indicated when a patient wishes to do a lot of kneeling or cannot
tolerate the quadriceps bar or encapsulation of the patella. The patient must have a stable
cruciate ligament with no need for an extension stop at the knee.
It is contraindicated, as is the PTB-SCSP socket, for patients with moderate to severe

ligamentous laxity who require the added stability of metal joints and a thigh corset.
Advantages (over the PTB-SCSP socket)
1. May make kneeling easier.

2. May be more cosmetic.
Disadvantages (as compared with the PTB-SCSP socket)
1. Does not provide a knee extension stop.

2. May provide less effective suspension than a PTB-SCSP since there is no
suprapatellar purchase and because the absence of patellar encapsulation makes the
medial and lateral walls more flexible.
3. Less mediolateral stability than the PTB-SCSP.
Variants of the PTB Supracondylar, Suprapatellar and PTB

Supracondylar Sockets
The PTB-SCSP socket usually incorporates a removable soft liner with a foam wedge buildup
over the medial femoral condyle that compresses sufficiently to allow the amputee to push his
residual limb past the supracondylar undercuts and into the prosthesis.
The socket with a removable medial brim (Fig 18B-8.) is another type of supracondylar
suspension. As the name implies, the proximal medial brim is removed to allow the residual
limb to be inserted into the socket. It is then replaced to provide purchase over the medial
femoral condyle. Laminated into the proximal brim is a steel bar that fits into a channel on the
medial aspect of the socket, thus allowing the medial brim to be removed and then replaced
in its original position. The anteroproximal part of the socket brim can also be made to
encompass the patella in the fashion of a PTB-SCSP socket.
A third variant is the removable medial wedge (Fig 18B-9.). Once the patient has inserted his
residual limb into the socket, the supracondylar area between the limb and the medial socket
wall is filled by a Plastisol or crepe wedge that "keys into" the proximomedial portion of the
socket brim.
The selection of supracondylar methods depends upon patient needs such as cosmesis,
durability, ease of donning and doffing, the need for a soft liner, and patient preference.
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. Simple and effective means of suspension.

2. Helps minimize socket pistoning.
3. Good auxiliary suspension.
4. 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.
Silicone Suction Socket

The silicone suction socket (3-S) (Fig 18B-11.) or Icelandic roll-on suction socket
(ICEROSS) was conceptualized and developed by Ossur Kristinsson with further development
by Durr-Fillauer Orthopedic, Inc. The socket utilizes a "silicone liner" either custom-made or
prefabricated. This liner is worn directly against the skin and dramatically reduces shear
forces created by socket pistoning. Suspension is achieved by the inherent suction
capabilities of a silicone material against skin and a shuttle lock mechanism at the distal end
of both liner and socket. The silicone liner is used strictly to provide suspension. It may be
used with a hard socket or with a soft, lined socket depending on the amputee's needs.
Advantages:
1. Improved suspension.
2. Increased range of motion in flexion.
3. Decreased shear on residual limb.
Disadvantages:
1. Some patients may have difficulty in donning the liner.

2. Punctures or tears in the silicone can dramatically decrease suction suspension.
Joints and Thigh Corset

The thigh corset (Fig 18B-12.), traditionally made of leather, is fastened snugly around the
distal two thirds of the patient's thigh and is attached to the socket by metal joints with
vertical support bars. Although joints and a corset may be the sole form of suspension, they
are often combined with waist belt suspension. In order to prevent the joints from reaching full
extension, which is noisy and soon wears the joints down, a posterior "check strap" is usually
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. Provides maximum mediolateral stability.

2. Can provide maximum prevention of recurvatum.
3. Redistributes some weight bearing and torque forces to the thigh.
4. Increases proprioceptive feedback.
Disadvantages:
1. Can contribute to distal edema.

2. Tends to atrophy thigh musculature.
3. Leather is not very hygienic.
4. Joint centers must be precisely located to minimize motion between the leg and the
prosthesis.
5. Adds weight and bulk to the prosthesis.
6. Not very cosmetic.
7. Requires more fabrication time.
8. Usually requires additional suspension of a fork strap and waist belt.
Waist Belt Suspension

The waist belt (Fig 18B-13.) can be used as an auxiliary suspension or as a sole means of
suspension. The standard system consists of a belt situated above the iliac crests or between
the iliac crests and the greater trochanters. On the amputated side, an elastic strap extends
distally to a buckle at midthigh. Fastened to this buckle is a strap that attaches to a PTB cuff
or inverted "Y" strap connected to the prosthesis.
Waist belt suspension is often used on postoperative or intermediate prostheses because it

maintains suspension regardless of residual-limb volume changes. It is also recommended
when all proximal constriction must be eliminated due to skin or vascular conditions. The
elderly or debilitated patient may prefer the added security of a waist belt. It also affords good
auxiliary suspension for sports prostheses.
The waist belt is not recommended for patients with severe scarring or sensitive skin in the
regions in contact with the belt.
Advantages:
1. Much of the weight of the prosthesis is distributed proximally over the iliac crests.
2. Enables patients to loosen the supracondylar cuff or other form of suspension.
3. Good auxiliary aid when other types of suspension are inadequate.
4. The elastic strap provides some knee extension assistance.
Disadvantages:
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, energy-
efficient 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.
Standard SACH Feet

Internal-keel SACH feet (Fig 18B-14.) include a solid wood or aluminum internal keel that
extends to the toe break and is surrounded by a molded external foam foot with cosmetic
toes and a cushioned heel wedge available in different densities.
The SACH foot has no movable components, so joint motion is simulated by the rubber
surrounding the keel. Plantar flexion is replaced by the compression of the heel wedge. Ankle
dorsiflexion is not available in the SACH foot. Neither inversion nor eversion of the ankle is
provided, although forces in the coronal plane are dampened by compression of the rubber
sole. Forefoot dorsiflexion is simulated by the flexible toe portion distal to the end of the
internal keel.
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. Moderate weight.
2. Good durability.
3. No moving components.
4. Minimal maintenance.
5. Good shock absorption for moderately active patients.
Disadvantages:
1. Limited plantar flexion and dorsiflexion adjustability.

2. The heel cushion deteriorates over time.
3. The heel cushion may loose elasticity.
4. The rigid forefoot provides poor shock absorption for high-output activities.
Other SACH Foot Types

The Syme SACH foot (Fig 18B-16.) was designed to provide the ankle disarticulation
amputee with the advantages of a SACH foot. Since an ankle disarticulation in an adult
results in only an average I½ in. shortening of the leg, the space available for the addition of
a prosthetic foot is limited. The Syme foot, therefore, is lower in height than the SACH foot in
order to accommodate this minimal ground clearance. Important to note is the thinner heel
cushion. Because the foot height is reduced, the heel cushion is also reduced and therefore
less shock absorbent.
In the external-keel SACH foot (Fig 18B-17.) the keel portion is not incorporated within the
rubber foot. Instead, the rubber portion of the foot is affixed to the keel. It is used for
exoskeletal prostheses only. This foot is recommended for a Syme prosthesis when an
internal-keel foot will not accommodate a minimal leg length discrepancy. The need for
optimum cosmesis at the ankle on an exoskeletal prosthesis may also be an indication for an
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 single-
axis 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. Relatively high maintenance due to moving components.

3. Less cosmetic.
4. 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.
Advantages:
1. Allows motion in all planes.

2. Reduces torque on the residual limb.
3. Adjustability.
Disadvantages:
2. Increased maintenance.
3. Decreased cosmesis.
4. May provide less stability than other feet on smooth surfaces.
Flexible-Keel- Dynamic-Response Feet

Prosthetic feet are primarily designed for walking, yet many lower-limb amputees have the
desire to be more active and therefore require the use of a prosthetic foot that will allow them
increased activity. This need has promoted research and resulted in a new generation of feet
(Fig 18B-20. and Fig 18B-21.) that aid the more active amputee.
These feet incorporate a shock absorption mechanism in the form of a flexible keel that
dissipates energy, provides a smoother gait, and gives some degree of push-off that the rigid
keel cannot provide. As a patient's cadence increases, the amount of time spent on the heel
decreases, while the amount of time spent on the forefoot increases. Since relatively more
time is spent, and considerably more forces are exerted on the forefoot, there is an increase
in the dorsiflexion moment. Through the use of new designs and materials, this dorsiflexion
moment allows the keel to compress or distort, thereby absorbing energy that is released
during push-off, and aids in propelling the patient forward. Some of the materials currently in
use include graphite composite, Delrin, Kevlar, polyurethane elastomer, and flexible rubber,
which generally result in a lighter-weight foot. In addition, the feet allow a more fluid motion,
which produces a more normal gait.
BIOMECHANICAL VARIABLES IN TRANSTIBIAL

PROSTHETICS
The successful fitting of a transtibial prosthesis requires a thorough understanding of the
biomechanical variables involved and the ability to achieve an appropriate compromise
between these variables to meet the unique needs of each patient. Biomechanical factors in
transtibial prosthetics can be divided into four broad categories: socket fit, alignment, foot
function, and suspension (Fig 18B-22.).
Biomechanics of Transtibial Socket Fit

The prosthetic socket is the primary connection between the patient's residual limb and the
prosthesis. As such it must provide comfort and function to the patient under the duress of
two force systems: the weight of the body due to gravity and the forces applied to the
residual limb through contact with the socket. These forces are continually changing during
both static and dynamic use of the prosthesis. The successful resolution of these forces can
come about only through careful attention during patient evaluation, casting, and socket
modification to the following details.
Displacement and Pressure Tolerance of Residual-Limb Tissues (Total

Contact)
In theory, residual-limb/socket pressures could be maximally reduced by ensuring that every
square centimeter of the residual limb is in contact with the socket and is sharing an equal
portion of the load. In actual practice this is complicated by differences in tissue displacement
and tissue pressure tolerances. For example, some bony portions of the residual limb like the
distal part of the tibia or the head of the fibula cannot be compressed as much as soft-tissue
areas.
Since soft tissues are displaced during axial loading, a socket that simply makes equal
contact with the surface area of the residual limb may cause more pressure over bony
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.
Modification for Dynamic Forces

In normal human locomotion, floor reaction forces produce moments at the joints of the lower
limb. Similar forces exist during ambulation with a prosthesis, but they are applied through the
prosthetic socket to the enclosed residual limb. These forces upon the residual limb must be
managed to achieve socket comfort and prevent skin breakdown. The major dynamic forces
to be considered are anteroposterior and mediolateral forces. Anteroposterior forces are
generated from heel strike to foot flat while a powerful knee flexion moment exists. Knee
stability is maintained by contraction of the quadriceps. The resulting forces between the
socket and residual limb are concentrated on the an-terodistal portion of the tibia and
posteroproximal soft tissue (Fig 18B-25.). The socket, therefore, must provide even pressure
distribution in the popliteal area and anterodistal relief coupled with anterior, medial, and
lateral counterpressures to prevent excessive pressure over the distal end of the tibia.
Mediolateral forces occur during single-limb support on the prosthetic side when floor reaction
forces may result in varus or valgus forces. As a result, the socket tends to change its
angular relationship with respect to the residual limb. With normal foot inset, forces are
generally increased over the proximomedial and disto-lateral aspects of the residual limb.
These forces can be reduced if the foot is moved laterally, but since foot inset is desirable in
most cases, the prosthetic socket must accommodate these forces. Proximomedial forces are
not a significant problem because they are focused upon the pressure-tolerant medial femoral
condyle and medial tibial flare. But distolateral forces can create excessive pressure on the
transected end of the fibula. Socket modifications to prevent this include relief for the
distolateral aspect of the fibula, lateral stabilizing pressure along the shaft of the fibula, and
lateral stabilizing pressure over the anterior compartment (pretibial muscle group) (Fig 18B-
26).
Other dynamic forces created within the socket that may present prosthetic problems include
torque and shear. If excessive torque exists, the tendency of the socket to rotate in relation to
the residual limb may cause discomfort, skin breakdown, or gait deviations. Shear occurs
whenever the socket moves in a direction opposite to residual-limb motion. For example, if a
patient's suspension is too loose, the prosthesis tends to drop away from the limb during
swing phase, only to be driven back to its correct position during heel contact. This proximal
and distal motion creates shear forces between the residual limb and the socket. Shear
forces can occur in any plane.
A certain amount of shear is unavoidable because some motion between the socket and the
underlying tissues will always occur. Excessive shear forces result in discomfort or skin
breakdown. Patients with sensitive skin, such as diabetic or burn patients, may be especially
susceptible to skin breakdown from shear forces. These forces can be reduced by a soft,
socket insert or a nylon sheath worn directly over the skin. Rotation units or "torque
absorbers" are another option. They can be used in transtibial prostheses when the patient
uses the prosthesis for activities such as golfing that generate an unusually high amount of
torque or to protect fragile skin. Proprioception and sensory feedback with the prosthesis are
increased when the socket is in intimate contact with the residual limb.
Biomechanics of Transtibial Prosthetic Alignment

This is the second broad category of biomechanical factors in transtibial prosthetics.
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.
Biomechanics of Prosthetic Feet

It is essential to have a thorough understanding of prosthetic foot biomechanics because
often foot selection alone can determine the ultimate success or failure of a prosthesis. There
are six possible variables to be considered when choosing a prosthetic foot. They are
alignment (previously discussed), length of the toe lever arm, width of the keel, flexibility of
the keel, durometer of the heel cushion, and fit of the prosthetic foot within the shoe.
A common misconception when discussing foot function is to confuse toe break location with
toe lever-arm length. The toe lever arm diminishes at the toe break but includes the entire
length of the foot. This overall lever arm can be shortened or lengthened by moving the foot
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, external-
keel 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 lever-
arm 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.
PRESCRIPTION OF TRANSTIBIAL PROSTHESES

When making decisions about a prosthetic prescription the clinic team must analyze available
patient information to formulate a plan for prosthetic treatment. The team should be familiar
with socket designs, suspension systems, shanks and feet, as well as the indications for
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
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.
Residual Limb Shape

This helps identify potential fitting problems. A bulbous residual limb, which is often present
shortly after amputation, has a larger circumference distally than proximally. If the difference
between circumferences is large enough, the patient will be unable to don or doff the
prosthetic socket. One solution is a temporary, nonremovable plaster of paris prosthesis to be
utilized until the distal circumference of the residual limb has decreased enough to allow
donning and doffing of the socket. A conical residual limb is characteristic of a long-term
prosthetic wearer and should not present a fitting problem. A cylindrical residual limb is
probably the ideal shape since pressure and stabilizing forces can be applied evenly.
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.
Condition of Bony Anatomy

A soft liner may be indicated to provide protection to bony prominences. Bone spurs or
unbeveled bones that present a fitting problem should be brought to the attention of the
physician for possible surgical correction.
Condition of the Knee Joint

The stability of the knee joint is very important to the prosthetic prescription. If ligament laxity
is present, supracondylar or joint and corset suspension is recommended.
Condition of the Thigh Musculature

In transtibial prosthetics the quadriceps are probably the most important muscles for a
smooth, controlled gait. If these or other muscle groups are weak, the patient may require
physical therapy for strengthening.
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
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.
COMPUTER-AIDED DESIGN, COMPUTER-AIDED

MANUFACTURE
Computer-aided design-computer-aided manufacture (CAD-CAM) is beginning to play a role
in the practice of prosthetics and orthotics. Transtibial prostheses of today are designed and
fabricated by using subjective techniques that can be difficult to teach and reproduce.
The traditional methods are labor intensive and use calipered measurements, palpation, and
molded plaster impressions to gain data regarding residual-limb size and shape. This results
in a qualitative evaluation of socket fit rather than a more objective quantitative evaluation.
Without quantitative information, a well-fitting socket is difficult to produce and analyze. The
traditional process is also time-consuming because of the trial-and-error method that even
the most experienced prosthetist must use.
As more accurate methods of data collection are developed through CAD, it is hoped that the
time and effort of the prosthetist can be greatly reduced. Presently the data collection
methods include digitized passive plaster impressions, an optical shape sensor that rotates
about the limb to collect data points of the high-contrast silhouette, laser shape sensing, and
experimental use of ultrasound to gain information regarding a patient's residual limb. Each of
these methods provides residual-limb topography from which residual-limb changes can be
monitored and documented. This method of data gathering and documentation can potentially
be applied to most levels of amputation as well as to many limbs requiring orthotic care.
Once the data are stored in the computer, the prosthetist makes modifications to the three-
dimensional image on screen. Software packages offer a variety of features with which to
manipulate shapes. Once the desired shape is complete, the data are then sent to a
numerically controlled milling machine where a positive model is carved from a plaster blank.
From this point traditional fabrication and fitting techniques are utilized. If the patient should
require socket modifications, they are made on the electronic model, and a new socket is
fabricated by incorporating the changes.
Data collected by computers could be used to create a data base from which ideal socket
shapes might be developed. A clearer understanding of what constitutes a well-fitting socket
could have a profound effect on prosthetic practice. Although early CAD systems were
greeted with some skepticism, as the technology has evolved, it is now evident that CAD will
become a very useful tool for the prosthetist-orthotist.
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
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,
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 below-
the knee amputation. J Bone Joint Surg [Am] 1979; 6:724-729.
19A: Surgical Procedures | O&P Virtual Library
Search
GO
Knee Disarticulation: Surgical Procedures Reproduced with

permission from
Michael S. Pinzur, M.D. Bowker HK,
Michael JW (eds):
When compared with transfemoral amputation, knee disarticulation (through-knee amputation) Atlas of Limb
Prosthetics:
has the potential benefits of (1) durable end weight bearing (direct load transfer); (2) retention
of a long, powerful, muscle-stabilized femoral lever arm; (3) ease of prosthetic socket Rehabilitation Principles.
suspension due to the bulbous end; (4) decreased surgical blood loss and; (5) resistance to Rosemont, IL, American Academy
infection by maintaining the cartilage barrier to infection. of Orthopedic Surgeons, edition 2,
Its use in growing children has generally been confined to the treatment of congenital
anomalies, malignant tumors, nonsalvageable trauma, or infection. Knee disarticulation Much of the material in this text
maintains femoral length in growing children by preserving the growth potential of the distal
femoral epiphysis. It also avoids the risk of appo-sitional bony overgrowth inherent in Deficiencies: Surgical, Prosthetic,
pediatric transosseous amputation. The weight-bearing capacity of the distal end of the femur and Rehabilitation Principles
allows fabrication of a prosthetic socket with direct load transfer. The retained femur tends to (retitled third edition of Atlas of
grow at a slower rate than the contralateral femur, eventually allowing the prosthetic knee Limb Deficiencies), ©American
joint center to approach the same level as the normal knee. Academy or Orthopedic Surgeons.
This amputation level is infrequently used in adults for both cosmetic and functional reasons. this text.
The residual limb is perceived to be unsightly due to its length and distal bulbousness. If a
standard transfemoral (above-knee) prosthetic knee joint is used in a knee disarticulation Funding for digitization
prosthesis, its knee center will be far distal to that of the contralateral normal knee center. of the Atlas of Limb
External knee hinges improve sitting cosmesis somewhat but are cumbersome, unsightly, Prosthetics was
somewhat unstable, and often damage overlying clothing. Development of the polycentric provided by the
prosthetic knee joint has allowed the prosthetic knee joint center to approach that of the Northern Plains Chapter of the
normal knee, thereby smoothing out the gait pattern and making the procedure a more American Academy of Orthotists &
Prosthetists
reasonable option in adults.
USE IN THE NONWALKER

Nonwalking patients often develop knee flexion contractures following transtibial (below-knee)
amputation or hip flexion-abduction contractures following transfemoral amputation due to You can help expand the
muscle imbalance. Knee flexion contracture may lead to distal stump ulcers in the transtibial O&P Virtual Library with a
amputee (Fig 19A-1.). The residual limb of the transfemoral amputee with hip joint tax-deductible contribution.
contracture provides only a small posterior thigh platform for sitting and a short lever arm for
transfer (Fig 19A-2.,A and B). The residual limb in the knee disarticulation amputee is
muscle balanced, so these patients rarely develop early or late hip joint contracture. A large
surface area for weight bearing and balance while sitting and for turning in bed is provided as
well as a long lever arm for transfers (Fig 19A-3.).
PROSTHETIC CONSIDERATIONS FOR THE POTENTIAL

WALKER
The active walker should benefit from the direct load transfer possible following knee
disarticulation. This may be limited with some techniques for knee disarticulation in which the
soft-tissue envelope covering the femoral condyles and interfacing with the prosthetic socket
consists only of skin. The knee disarticulation technique described by Wagner provides a soft-
tissue envelope over the femoral condyles that is composed of a mobile nonadherent
gastrocnemius muscle flap and full-thickness skin. This cushioned, shear-absorbing, weight-
bearing platform comfortably allows direct load transfer, which is preferable to the
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
of the femur to efficiently dissipate pressure. While this provides an excellent method of
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 weight-
bearing 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.
USE IN THE TRAUMA OR INFECTION PATIENT

Push-off at the terminal stance phase of gait is accomplished by advancement of the limb
against a stable foot and ankle. In patients with nonsalvageable lower limbs secondary to
trauma or infection, every effort should be made to retain the forward propulsive capacity of
the knee joint and proximal end of the tibia. Transtibial amputation should be performed when
the following structures can be retained: (1) a serviceable joint with no more than a 25-
degree loss of full extension, (2) the proximal end of the tibia including the patellar tendon
attachment, (3) an adequate soft-tissue envelope of mobile muscle to cover the end of the
tibia and, (4) full-thickness skin in areas of load transfer. A transtibial amputation without an
adequate soft-tissue envelope in an active post-traumatic patient will often lead to continued
skin breakdown and residual-limb discomfort. If these problems cannot be overcome by
plastic revision of the residual limb or by use of a weight-bearing thigh corset, these patients
may be better served by provision of an adequate soft-tissue envelope at the knee
disarticulation level (Fig 19A-4.).
USE IN THE DYSVASCULAR PATIENT

Viable tissue to provide an adequate soft-tissue envelope is the first consideration. Patients
amputated at the level of the tibial tuberosity with retention of the patellar tendon insertion
retain a functional knee joint and transtibial amputee gait. It is unusual to see a patient with
the vascular capacity to heal a surgical wound at the knee disarticulation level not be able to
heal at the high transtibial level. Viability of remaining tissue in the dysvascular patient is
determined by preoperative vascular testing and intraoperatively by muscle color and
consistency, skin and muscle bleeding, and muscle contractility with electrical stimulation.
When a knee flexion contracture approaches 50 degrees, knee joint excursion and hence
forward propulsion following transtibial amputation will not be adequate to make functional use
of the quadriceps-tibia lever arm due to the greatly increased energy cost of flexed-knee gait.
Small knee flexion contractures can sometimes be improved following prosthetic limb
fitting, but when the contracture approaches 50 degrees, the patient may be better served
with knee disarticulation.
Prosthetic accommodation of a hip flexion contracture also becomes difficult when that
contracture exceeds 30 degrees. Increased hip flexion at initial floor contact (heel strike)
causes the dynamic weight-bearing line (hip-knee-ankle axis) to fall posterior to the knee
center. When this happens, the knee will "buckle," and the patient will stumble or fall unless
he can accomodate by forceful quadriceps contraction. Hip flexion contractures can frequently
be corrected by having the patient lie prone for periods sufficient to stretch out the deformity.
Surgical correction is rarely indicated.
SURGICAL PROCEDURES
Soft-Tissue Envelope
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 19A-
6.,A). On closure, the surgical scar lies posteriorly, between the femoral condyles (Fig 19A-
6.,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.
Anterior and Posterior Skin Flaps

The incision for the anterior flap begins posteromedially just proximal to the joint line and
extends convexly, anteriorly, and distally to a point approximately 2.5 cm distal to the tibial
tuberosity. It then curves proximally and posterolaterally to end just proximal to the joint line.
The posterior flap is also convex but somewhat shorter than the anterior flap. The patellar
ligament is incised at its insertion, and the knee joint capsule is incised circumferentially. The
cruciate ligaments are severed from their attachment on the tibia. The vascular bundle is
ligated at the joint level, and the sciatic nerve is severed proximally. The gastrocnemius is
removed from its origin on the femur. The semimembranosus, semitendinosus, and biceps
femoris muscles are divided at a level leaving adequate length for suturing to the patellar
tendon without undue tension. The ili-otibial band and pes anserinus are sutured to the
remaining anterior retinaculum. The skin is reapproximated and an appropriate dressing
applied (Fig 19A-8.).
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 (½ 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.).
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 residual-
limb 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.
Search
GO
Knee Disarticulation: Prosthetic Management Reproduced with

permission from
John W. Michael, M.Ed., C.P.O. Bowker HK,
Michael JW (eds):
Knee disarticulation is an uncommon level for amputation in North America and hence is Atlas of Limb
Prosthetics:
seldom encountered by the physician or prosthetist. Most demographic surveys suggest that
the frequency of knee disarticulation in the United States is between 1% and 2% of all major Rehabilitation Principles.
lower-limb amputations. The incidence appears to be similar in many other countries but Rosemont, IL, American Academy
gradually increases to about 20% in centers that advocate this level, such as those in of Orthopedic Surgeons, edition 2,
Copenhagen and Toronto. 1992, reprinted 2002.
Batch and colleagues began their 1954 paper with a statement that aptly summarizes the Much of the material in this text
contemporary situation, which has apparently changed very little over the intervening 38
years: Deficiencies: Surgical, Prosthetic,
"Disarticulation at the knee joint has been periodically extolled as the procedure (retitled third edition of Atlas of
of choice over amputation through the thigh. Convincing arguments and Limb Deficiencies), ©American
statistics have been presented to support this view, but the procedure has not Academy or Orthopedic Surgeons.
been generally accepted because of the belief that the stump is unsightly and Click for more information about
this text.
that the prosthesis is difficult to fit, and because of lack of experience with the
procedure."
POSTOPERATIVE MANAGEMENT Prosthetics was
provided by the
Although immediate postoperative fitting with a prosthesis is technically feasible, it is rarely Northern Plains Chapter of the
provided today. This may have more to do with the unfa-miliarity of this level of amputation to American Academy of Orthotists &
both prosthetist and surgeon than any other factor. Soft gauze dressings followed by elastic Prosthetists
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
apparatus over it), Unna's paste semirigid dressing, and a novel polyurethane foam
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 You can help expand the
immediate ambulation on a plaster of paris socket is seldom advocated for the dys-vascular O&P Virtual Library with a
individual today, some opt to use the postoperative plaster cast alone, preferably applied by tax-deductible contribution.
the surgeon in the operating theater. Those who advocate such a rigid dressing believe that it
enhances wound healing and facilitates rehabilitation.
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
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,
it may be necessary to augment suspension with suction or a Silesian belt variant (Fig
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
children. Suspension is achieved by adjustable supracondylar straps (Fig 19B-5.). Because
immature condyles are not very bulky, it is sometimes possible to create a self-suspending
socket where flexible inner walls barely allow the condyles to pass (Fig 19B-6.). This
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
developed for molded leather sockets (Fig 19B-7.), it can be easily adapted to modern
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
one of the leading prosthetic advocates of knee disarticulation fittings. With two decades of
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
success even with geriatric and bilateral amputees (Fig 19B-9.). Because the polyethylene
foam inner liner can be readily adjusted to maintain snug pressure over the condyles, marked
distal atrophy occurs over time. This ultimately improves cosmesis for fleshy individuals
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
Icelandic Push-on Suction Socket (ICEPOSS). The majority of the thigh is not covered by
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
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-
controlled cylinder with these hinges, but durability remains a concern (Fig 19B-12.).
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,
including those designed for knee disarticulation. As he notes, it is possible to analyze the
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
point of rotation of the knee mechanism (Fig 19B-14.). At heel strike, the four-bar knee
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
protrusion of the knee (Fig 19B-17.). It is available with either mechanical swing-phase
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 19B-
19.). 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
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 knee-
disarticulation 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
16. Glattly HW: A statistical study of 12,000 new amputees. South Med J 1964; 57:1373-
1378.
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.
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
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.
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.
20A: Transfemoral Amputation | O&P Virtual Library
Search
GO
Transfemoral Amputation: Surgical Procedures Reproduced with

permission from
Frank Gottschalk, M.D., F.R.C.S.Ed., F.C.S.(S.A.)Orth. Bowker HK,
Michael JW (eds):
It is well accepted that transfemoral (above-knee) amputees have an increased energy Atlas of Limb
Prosthetics:
expenditure for walking. Even those with no concomitant medical problems are unable to
achieve normal gait in terms of velocity, cadence, or walking economy. Older dysvascular Rehabilitation Principles.
amputees do not have the physical reserve required and oftentimes will be limited household Rosemont, IL, American Academy
walkers or be totally unable to use a transfemoral prosthesis. of Orthopedic Surgeons, edition 2,
Despite improvements in prosthetic design and fabrication, artificial limbs are unable to
provide a reasonable replacement for the lost limb when poor surgery has been done and an Much of the material in this text
inadequate residual limb has been created. Too often the procedure is performed without
thought for biomechanical principles or preservation of muscle function. Although one of the Deficiencies: Surgical, Prosthetic,
major goals of surgery is primary wound healing, this can be achieved while maintaining and Rehabilitation Principles
biomechanical principles of lower-limb function. In the majority of transfemoral amputees who (retitled third edition of Atlas of
have had a conventional surgical procedure, the energy expenditure will be 65% or more Limb Deficiencies), ©American
above normal for level walking at a regular walking speed. It is important to maintain as Academy or Orthopedic Surgeons.
much length as possible when doing a transfemoral amputation. The longer the residual limb, Click for more information about
this text.
the easier it is to suspend a prosthesis as well as to align it. The functional ability of the
patient is also improved with a longer residuum. In some circumstances a higher level of
amputation may be dictated by the prevailing local pathology. In these cases a small portion Funding for digitization
of the femur at the trochanteric level should be left where possible. This allows for enhanced of the Atlas of Limb
prosthetic fitting by providing additional contouring. In those patients where prosthetic use is Prosthetics was
not considered, as long a stump as possible should be left. This provides a longer lever arm provided by the
and may help with transfers as well as reduce the potential for bone erosion through the soft
tissues. 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 You can help expand the
measures 3 degrees from the vertical. The femoral shaft axis measures 9 degrees from the O&P Virtual Library with a
vertical. The normal anatomic alignment of the femur is thus in adduction, which allows the tax-deductible contribution.
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
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
ischium as a fulcrum. Another method using prosthetic alignment with adjustment of socket
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-to-
normal 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
standard texts. A muscle-preserving technique is preferred whereby the distal insertions of
the muscles are resected from the bony attachment. Once the myodesis has been done, the
remaining tissue can be excised.
INDICATIONS FOR TRANSFEMORAL AMPUTATION
Vascular Disease
This is probably the most common cause for transfemoral amputation. Although this
procedure is done less frequently than in the past, it is often necessary in those patients with
very severe vascular and diabetic disease who are deemed to have poor potential to heal a
lower-level amputation. The majority of these patients have widespread systemic
manifestations of the disease which may often compromise their postoperative rehabilitation.
Their physical reserve is often insufficient for them to become prosthetic users. Patients with
combined diabetic/vascular disease tend to be an average of 10 years younger than those
patients with purely vascular problems (refer to Chapter 2C). Patients with purely vascular
disease tend to have a higher incidence of transfemoral amputation.
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.
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 20A-
4.). 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.
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.
GENERAL POSTOPERATIVE CARE

While the wound is healing, the patient should be mobilized in a wheelchair and in the
parallel bars and upper-body exercises started. In addition, conditioning of the well leg should
take place. Most often, the sutures can be removed at around 2 weeks for traumatic
amputations and at 3 weeks in the dysvascular amputee. During this time the patient will
have been wrapping the residual limb or using a shrinker. A temporary plastic adjustable
prosthesis can now be fitted and gait training started. The patient needs to have sufficient
upper-body strength to use crutches or a walker. Flexion contractures should be prevented
from occurring by correct positioning of the patient in bed as well as muscle-strengthening
exercises. By using aggressive rehabilitation techniques in a motivated patient, early return to
walking can be accomplished in a short time. Those patients who do not have the physical or
mental ability to participate in a rehabilitation program designed to teach prosthetic use will be
better off using a wheelchair. Transfer training is important in this regard. The decision to
provide the patient with a wheelchair should be made early in the postoperative period.
The overall rehabilitation of the patient with a trans-femoral amputation begins at the time of
surgery and continues until the patient has achieved maximum functional independence for
that individual. The appropriate surgery allows for easier prosthetic fitting as well as
enhancing physical therapy to allow the patient to achieve the goals set by the treating team.
References:
1. Bohne WHO: Above the knee amputation, in Atlas of Amputation Surgery. New York,
Thieme Medical Publishers, 1987, pp 86-90.
2. Burgess E: Knee disarticulation and above-knee amputation, in Moore W, Malone J
(eds): Lower Extremity Amputation. Philadelphia, WB Saunders Co, 1989.
3. Christensen K, Falstie-Jensen N, Christensen E, et al: Results of amputation for
gangrene in diabetic and non-diabetic patients. J Bone Joint Surg [Am] 1988; 70:1514-
1519.
4. Freeman MAR: The surgical anatomy and pathology of the arthritic knee, in Freeman
MAR (ed): Arthritis of the Knee. New York, Springer-Verlag NY Inc, 1980, pp 32-33.
6. Gottschalk F, Kourosh S, Stills M, et al: Does socket configuration influence the
position of the femur in above-knee amputation? J Prosthet Orthot 1989; 2:94-102.
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 above-
knee amputees with special regard to the hip joint. Scand J Rehabil Med 1973; 5:55-
66.
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.
Search
GO
Transfemoral Amputation: Prosthetic Management Reproduced with

permission from
C. Michael Schuch, C.P.O. Bowker HK,
Michael JW (eds):
Atlas of Limb
REVIEW OF TRANSFEMORAL BIOMECHANICS Prosthetics:
The basic goals for fitting and aligning prostheses for transfemoral amputees seem simple Rehabilitation Principles.
enough: (1) comfort, (2) function, and (3) cosmesis; however, obtaining these goals is
significantly more challenging than might be expected. This is because of the many and 1992, reprinted 2002.
varied interrelationships between patient diagnosis, prognosis, medical history, residual and
intact anatomy and kinesiology, and available prosthetic technology. Much of the material in this text
Analysis and Relevance of Residual-Limb Range of Motion Deficiencies: Surgical, Prosthetic,
Careful measurement and evaluation of residual and intact anatomy and kinesiology are (retitled third edition of Atlas of
essential for correct socket design and initial socket alignment. The necessity for Limb Deficiencies), ©American
measurement of lengths, circumferences, and diameters is obvious enough. Perhaps more Academy or Orthopedic Surgeons.
important and less understood is the need for accurate measurement and evaluation of the
this text.
range of motion of the residual limb in both the sagittal and coronal planes.
Range of motion in the sagittal plane consists of flexion and extension of the residual femur. Funding for digitization
Especially important is the amputee's ability to extend the residual femur fully. The normal hip of the Atlas of Limb
is capable of a maximum of 5 degrees of extension posterior to the vertical without anterior Prosthetics was
pelvic rotation or lordosis. The inability to fully extend the residual femur usually indicates a provided by the
hip flexion contracture. Owing to the location of muscle insertion points, the flexors of the hip Northern Plains Chapter of the
have a better mechanical advantage than the hip extensors do; thus a hip flexion contracture
Prosthetists
is not uncommon and is more prevalent in shorter residual limbs. This range of motion in the
sagittal plane should be documented along with other necessary measurements.
Range of motion in the coronal plane consists of abduction and adduction of the residual
femur. Especially important is the amputee's ability to adduct the residual femur fully,
equivalent to the adduction of the femur on the sound side. Normal femoral adduction angles
average about 6 degrees. The inability to fully adduct the residual femur usually indicates You can help expand the
an abduction contracture. The adductors of the femur are at a mechanical disadvantage when
compared with the abductors due to their location and the fact that the most effective
adductors have been severed at amputation. Abduction contractures, like hip flexion
contractures, are not uncommon and are more prevalent in shorter residual limbs. This range
of motion in the coronal plane should also be documented.
The analysis and measurement of the ranges of motion of the femur in the sagittal and
coronal planes are important in establishing the initial angular alignment of the socket for a
transfemoral prosthesis. Proper planning and incorporation of these angular measurements
into the socket and overall prosthesis design allow for certain biomechanical and alignment
principles that are advantageous to the amputee during the various phases of gait. This will
be demonstrated in the next sections on the biomechanics of transfemoral prosthetics.
Biomechanics of Knee Stability-Stance Phase of Gait

Knee stability in a transfemoral prosthesis refers to the ability of the prosthetic knee to remain
extended and fully supportive of the amputee during the stance phase of walking. Knee
instability is the buckling or unintended flexing of the prosthetic knee during the stance phase
of walking. Obviously, instability can be quite dangerous by causing unexpected falls.
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:
involuntary knee control and voluntary knee control (Fig 20B-1.).
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
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.
Biomechanics of Pelvis and Trunk Stability-Stance Phase of Gait

In any discussion of gait of the transfemoral amputee, two specific goals are mediolateral
pelvis-trunk stability and a narrow-based gait. These two goals are very much interrelated
and are perhaps the most difficult and challenging of goals facing the prosthetist as well as
the amputee.
In normal locomotion, the pelvis drops about 5 degrees toward the unsupported side during
midstance, with such motion occurring around the hip joint of the weight-bearing limb. The
hip abductors, primarily the gluteus medius, prevent any additional drop through eccentric
contraction. This phenomenon is one of several "gait determinants" inherently designed to
provide energy efficiency in normal locomotion. In normal locomotion, weight bearing
occurs through the bones of the leg, and contraction of the gluteus medius is effective in
controlling pelvic tilt at the hip joint of the stance leg. In the case of the transfemoral
amputee, the femur does not terminate in a foot planted firmly on the ground. The residual
femur, now a lever only 40% or less of the normal length of the lower limb, floats in a mass
of muscle, tissue, and fluid. The residual femur tends to displace laterally in the mass of
residual muscle and tissue rather than maintain horizontal stability of the pelvis and trunk.
This lack of support and ineffective pelvic stabilization results initially in excessive pelvic tilt
from the prosthetic support leg (positive Trendelenburg sign), with concurrent perineal or
pubic ramus pressure and discomfort. The amputee will typically compensate by widening the
base of his gait and using trunk sway over the wide-based point of support (compensatory
Trendelenburg) rather than gluteus medius activity.
Effective pelvis-trunk stabilization and the resultant narrow-based gait can only be achieved in
a transfemo-ral prosthesis by providing adequate lateral support to the femur. The femur
must be maintained in a position as near as possible to normal adduction, thereby putting the
gluteus medius and other abductor muscles in a position of stretch that allows them to
function most effectively. This objective is accomplished through socket design and alignment,
with particular attention to the medial and lateral walls of the socket (Fig 20B-3.). Generally,
the medial wall is flat and vertical to help distribute stance-phase counterpressure forces; the
lateral wall of the socket should be designed and aligned in a position of adduction that
matches the "adduction angle" measurement obtained early in the residual-limb range-of-
motion evaluation. Obviously, restriction of adduction, as when an abduction contracture is
present, will significantly limit the ability to control pelvis and trunk stability.
Additional factors that affect the ability to maximize mediolateral pelvis and trunk stability are
the length of the residual limb, proximomedial tissue density, and proper alignment of the
prosthetic components below the socket. These factors are discussed below.
A longer residual limb provides a longer lever and larger surface area over which to distribute
the inherent forces. Shown in Fig 20B-4. is a lever system: "W" (weight), "F" (fulcrum), "P"
(proximal part of the femur), and "D" (distal part of the femur). The effective lever arms are
"W-F" and "P-D," and resulting forces or moments depend on weight and lever length. For
example, if the lever "W-F" has an effective length of 4 in. and the force or weight is 150 lb,
the moment or torque around this lever system will be 600 in. lb. If the lever "P-D" is 10 in.,
only 60 lb of force need be exerted to equalize the moment or torque of 600 in.-lb and thus
stabilize the pelvis and trunk. However, if the femur length as simulated by lever "P-D" is only
5 in. in length, 120 lb of force is required to equalize the 600 in.-lb of torque, thus subjecting
our hypothetical femur to much greater levels of pressure. The more evenly that pressures
can be distributed, the more tolerable they become. If the force is distributed over a smaller
area, pressure concentration may cause discomfort, pain, or skin breakdown. For this reason,
the shorter the residual limb, the more difficult the task of establishing and maintaining
mediolateral pelvis and trunk stability. In these situations, the ideal gait is compromised for
the first and foremost goal of comfort (Fig 20B-5.,A and B).
The biomechanical reaction to the contraction of the hip abductors and resultant femoral force
against the lateral wall of the transfemoral socket is a laterally directed force or moment
concentrated at the proximo-medial aspect of the transfemoral socket during mid-stance.
When coupled with the normal and desirable gait determinant of lateral pelvic shift over the
support limb, the forces generated at the perineum are significant. Firmer, denser, and more
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
viewed from the sagittal plane. Foot placement in the coronal plane is best determined
dynamically by using adjustable alignment devices within the prosthesis (Fig 20B-6.).
Biomechanics of Knee and Shank Control-Swing Phase of Gait

The requirements and goals of the swing phase of gait for the transfemoral amputee are
normally easier to attain and are less demanding than those of the stance phase of gait.
However, from the standpoint of energy consumption, significant deviations result in greater
demand. Our discussion will focus on two aspects of the transfemoral prosthesis swing
phase: swing-phase timing control and swing-phase tracking.
When the prosthesis is aligned with too much "alignment stability," excess energy and effort
are required to initiate knee flexion. Overcoming such "alignment stability" takes effort and
delays the initiation of swing phase. Vaulting, which is usually thought of as a deviation in
response to a prosthesis that is too long, can also serve to subtly compensate for a delayed
advancement of the prosthetic shank in midswing.
Swing-phase tracking refers to the smoothness of the pathways of the prosthetic limb during
the swing phase of the gait cycle. Goals are to minimize vertical displacement of the
prosthesis on the residual limb and to minimize deviations in the sagittal plane as the
prosthetic limb advances during swing phase. Problems with vertical displacement are due to
poor suspension and resulting piston action and/or inappropriate length of the prosthesis.
Deviations in the sagittal plane include "whips" during the swing phase caused by improper
socket shape or improper knee axis alignment, as well as circumduction, usually caused by
excessive prosthesis length or poor alignment.
TRANSFEMORAL SOCKET DESIGNS: VARIATIONS AND

INDICATIONS
Overview of Transfemoral Variants

The total-contact quadrilateral socket, which has both American and European variations, was
the socket of choice from the 1960s until recently and remains the most commonly prescribed
socket system even today, despite new designs and techniques.
By the early 1980s, innovative designs for transfemo-ral sockets began to emerge and were
published under various acronyms. This socket design and philosophy has become known
generically as the "ischial containment" socket. The origin is attributed to Ivan Long, with
credit for furthering its development due John Sa-bolich, Thomas Guth, Daniel Shamp, and
Christopher Hoyt. Techniques of molding and fabricating the socket remain similar in
content and approach to those of the quadrilateral socket. Changes center around the
position of the ischium with respect to the socket proper and related biomechanical and
socket comfort enhancements.
Specific Transfemoral Socket Designs and Rationale

Hall described five important principles of socket design that were intended as objectives of
the quadrilateral socket but apply equally well to any modern trans-femoral socket :
1. The socket must be properly contoured and relieved for functioning muscles.
2. Stabilizing pressure should be applied on the skeletal structures as much as possible
and areas avoided where functioning muscles exist.
3. Functioning muscles, where possible, should be stretched to slightly greater than rest
length for maximum power.
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
consistent with the residual function available to the amputee. These characteristics will
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."
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.
Ischial Containment Socket

The term "ischial containment" is rather self-descriptive. It describes several similar concepts
in socket design in which the ischium (and in some cases the ischial ramus) are enclosed
inside the socket.
Pritham has described objectives that would ideally be achieved in the ischial containment
socket :
1. Maintenance of normal femoral adduction and narrow-based gait during ambulation.

2. Enclosure of the ischial tuberosity and ramus, to varying extents, in the socket medially
and posteriorly so that forces involved in maintenance of mediolateral stability are
borne by the bones of the pelvis medially and not just by the soft tissues distal to the
pelvis, that is to say, creation of a "bony lock."
3. Maximal effort to distribute forces along the shaft of the femur.
4. A decreased emphasis on a narrow AP diameter between the adductor longus-
Scarpa's triangle and ischium for the maintenance of ischial-gluteal weight bearing.
5. Total contact.
6. Utilization of suction socket suspension whenever possible.
The physical and functional characteristics of this socket will be described within the
perspectives of comfortable weight bearing, stance-phase stability, and normal swing phase.
Weight bearing in the ischial containment socket is focused primarily through the medial
aspect of the ischium and the ischial ramus. The socket encompasses both the ischial
tuberosity and the ramus; the specific contour depends on the musculature, soft tissue, and
skeletal structure of the amputee. As opposed to the quadrilateral socket, in which the
proximal contours are affected primarily by muscular variation, proximal contours of the ischial
containment socket are affected by differences in pelvic skeletal anatomy. Of particular
importance are the variations in the position of the ischium with respect to the trochanter; in
females, the is-chia are positioned more laterally, or closer to the trochanter, to allow for
childbearing (Fig 20B-10.). The posterior brim of the socket is proximal to and tightly
posterior to the ischium. Countersupport, intended to keep the ischium and ramus solidly
against the medio-posterior aspect of the socket, is produced in three ways. First, the
"skeletal mediolateral" dimension, the distance between the medial aspect of the ischium and
the inferolateral edge of the trochanter, must be carefully designed into the socket. Second,
countersupport occurs through the "distal mediolateral" dimension, a soft-tissue measurement
that reflects the diameter of the residual limb 1 to 2 in. distal to the skeletal mediolateral
dimension. The third form of counterpressure, most important in females because of their
pelvic anatomy, is anterolateral counterpressure from the trochanter anteriorly to the tensor
fasciae latae. Additional weight-bearing support is thought to be provided by the gluteal
musculature and the lateral aspect of the femur distal to the trochanter, as well as from
pressures distributed as evenly as possible over the entire surface of the residual limb. It
should be noted that significantly more residual limb surface and volume is contained within
the ischial containment socket as compared with the quadrilateral socket. Therefore, identical
residual limbs have greater force distribution and hence lower pressures with an ischial
containment design.
It has been hypothesized that the quadrilateral socket is displaced laterally during midstance
and thus results in a shearing force on the perineal tissues. Secondarily, femoral abduction
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.
Flexible Transfemoral Sockets

In 1983 Kristinsson of Iceland introduced the concept of a flexible socket design. Taught in
the United States under various acronyms such as ISNY (Icelandic-Swedish-New York) and
SFS (Scandinavian Flexible Socket), these techniques have gained considerable favor during
the past decade. The concept uses flexible thermoplastic vacuum-formed sockets
supported in a rigid (or semirigid) fenestrated frame or socket retainer (Fig 20B-13.,A-D).
The socket retainer may be either vacuum-formed or laminated plastic (Fig 20B-14.).
Kristinsson describes a flexible socket as follows: "To label a socket as flexible I would say
that you should be able to deform it by your hands, and the material should not be elastic
enough to stretch under the loads it will be subjected to." Kristinsson additionally states:
When designing a flexible socket system the most critical aspect for the comfort
of the wearer is how the frame is designed. It has to be capable of supporting
the flexible socket, preventing permanent deformation, and the socket-frame
combination has to be structurally strong and stable enough to counteract the
reaction forces.
The advantages of flexible wall sockets as put forth by Pritham are as follows :
1. Flexible walls
2. Improved proprioception
3. Conventional fitting techniques
4. Minor volume changes readily accommodated
5. Temperature reduction
6. Enhanced suspension
Pritham proposes the following indications for use of a flexible 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.
Socket Indications-Current Trends

The question has been previously put forth: how is the clinician to choose among these
competing philosophies? Some of the new socket designs have been associated with
strident claims coupled with concurrent rebuttal of the quadrilateral design. To quote Pritham,
In the process considerable confusion has caused many of the issues involved
to be obscured; and somehow or another, the perception that the new style
sockets are different from quadrilateral style sockets and unaffected by the
principles of above-knee prosthetics as explained by Radcliffe (1955, 1970,
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
shared clinical experience and workshops because there are no impartial field tests or
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.
TRANSFEMORAL PROSTHETIC COMPONENTS:

VARIATIONS, INDICATIONS, CONTRAINDICATIONS
Systems Overview
As noted by Wilson,
The above-knee prosthesis consists of a minimum of four major parts: the

socket, the knee system, the shank (or shin), and the foot-ankle system. If
suction is not used to retain the leg in place, a suspension system is needed. A
variety of designs for each of these components is available which can be
combined to meet the individual needs of the amputee.
Two construction alternatives are available for trans-femoral prostheses (Fig 20B-15.,A and
B). The traditional form of construction is the exoskeletal or "crustacean" design fabricated
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.
Prosthetic Knee Components

Prosthetic knees provide three functions: (1) support during stance phase, (2) smooth and
controlled swing phase, and (3) unrestricted flexion for sitting, kneeling, stooping, and related
activities. In most cases, the knee component systems described are available in both
exoskeletal and endoskeletal formats.
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
residual limbs (Fig 20B-19.,A and B).
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).
Weight-activated Stance-control Knee

In this knee mechanism, when weight is applied, a braking mechanism mechanically prevents
the knee from flexing or buckling. The amount of weight required to effectively engage the
"brake" and prevent flexion can be adjusted depending on the amputee's weight, activity level,
and stance-control needs. The "braking" mechanism is usually only effective to a maximum
range of 15 to 20 degrees of flexion (Fig 20B-21.,A and B).
This knee design is generally used for weak or debilitated amputees who cannot rely on more
complicated and demanding means of stance control. The primary disadvantage is increased
maintenance. An additional disadvantage is delayed initiation of swing phase if the stance-
control "brake" is set for a high degree of stance stability.
Manual Locking Knee

This knee unit automatically locks in extension but can be unlocked by voluntary action.
Ambulation with the locking mechanism disengaged is also possible.
When locked, this knee is by far the most stable during stance. However, due to the lack of
knee flexion during swing phase, increased energy expenditure and gait deviations often
occur during ambulation with a locked knee.
A positive locking knee is generally indicated for weak, unstable, debilitated amputees, but
may also be used by amputees in unstable situations such as uneven terrain when hiking or
hunting or activities such as fishing while standing in a boat.
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
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
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.
Knee-shank Rotation Components

Such components were initiated in the Orient where sitting cross-legged on the floor is a
cultural requirement. By releasing a locking mechanism, the knee and shank are free to
rotate. This can also facilitate entry/ exit to or from confined spaces such as an automobile.
Multiaxis Ankle Modules

These are modular, endoskeletal components that provide multiple degrees of motion within
the ankle independent of the foot. Conventional multiaxial feet require the use of a specific
ankle-foot combination. The multiaxis ankle modules are adaptable to a variety of feet.
Although primarily intended for endoskeletal prostheses, they can also be incorporated into an
exoskeletal prosthesis by creating a hybrid system. This type of ankle system smooths out
the gait pattern and enhances knee stability in transfemoral prostheses.
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
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.
Hip Joint With Pelvic Band and Belt

Although this form of belt does provide suspension, there are simpler and less cumbersome
alternatives if suspension alone is the goal. The hip joint with pelvic band and waist belt also
provides rotational stability plus a significant degree of mediolateral pelvic stability. This is
usually necessary in obese amputees or those with significant redundant tissue that is difficult
to stabilize. For the patient with weak hip abductors, this suspension is particularly useful (Fig
20B-23.,B). Because most amputees object to the weight and bulk of this suspension, it is
generally reserved for cases where rotational control or mediolateral stability is needed.
PRESCRIPTION CRITERIA: RELEVANT CASE

PRESENTATIONS
General Considerations
When recommending transfemoral prosthetic components, two levels of criteria may be
utilized. The first and most important level includes previous experience of the amputee,
safety requirements, and functional requirements. Secondary considerations include the level
of amputation, vocational and avocational needs, durability of components, weight of
components, cosmesis, and cost.
Prosthetic components that previously have been satisfactory should not be changed without
significant discussion with the amputee. The longer the amputee's experience with a specific
system, design, component, etc., the less the likelihood of success in change.
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
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 S-
N-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-and-
stance 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.
SUMMARY AND CONCLUSION

During the decade of the 1980s, significant and controversial progress and change have
taken place in transfemoral prosthetics. Clinical improvements and new materials and
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.
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
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.
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
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, Prosthetics-
Orthotics 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
for Prosthetics and Orthotics, 1989, pp 2-3.
35. Wilson AB Jr: Limb Prosthetics, ed 6. New York, Demos Publications, 1989.
Search
GO
Hip Disarticulation and Transpelvic Amputation: Surgical Reproduced with

Procedures permission from
Bowker HK,
Michael JW (eds):
Robert E. Tooms, M.D. Atlas of Limb
Frederick L. Hampton, C.P. Prosthetics:
Hip disarticulation is the surgical removal of the entire lower limb by transection through the Rehabilitation Principles.
hip joint. Transpelvic amputation is the surgical removal of the entire lower limb plus all or a
major portion of the ilium. Ablative surgery of this magnitude is indicated most often to 1992, reprinted 2002.
eradicate a malignant tumor of the bone or soft tissues about the thigh, hip, or pelvic region.
Less frequent indications are extensive trauma or uncontrolled infections, especially gas Much of the material in this text
gangrene. On rare occasions, the function and prosthetic fit of a congenital limb anomaly may has been updated and published
be improved by surgical conversion to a hip disarticulation. in Atlas of Amputations and Limb
SURGICAL TECHNIQUES (retitled third edition of Atlas of
The basic surgical techniques outlined here may require selective modification because of Academy or Orthopedic Surgeons.
limb scarring, draining sinus tracts, or the location of a tumor. In most instances, however, the
this text.
techniques are followed as presented.

Hip Disarticulation of the Atlas of Limb
Prosthetics was
The technique of hip disarticulation as described by Boyd is the basic procedure in general provided by the
use. In developing his technique, Boyd attempted to minimize blood loss by transecting Northern Plains Chapter of the
muscles at either their origin or insertion, these areas being relatively avascular. The resultant American Academy of Orthotists &
stump is well padded and provides an excellent weight-bearing surface for prosthetic use. Prosthetists
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
malignancies. The standard incision is an anterior racquet incision, which begins just
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 You can help expand the
distal to the ischial tuberosity and then curves laterally to pass about 8 cm distal to the base O&P Virtual Library with a
of the greater trochanter. From this point, the incision swings anteriorly and proximally to join tax-deductible contribution.
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).
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
this chapter, the technique as described by King and Steelquist 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.
Search
GO
Hip Disarticulation and Transpelvic Amputation: Reproduced with

Prosthetic Management permission from
Bowker HK,
Michael JW (eds):
Tony van der Waarde, C.P.(c), F.C.B.C. Atlas of Limb
John W. Michael, M.Ed., C.P.O. Prosthetics:
Although the anatomic differences between hip disarticulation and transpelvic Rehabilitation Principles.
(hemipelvectomy) amputations are considerable, prosthetic component selection and
alignment for both levels are quite similar. The major differences are in socket design and 1992, reprinted 2002.
will therefore be discussed in some detail. A full surgical report identifying muscle
reattachments along with postoperative radiographs can be extremely valuable during the Much of the material in this text
initial examination of the amputation site, particularly if any portions of the pelvis have been has been updated and published
excised. This information, combined with a thorough physical examination and a precise in Atlas of Amputations and Limb
plaster impression, will influence the ultimate fit and function of the prosthesis.
Many authors have noted that the rejection rates for lower-limb prostheses are the highest at
these proximal levels. The energy requirements to use such prostheses has been reported Academy or Orthopedic Surgeons.
to be as much as 200% of normal ambulation. At the same time, the lack of muscle power Click for more information about
at the hip, knee, and ankle/foot results in a fixed, slow cadence. As a practical matter, only this text.
those who develop sufficient balance to ambulate with a single cane (or without any external
aids at all) are likely to wear such a prosthesis long-term. Those who remain dependent on
dual canes or crutches for balance eventually realize that mobility with crutches and the
remaining leg, without a prosthesis, is much faster and requires no more energy expenditure Prosthetics was
than using a prosthesis does. provided by the
Prosthetic fitting is typically limited to motivated and physiologically vigorous individuals; still, American Academy of Orthotists &
a significant number do not become long-term wearers. To investigate this further, the senior Prosthetists
author (T.v.d.W) studied a group of 20 male and female hip disarticulation and transpelvic
amputees who were representative of the age and diagnoses typically encountered. Only
15% had been full-time users of their initial prostheses; many complained of how
cumbersome or uncomfortable their rigid sockets seemed.
After a 3-year follow-up during which these patients were fitted with a totally new prosthesis You can help expand the
that included a novel silicone rubber socket (Fig 21B-1.), a significant improvement in O&P Virtual Library with a
prosthesis utilization was noted. The majority increased their wearing time; in fact, the full- tax-deductible contribution.
time users' group increased from 15% to 65%. Ninety percent of those polled reported that
increased comfort was the main reason for using the prosthesis more often. Other significant
reasons were less effort when walking and improved appearance of the prosthesis.
Interestingly, the actual weight of the prosthesis had increased in several cases due to
incorporation of more sophisticated componentry such as units to absorb torque while walking.
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
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.
HIP JOINT MECHANISMS

The sections dealing with joint and foot mechanisms are reprinted, with minor
modifications, from Michael J: Clin Prosthet Orthot 1988; 12:99-108.
One of the inherent limitations of the Canadian design is that the prosthesis must be
significantly short (1 cm+) to avoid forcing the amputee to vault for toe clearance. Fig 21B-3.
and Fig 21B-4. illustrate why this is so. At toe-off, the heel rises up during knee flexion and
pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains
vertical until the knee has reversed its direction of motion and contacted the knee stop. Only
then does the thigh segment rotate anteriorly and cause the hip joint to flex. In essence, the
prosthesis is at its full length during midswing. Since the patient has no voluntary control over
any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground
clearance.
In an effort to overcome this limitation, the hip flexion bias system was developed for the
young, active amputee who wished to walk rapidly. At toe-off, kinetic energy from the coil
spring is released, and the prosthetic thigh is thrust forward. Not only does this provide the
amputee with a more normal-appearing gait, it also improves ground clearance. As a result,
the prosthesis can be lengthened to a nearly level configuration in most cases (Fig 21B-5.).
However, two potential problems have been noted with this approach. One is the
development of annoying squeaks in the spring mechanisms after a few months of use, which
sometimes tend to recur inexorably. A more significant concern is that as the spring
compresses between heel strike and midstance, it creates a strong knee flexion moment.
Unless this is resisted by a stance control knee with a friction brake or a polycentric knee
with inherent stability, the patient may fall. Since the friction-brake mechanisms lose their
effectiveness as the surface wears, the polycentric knee is the preferred component with this
hip mechanism.
Another hip joint option is the Otto Bock four-bar knee disarticulation joint mounted in reverse
as proposed by Peter Tuil of The Netherlands (Fig 21B-6.). Benefits claimed are parallel to
those expected from a polycentric knee unit: increased ground clearance during swing phase
due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike
amputees comment favorably on the smooth deceleration and good appearance while sitting
that this joint offers.
KNEE JOINT MECHANISMS

Other than the exception discussed above, knee mechanisms are selected by the same
criteria as for transfemoral (above-knee) amputees. The single-axis (constant-friction) knee
remains the most widely utilized due to its light weight, low cost, and excellent durability.
Friction resistance is often eliminated to ensure that the knee reaches full extension as
quickly as possible. A strong knee extension bias enhances this goal and offers the patient
the most stable biomechanics possible with this mechanism. Although the single-axis type
was proposed as the knee of choice for the Canadian hip disarticulation design, more
sophisticated mechanisms have proved their value and are gradually becoming more
common.
The friction-brake stance control (safety) knee is probably the second most frequently utilized
component. Because there is very little increase in cost or weight and reliability has been
good, many clinicians feel that the enhanced knee stability justifies this approach, particularly
for the novice amputee. Missteps causing up to 15 degrees of knee flexion will not result in
knee buckle, which makes gait training less difficult for the patient and therapist. The major
drawback to this knee is that the limb must be non-weight bearing for knee flexion to occur.
Although this generally presents no problem during swing phase, some patients have difficulty
in mastering the weight shift necessary for sitting. It should be noted that use of such knee
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 (four-
bar) 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
amputee. Patients with all levels of amputation, up to and including translumbar
(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.
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"
designs. Other members of this class include the STEN foot and the Otto Bock Dynamic
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
firmly planted on the floor as the body "rides" the prosthesis over it. This creates a
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.
SOCKET DESIGNS AND CASTING TECHNIQUES

The most important part of any prosthesis is the socket, which provides the man-machine
interface. During the initial assessment of the amputee, examination of postoperative
radiographs and careful palpation of the pelvis are recommended. Some amputees present as
"hip disarticulation" when they have a short femoral segment remaining or as "transpelvic"
when part of the ilium, sacrum, or ischium remains. Unanticipated bony remnants can
become a puzzling source of discomfort. On the other hand, they may sometimes be utilized
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
ischium and ascending ramus is now more widely recognized. The same principles can
readily be applied to hip disarticulation sockets to increase both comfort and control (Fig
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 lower-
limb amputation, the most commonly utilized socket material is a rigid thermosetting resin:
polyester or acrylic. An increasing trend toward more flexible thermoplastic materials is
evident, as in other aspects of prosthetic practice. One of the authors (J.W.M.) has fitted
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
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
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; 50:389-
391.
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.
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; 56:9-
17.
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; 49:987-
990.
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.
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.

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.
61. Simons BC, Lehman JF, Taylor H, et al: Prosthetic management of hemicorporectomy.
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
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.
Search
GO
Translumbar Amputation (Hemicorporectomy): Surgical Reproduced with

Procedures permission from
Bowker HK,
Michael JW (eds):
Lawrence D. Wagman, M.D. Atlas of Limb
Jose J. Terz, M.D. Prosthetics:
PATIENT SELECTION Rosemont, IL, American Academy
Ablation of the caudal 50% of the human body has been named by the level of amputation, 1992, reprinted 2002.
translumbar amputation (TLA), and by the extent of amputation, hemicorporectomy. Much of the material in this text
Regardless of the nomenclature, this operative procedure is extensive in its loss of structure has been updated and published
and function. Fortunately, due to advances in surgical reconstruction, physical and social in Atlas of Amputations and Limb
rehabilitation, prosthetic materials and fitting, and functional aids to the handicapped, the Deficiencies: Surgical, Prosthetic,
ravages of the operative procedure can be ameliorated. Unlike all other amputations, TLA and Rehabilitation Principles
involves the loss of structures used in functions other than mobility and manipulation. The (retitled third edition of Atlas of
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 Click for more information about
endocrine and reproductive organs. The extensive known, anticipated, and guaranteed this text.
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. Funding for digitization
TLA cannot be planned and executed in a short period of time. Patients must be slowly Prosthetics was
provided by the
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 American Academy of Orthotists &
deciding on the operation, and it may be anticipated that a patient will cancel or delay the Prosthetists
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 O&P Virtual Library with a
whom there is an excellent chance for long-term cure. These might include low-grade tax-deductible contribution.
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.
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
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 soft-
tissue 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,
and muscle perfused by the femoral artery (Fig 22A-2., Fig 22A-3., Fig 22A-4., and Fig
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
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 ß-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
(prevented by the nonrefluxing ureteral implantation in the Indiana pouch), and metabolic
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
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.
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.
22B: Prosthetic Considerations | O&P Virtual Library
Search
GO
Translumbar Amputation (Hemicorporectomy): Reproduced with

Prosthetic Considerations permission from
Bowker HK,
Michael JW (eds):
Greg Gruman, C.P. Atlas of Limb
John W. Michael, M.Ed., C.P.O. Prosthetics:
OVERVIEW Rosemont, IL, American Academy
The translumbar (hemicorporectomy) amputee requires a special degree of care from the 1992, reprinted 2002.
entire medical and prosthetic management team since this level of amputation represents a Much of the material in this text
heroic effort to save the patient's life in the face of severe trauma, infection, or cancer. It has been updated and published
requires the full cooperation of both the professionals involved and the amputee himself to in Atlas of Amputations and Limb
achieve success. Deficiencies: Surgical, Prosthetic,
Prior to performing the operation, the surgeon will ensure that the patient understands both (retitled third edition of Atlas of
the outcome of the procedure and the potential for rehabilitation. Ideally, the patient will Limb Deficiencies), ©American
have good support from spouse and family and will have completed a realistic goal-setting Academy or Orthopedic Surgeons.
process. The purpose of preprosthetic therapy is strengthening of the entire upper part of
this text.
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 Funding for digitization
therefore rarely encountered in clinical practice. There is a tendency for the prosthetist, of the Atlas of Limb
therapist, and physician to feel overwhelmed when faced with this challenge (Fig 22B-1.). Prosthetics was
However, prior experience with paraplegics is very good preparation for working with the TLA provided by the
survivor. In fact, ambulation may be easier for the translumbar amputee since the weight of Northern Plains Chapter of the
modern prosthetic limbs is but a fraction of the weight of the missing portions of the body.
Prosthetists
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 You can help expand the
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.
SITTING PROSTHESIS
Most authors advise provision of a static sitting support system prior to consideration of
ambulatory prostheses, and many variants have been detailed in the literature. This
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.
Initially, the sitting device has a level distal surface to enhance safety and stability (Fig 22B-
2.). 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
elbow flexion. Ideally it will provide sufficient stability to allow the amputee to pick up small
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
design of an accurate weight-bearing cast in a vertical position. It is important to place the
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. have summarized the goals of socket design for the translumbar amputee as
follows:
1. Independent transfer in and out of the socket (Fig 22B-3.)

2. Sufficient stability to permit free use of the upper limbs and wheelchair mobility
3. Minimum socket tolerance of two 4-hour periods daily
4. Sufficient weight-bearing pressure distribution to prevent skin necrosis
5. Allowance for adequate respiratory exchange
6. No abdominal pain or nausea from pressure within the socket
7. Prevention of eversion of the colostomy and ileal bladder drainage bags
8. Easy access to drainage bags for self-care
9. 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
to reduce the pressure per square centimeter. Although earlier reports speculated about
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,
analogous to the advice given paraplegics to avoid skin breakdown. Over a period of
weeks or months, the amputee can gradually increase tolerance to an upright posture in the
device up to 8 hours or more daily. Several reports of return to gainful employment have
been noted in the literature.
AMBULATORY PROSTHESES
Having accomplished this degree of independence, some amputees will request prosthetic
legs for cosmetic purposes or to permit limited ambulation. Davis et al. have reported long-
term 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
hopelessness and helpless invalidism." Williams concurs and reports that "when the patient
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
crutches or swing-to using a walker. As is the case with paraplegia, it is the upper portion
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 solid-
ankle 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
weight. Due to the ease of interchangeable components, endoskeletal designs permit
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.
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; 57:471-
476.
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
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; 23:408-
413.
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; 59:988-
993.
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.
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.
23: Physical Therapy Management of Adult Lower-Limb Amputees | O&P Virtual Library
Search
GO
Physical Therapy Management of Adult Lower-Limb Reproduced with

Amputees permission from
Bowker HK,
Michael JW (eds):
Robert S. Gailey, Jr., M.S.Ed., P.T. Atlas of Limb
Curtis R. Clark, P.T. Prosthetics:
The prosthetist and the physical therapist, as members of the rehabilitation team, often Rehabilitation Principles.
develop a very close relationship when working together with lower-limb amputees. The
prosthetist is responsible for fabricating and modifying the specific socket design and 1992, reprinted 2002.
providing prosthetic components that will best suit the life-style of a particular individual. The
physical therapist's role is threefold. First, the amputee must be physically prepared for Much of the material in this text
prosthetic gait training and educated about residual-limb care prior to being fitted with the has been updated and published
prosthesis. Second, the amputee must learn how to use and care for the prosthesis. in Atlas of Amputations and Limb
Prosthetic gait training can be the most frustrating, yet rewarding phase of rehabilitation for all
involved. The amputee must be patiently educated in the biomechanics of prosthetic gait. (retitled third edition of Atlas of
Once success is achieved, the amputee may look forward to resuming a productive life. Third, Limb Deficiencies), ©American
the therapist should introduce the amputee to higher levels of activities beyond just learning Academy or Orthopedic Surgeons.
to walk. Although the amputee may not be ready to participate in recreational activities Click for more information about
immediately, providing the names of support groups and disabled recreational organizations this text.
can furnish the necessary information for the individual to seek involvement when ready.
PRESURGICAL MANAGEMENT of the Atlas of Limb
Prosthetics was
provided by the
Initial Patient Contact Northern Plains Chapter of the
This time provides an opportunity for the therapist to introduce himself to the patient and, in Prosthetists
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 You can help expand 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.
POSTSURGICAL MANAGEMENT
Evaluation
Past Medical History

A complete medical history should be taken from the patient or obtained from the medical
records to provide the therapist with information that may be pertinent to the rehabilitation
program.
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.
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.
Ambulation With Assistive Devices Without a Prosthesis

A traditional evaluation of the amputee's potential for ambulation is performed, including
strength of the sound lower limb and both upper limbs, single-limb balance, coordination, and
mental status. The selection of an assistive device should meet with the amputee's level of
skill, while keeping in mind that with time the assistive device may change. For example,
initially an individual may require a walker, but with proper training, forearm crutches may
prove more beneficial as a long-term assistive device.
Some patients who have difficulty in ambulating on one limb secondary to obesity, blindness,
or generalized weakness can still be successful prosthetic ambulators when the additional
support of a prosthesis is provided (Fig 23-1a. and Fig 23-1b.).
Cardiac Precautions for Amputees

During the initial chart review, the therapist should make note of any history of coronary artery
disease, congestive heart failure, peripheral vascular disease, arteriosclerosis, hypertension,
angina, arrhythmias, dyspnea, angioplasty, myocardial infarction, arterial bypass surgery, as
well as prescribed cardiovascular medications that may affect the blood pressure and heart
rate.
The heart rate and blood pressure of every patient should be closely monitored during initial
training and thereafter as the intensity of training increases. If the amputee experiences
persistent symptoms such as shortness of breath, pallor, diaphoresis, chest pain, headache,
or peripheral edema, further medical evaluation is strongly recommended.
Patient Education: Limb Management
Limb Care
It is important that the patient understand the care of the residual limb and sound limb. For
example, the dysvascular patient's prosthetic gait training could be delayed 3 to 4 weeks if an
abrasion should occur. The patient must be taught the difference between weight-bearing
areas and pressure-sensitive areas and also be oriented to the design of the socket and the
functions of the prosthetic componentry.
Problem Detection/Skin Care

Every patient should be instructed to visually inspect the residual limb on a daily basis or
after any strenuous activity. More frequent inspection of the residual limb should be routine in
the initial months of prosthetic training. A hand mirror may be used to view the posterior
aspect of the residual limb. Reddened areas should be monitored very closely as potential
sites for abrasions. If a skin abrasion occurs, the patient must understand that in most cases
the prosthesis should not be worn until healing occurs.
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
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 residual-
limb/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.
Donning and Doffing of the Prosthesis

Today, there is a wide variety of suspension systems for all levels of amputation. To list just a
few possibilities, the transtibial amputee has the option of a hard socket with or without a soft
insert, which could include auxiliary suspension, a medial wedge, and suction or suction
silicone sockets, while the transfemoral amputee has the choice of a nonsuction external
suspension or a suction suspension socket that can be donned with an elastic bandage, pull
sock, wet fit, or a silicone sleeve. The methods of donning each of these combinations are
too numerous for the scope of this chapter; however, what is important is that the amputee
become proficient in the method of donning and doffing his particular prosthesis.
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.).
Preprosthetic Exercise
Strengthening
Eisert and Tester first described dynamic residual-limb exercises in 1954. Since then, their
antigravity exercises have been the most favored method of strengthening the residual limb.
These dynamic exercises require little in the way of equipment. A towel roll and step stool are
all that is required. They also offer benefits aside from strengthening, such as desensiti-
zation, bed mobility, and joint ROM. The exercises are relatively easy to learn and can be
performed independently, thus permitting the therapist to spend patient contact time on other
more advanced skills.
Incorporating isometric contractions at the peak of the isotonic movement will help to
maximize strength increases. A period of a 10-second contraction followed by 10 seconds of
relaxation for 10 repetitions gives the patient an easy mnemonic to remember, the "rule of
ten." The rationale behind a 10-second contraction is that a maximal isometric contraction
can be maintained for 6 seconds; however, there is a 2-second rise time and a 2-second fall
time for a total of 10 seconds.
All amputees should consider performing abdominal and back extensor strengthening
exercises to maintain trunk strength, decrease the possible risk of back pain, and assist in the
reduction of gait deviations associated with the trunk.
The following illustrations demonstrate the basic dynamic strength training program for
transfemoral and transtibial amputees (Fig 23-4.).
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.
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.
Unsupported Standing Balance

In preparation for ambulation without a prosthesis, all amputees must learn to compensate for
the loss of weight of the amputated limb by balancing the center of gravity over the sound
limb. Although this habit must be broken when learning prosthetic ambulation, single-limb
balance must be learned initially to provide confidence during stand pivot transfers,
ambulation with assistive devices, and eventually hopping, depending on the amputee's level
of skill. A patient should be able to balance for at least 0.5 seconds to allow for smooth and
safe progression of an assistive device during ambulation.
One method of progressive ambulation starts with the amputee standing in the parallel bars
while using both hands for support. Once confidence in standing with double arm support is
attained, the hand on the same side as the amputated limb should be removed from the bars;
subsequently both hands are removed as independent balance is achieved. In order to
improve balance and righting skills, the patient should be challenged by gently tapping the
shoulders in multiple directions or tossing a ball back and forth (Fig 23-7.). Allow enough
time between taps or throws for the patient to regain a comfortable standing posture. Once
confidence is gained within the parallel bars, the patient should practice these skills outside
the parallel bars, eventually progressing to hopping activities.
Ambulation With Assistive Devices

All amputees will need an assistive device for times when they choose not to wear their
prosthesis or for occasions when they are unable to wear their prosthesis secondary to
edema, skin irritation, or poor prosthetic fit. Other amputees will require an assistive device
while ambulating with the prosthesis. There are a variety of assistive devices to choose from.
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.
Pregait Training
Balance and Coordination

After the loss of a limb, the decrease in body weight will alter the body's center of gravity. In
order to maintain the single-limb balance necessary during stance without a prosthesis,
ambulating with an assistive device, or single-limb hopping, the amputee must shift the center
of gravity over the base of support, which in this case is the foot of the sound limb. As
amputees become more secure in their single-limb support, there is greater difficulty in
reorienting them to maintaining the center of gravity over both the sound and prosthetic limbs.
Ultimately, amputees must learn to maintain the center of gravity and their entire body weight
over the prosthesis. Once comfortable with weight bearing equally on both limbs, the
amputee can begin to develop confidence with independent standing and eventually with
ambulation.
Orientation to the Center of Gravity and Base of Support

Orientation of the center of gravity over the base of support in order to maintain balance
requires that the amputee become familiar with these terms and aware of their relationship.
The body's center of gravity is located just anterior to the second sacral vertebra. Average
persons stand with their feet 5 to 10 cm (2 to 4 in.) apart, varying according to body height.
Various methods of proprioceptive and visual feedback may be employed to promote the
amputee's ability to maximize the displacement of the center of gravity over the base of
support. The amputee must learn to displace the center of gravity forward and backward, as
well as from side to side (Fig 23-8. and Fig 23-9.). These exercises vary little from traditional
weight-shifting exercises, with the one exception that concentration is placed on the
movement of the center of gravity over the base of support rather than weight bearing into
the prosthesis. Increased weight bearing will be a direct result of improved center of gravity
displacement and will establish a firm foundation for actual weight shifting during ambulation.
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 single-
limb 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.).
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.
Gait-Training Skills
Sound Limb and Prosthetic Limb Training

Another component in adjusting to the amputation of a limb is restoration of the gait
biomechanics that were unique to a particular person prior to the amputation. That is to say,
not everyone has the same gait pattern. Prosthetic developments in the last decade have
provided limbs that more closely replicate the mechanics of the human leg. Therefore, the
goal of gait training should be the restoration of function to the remaining joints of the
amputated limb. Prosthetic gait training should not alter the amputee's gait mechanics for the
prosthesis, but instead, the mechanics of the prosthesis should be designed around the
amputee's individual gait.
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
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.
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
influenced by the speed of ambulation. With acceleration of gait, arm swing
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
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.
Advanced Gait-Training Activities
Stairs
Ascending and descending stairs is most safely and comfortably performed one step at a time
(step by step). A few exceptional transfemoral amputees can descend stairs step over step,
with or without a railing, or by the "jackknifing" method. Even fewer, very strong transfemoral
amputees can ascend stairs step over step. Most transtibial amputees have the option of
either method, while hip disarticulates and transpelvic amputees are limited to the step-by-
step method.
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.
Transfemoral Amputees: Step Over Step

Timing and coordination become critical factors in executing stair climbing step over step. As
the transfemoral amputee approaches the stairs, the prosthetic limb is the first to ascend the
stairs by rapid acceleration of hip flexion with slight abduction in order to achieve sufficient
knee flexion to clear the step. Some transfemoral amputees will actually hit the approaching
step with the toe of the prosthetic foot to achieve adequate knee flexion. With the prosthetic
foot firmly on the step, usually with the toe against the step riser, the residual limb must exert
a great enough force to fully extend the hip so that the sound foot may advance to the step
above. As the sound-side hip extends, the prosthetic-side hip must flex at an accelerated
speed to achieve sufficient knee flexion to place the prosthetic foot on the next step above.
Descending stairs is achieved by placing only the heel of the prosthetic foot on the stair
below and then shifting the body weight over the prosthetic limb, thus passively flexing the
knee. The sound limb must quickly reach the step below in time to catch the body's weight.
The process is repeated at a rapid rate until a rhythm is achieved. Most transfemoral
amputees who have mastered this skill descend stairs at an extremely fast pace, much faster
than would be considered safe for the average amputee. In fact, both ascending and
descending stairs step over step for transfemoral amputees is so difficult and energy
demanding that the majority who master these skills still prefer the step-by-step method.
Transtibial Amputees: Step Over Step

When ascending stairs, the transtibial amputee who does not have the ability to dorsiflex his
foot/ankle assembly must generate a stronger concentric contraction of the knee and hip
extensors in order to successfully transfer body weight over the prosthetic limb.
Descending stairs is very similar to normal descent with one exception: only the prosthetic
heel is placed on the stair. This compensates for the lack of dorsiflex-ion within the foot/ankle
assembly.
Crutches
When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use
both crutches in the traditional manner.
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.
Ramps and Hills

Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion
present within most prosthetic foot/ankle assemblies. For most amputees, descending inclines
is even more difficult than ascending, primarily because of the lack of plantar flexion in the
foot/ankle assembly. Prosthesis wearers with knee joints have the added dilemma of the
weight line falling posterior to the knee joint, resulting in a flexion moment.
When ascending an incline, the body weight should be slightly more forward than normal to
obtain maximal dosiflexion with articulating foot/ankle assemblies or to keep the knee in
extension. Depending on the grade of the incline, pelvic rotation with additional acceleration
may be required in order to achieve maximal knee flexion during swing.
Descent of an incline usually occurs at a more rapid pace than normal because of the lack of
plantar flexion resulting in decreased stance time on the prosthetic limb. Amputees with
prosthetic knees must exert a greater-than-normal force on the posterior wall of the socket to
maintain knee extension.
Most amputees find it easier to ascend and descend inclines with short but equal strides.
They prefer this method since it simulates a more normal appearance as opposed to the
sidestepping or zigzag method.
When ascending and descending hills, the amputee will find sidestepping to be the most
efficient means. The sound limb should lead and provide the power to lift the body to the next
level, while the prosthetic limb remains slightly posterior to keep the weight line anterior to the
knee and act as a firm base.
During descent the prosthetic limb leads but remains slightly posterior to the sound limb. The
prosthetic knee remains in extension, again acting as a form of support so that the sound
limb may lower the body.
For hip disarticulates or transpelvic amputees, sidestepping is the most common alternative
regardless of the grade of the incline.
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
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,
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
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 hop-
skip 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:
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; 16:290-
333.
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; 10:48-
105.
24A: Fitting and Training the Bilateral Lower-Limb Amputee | O&P Virtual Library
Search
GO
Special Considerations: Fitting and Training the Bilateral Reproduced with

Lower-Limb Amputee permission from
Bowker HK,
Michael JW (eds):
Douglas G. Smith, M.D. Atlas of Limb
Ernest M. Burgess, M.D. Prosthetics:
Joseph H. Zettl, C.P.
The bilateral lower-limb amputee has throughout recorded medical history presented a special
challenge for the rehabilitation team to provide a degree of mobility that would allow a more 1992, reprinted 2002.
normal place in society. Persons with high-level amputations or congenital limb deficits that
present a similar functional loss can occasionally walk without a prosthesis by using crutches Much of the material in this text
and a swing-through gait. This requires very good trunk and upper-body strength, sense of has been updated and published
balance, and muscle control. Such ambulation is seen very occasionally in children and in Atlas of Amputations and Limb
young adults. In most cases, assistive devices are necessary to stand and walk. Many simple
as well as ingenious means have been used by the amputee to move from place to place. (retitled third edition of Atlas of
Often the amputees self-designed and made devices that best suited their needs. Limb Deficiencies), ©American
The surgeon, the prosthetist, and the rehabilitation team have at their disposal today a wide Click for more information about
variety of prosthetic and assistive aids for providing comfortable standing and walking. The this text.
remarkable degree of functional restoration now possible can often permit the bilateral leg
amputee to participate in a life-style that socially and vocationally overcomes his physical
handicap.
Prosthetics was
Bilateral lower-limb amputations are much more frequent currently than in the past largely
provided by the
secondary to an aging population with an increased incidence of peripheral vascular disease Northern Plains Chapter of the
and diabetes mellitus. Improved medical management is continually increasing life expectancy American Academy of Orthotists &
throughout the industrialized world. As people live longer, the complications of diabetes, Prosthetists
peripheral vascular disease, and other chronic medical diseases progressively increase the
frequency of lower-limb loss. In 1985, there were 112,500 nontraumatic lower-limb
amputations in the United States, and 50% of these were in patients with diabetes. The 3-
year survival rate after a major amputation for diabetes or vascular disease is about 50% and
is essentially unchanged from the mid-1960s to the early 1980s. Since these disease states
are systemic, studies have shown that approximately 25% of the original group, or about 50% You can help expand the
of surviving patients, can be expected to lose the second limb by 2 to 3 years following the O&P Virtual Library with a
first amputation. The quality of surgical, medical, and rehabilitative care further results in a tax-deductible contribution.
life expectancy of months and often years as a bilateral lower-limb amputee. Mobility by
ambulation with prostheses profoundly improves the quality of life as compared with a
wheelchair existence.
There are also an increasing number of bilateral lower-limb amputees as a result of trauma,
especially in war or natural disasters. The current high quality and availability of military and
emergency medical care allows survival for many patients whose severe trauma would have
been fatal in previous decades. Loss of both lower limbs is also encountered in trauma
centers throughout the industrialized world. Motorcycle accidents, pedestrian involvement in
car or train accidents, and severe burns are generally responsible. Most of those sustaining
bilateral traumatic lower-limb amputations are adolescents and young adults. Prosthetic
rehabilitation potential is usually excellent.
Bilateral congenital leg amputations and limb deficiencies encompass a small but often
difficult group. With appropriate prosthetic management, rehabilitation can be surprisingly
successful and rewarding in these infants and children. Even if prosthetic ambulation is not
expected to continue into adult life, the independence and mobility achieved by aggressive
prosthetic rehabilitation in the early years improves the general health and social
development of these children.
SURGICAL DECISION MAKING

Retention of maximum limb length by amputation at the distalmost suitable level is particularly
important for the bilateral amputee. There is absolutely no added benefit to having both lower
limbs amputated at the same level. Even if a patient is a bilateral transtibial amputee, it is not
necessary to have both legs symmetrical, and all length possible that is suitable for prosthetic
fitting should be preserved (Fig 24A-1.). State-of-the-art plastic and microvascular
reconstructive surgery is on occasion justified to maintain residual-limb length. This is
particularly true when the amputations result from burns. Bone lengthening procedures,
however, are rarely justified. The surgical management of these difficult cases requires a full
knowledge of the principles of modern prosthetic management. The amputation site
becomes the new interface for human contact with the environment and must be as functional
and comfortable as possible (Fig 24A-2.).
Even in the bilateral amputee, there remain a few regions where it is not advisable to
amputate, not only because healing may be compromised but also because prosthetic
substitutions are unsatisfactory at these few levels in the lower portion of the leg. These
areas include the lower fifth of the leg down to but just above the Syme-level ankle
disarticulation, the very short
transtibial amputation above the attachment of the patellar tendon, and the very short
transfemoral amputation in the subtrochanteric region. In each of these instances it is usually
better to elect amputation at a higher level to permit improved prosthetic substitution and
patient comfort.
Although optimum function is usually the primary concern in amputation, the cosmesis of the
prosthetic limb replacement must also be considered. Syme ankle disarticulation and knee
disarticulation levels have a bulbous end and result in a less aesthetic appearance in the final
prosthesis. Patients with high cosmetic expectations might be dissatisfied with these levels
(Fig 24A-3.).
In the geriatric age group, the patient's activity level, ambulatory potential, cognitive skills,
vision, and overall medical condition must be evaluated to determine whether the distalmost
level is really appropriate for the patient. In ambulatory patients, the goal is to achieve healing
at the most distal level that can be prosthetically fit and allow successful rehabilitation. Most
unilateral transtibial amputees who were successful prosthetic ambulators will master bilateral
amputee gait if a transtibial or more distal amputation can be performed on the contralateral
limb. The success of rehabilitation decreases dramatically if transfemoral or higher-level
amputations need to be performed.
In nonambulatory patients, the goal is to obtain wound healing, minimize complications, and
improve sitting balance, transfers, and nursing care. For example, a bedridden patient with
hip and knee flexion contractures might be better served with a knee disarticulation or very
long transfemoral amputation than with a transtibial amputation. On the other hand, a geriatric
patient with a previous transfemoral amputation might be a nonambulator but still have
excellent independent transfers and bathroom skills. If the patient capable of independent
transfers develops contralateral foot gangrene, he might be best served by preserving all
possible length and prosthetic fitting, if the goal is to continue independent transfers and
bathroom activities. Such skills are extremely important in the bilateral amputee and should
be given careful preoperative evaluation, even in nonambulatory patients. Careful
preoperative assessment of the patient's potential and setting realistic goals can help direct
surgical level selection and postoperative rehabilitation wisely.
PROSTHETIC FITTING AND REHABILITATION

Rapid prosthetic rehabilitation of the multiple-limb amputee ensures the best results in
returning to an active, independent life-style. Speed of recovery is frequently indicative of how
well the patient will be able to perform predetermined rehabilitation goals. This is particularly
important in the management of the majority of amputees we are treating today, the elderly.
The psychological and economic benefits to this patient approach are also quite appreciable.
Contemporary prosthetic fitting of the bilateral lower-limb amputee can be categorized into
immediate postsurgical prosthetic fitting (IPPF), early postsurgical prosthetic fitting,
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.
Immediate Postsurgical Prosthetic Fitting

Ideally, IPPF with controlled weight bearing is the initial patient treatment of choice, especially
in the young traumatic amputee. The details and benefits of applying a rigid dressing (i.e.,
plaster of paris socket) with a pylon extension and prosthetic foot in the operating room have
been adequately documented in the literature. The primary consideration is achieving rapid,
optimal wound healing. This is accomplished by controlling postsurgical edema without
restricting circulation. Tissue support minimizes inflammatory reaction and reduces phantom
pain. The psychological benefits are significant as the patient wakes up with a prosthesis in
place of the amputated limb and rehabilitation starts immediately. Carefully controlled static
weight bearing can be initiated the first postoperative day or whenever the patient is
physically capable of tolerating the procedure. Use of a tilt table is necessary for the bilateral
amputee, with bathroom scales or other pressure-monitoring devices utilized to help regulate
weight bearing. As wound healing progresses and is monitored at the various cast change
intervals, weight-bearing increments are also accelerated accordingly. Actual ambulation
activities are delayed until the incisions have healed and sutures have been removed.
Patients with simultaneous bilateral amputations must be advanced more slowly and carefully
than the previous unilateral amputee who can tolerate unrestricted weight bearing on the
mature, previously amputated limb (Fig 24A-4.).
If prosthetic pylons have not been utilized initially, manually applied, simulated weight-bearing
activities are administered by the therapist or the patient himself through the cast (Fig 24A-
5.). The reduction in edema that results from simulated weight bearing decreases
postoperative discomfort. IPPF can be implemented in any hospital setting that has a trained
team of professionals available. The team consists of a surgeon, a prosthetist, a physical
therapist, a nurse, and other auxiliary personnel as might be required.
Early Postsurgical Prosthetic Fitting

Under certain conditions, the surgeon may defer application of a rigid dressing 1 to 3 weeks
postsurgically to or near the time when sutures are removed from the surgical incision.
Although we prefer immediate use of rigid dressings, to delay until suture removal is very
common in the bilateral amputee. At this stage, considerable postsurgical edema is usually
evident, and residual-limb or phantom pain can be exaggerated in spite of soft compression
dressings such as an elastic bandage or shrinker sock. In all probability, the patient has
been restricted to bed rest or limited to wheelchair mobility, which leads to physical
decompensation and muscle weakness. In a worst-case scenario, wound healing can be
compromised as a result of this delay.
The early prosthetic fitting techniques employed are the same as for the IPPF. If considerable
edema is evident at the initial application of the cast socket, frequent cast changes may be
indicated until this condition stabilizes. If a cast socket inadvertently comes off the limb, it
should not be pushed back on. Damage to the residual limb may result with associated pain
for the patient. A new cast socket must be applied without delay.
Removable cast sockets, in our experience, have been unsuccessful. As the name implies,
they are removable and can come off the residual limb at the most inappropriate time. The
need for daily wound inspection contradicts our position of undisturbed tissue support and
immobilization. Removable rigid dressings must be continuously monitored and require the
complete cooperation of a reliable patient. Regular-interval full-cast changes between 7 and
10 days are adequate for dressing changes unless wound problems require more frequent
attention.
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.
Preparatory Prosthetic Fitting

Preparatory prostheses, also referred to as intermediate or training prostheses, are useful if
the volume of the residual limb is expected to decrease rapidly in the near future or if a
gradual reduction of joint contractures will require repeated prosthetic realign-ment. This is
common in simultaneous bilateral amputees who cannot advance their weight bearing as
quickly as unilateral patients.
Such prostheses are also indicated for evaluating a patients potential to safely ambulate or to
demonstrate to a patient the energy and skill requirements associated with the use of
prostheses. If used in this context, preparatory prostheses are indeed justified and present
the best diagnostic and economic tool for measuring a patient's mobility capabilities. The
bilateral amputee greatly benefits from this approach (Fig 24A-6.).
Component choice is carefully prescribed in consideration of the particular patient's needs.

Likewise, the prosthetic socket configuration as well as design anticipates the patients
requirements and is the critical contact point of the human anatomy and the mechanical
substitute. Patient comfort will make the decisive difference between acceptance and
rejection of the prosthesis and is therefore a high priority.
Whenever possible, the components of choice should be the same as those anticipated for
the definitive prosthesis to minimize the retraining and relearning required. The economics of
this practice are realistic and obvious. It is frequently prudent to utilize definitive foot-shin-
knee components for the preparatory prosthesis and carry them over into the definitive
device. Commercially available, prefabricated, adjustable sockets may warrant consideration
in particular situations when in the opinion of the team this approach is pref-erable.
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
biomechanical fitting principles and static and dynamic test socket procedures combined
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 (CAD-
CAM) open the door to new and exciting possibilities to better serve the multiple-limb
amputee. All this demands greater knowledge and skills on the part of not only prosthetists
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
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 self-
induced mobility. Following bilateral hip disarticulations, the prosthetic socket is combined with
cosmetically enhanced thigh-shank-foot components that allow sitting, standing, and some
limited ambulation on the principles of a swivel walker. Often these patients have multiple
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
thermoplastic sockets mounted in rigid frames. This allows for socket replacements due to
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
suspension as early as 18 to 24 months of age. This eliminates most auxiliary suspension
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
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 full-
length 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 custom-
designed 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
residual limb. This becomes critical in the bilateral amputee. Thus, it is advisable to use
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
disarticulation or transtibial amputations. Knee instability and flexion contractures are major
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.
ADOLESCENT AND YOUNG ADULT AMPUTEES

This group of amputees frequently proves the prosthetic team wrong when told of physical
limitations associated with multiple amputations. The news media constantly remind us of the
stunning accomplishments of amputee athletes, including bilateral high-level lower-limb
amputees. These runners, swimmers, skiers, rowers, mountain climbers, basketball players,
etc., demonstrate the dangers of stereotyping amputees with outdated classifications.
Experience has proved that patients can excel safely if given the opportunity rather than being
told that they are unable to do so (Fig 24A-11.).
Most bilateral amputees perform these extracurricular recreational activities with conventional
prostheses. A few, more competitive amputee athletes may have special prostheses designed
to aid their accomplishments in competitive sports events. There is an abundance of materials
and componentry available from which to select what is most suitable for a particular
amputee. They should be allowed to evaluate different socket designs, knee components, and
feet to determine the best functional combination for their needs. This is an expensive and
time-consuming process but ensures the best results. Similarly, refinements of socket fit
through repeated static and dynamic test socket procedures, including proper alignment of
components, makes for more functional prostheses (Fig 24A-12.).
Suction suspension, including semiflexible transtibial and transfemoral sockets, is preferable

for bilateral amputees, so long as the amputee is able to don and doff the prostheses
effectively without assistance. Flexible brim, ischial containment transfemoral sockets provide
more comfort during ambulation and when seated by providing increased clearance in the
perineum. It must be noted, however, that there are numerous successful bilateral
transfemoral amputees utilizing quadrilateral or modified quadrilateral suction or semisuction
prostheses. Either these patients have not yet made the transition to ischial containment
socket designs, or they have tried the transition but prefer to remain with their previous
socket designs (Fig 24A-13.).
Early flexible inner sockets lacked durability. Surlyn and certain polyethylenes cracked and
buckled under rigorous use and required frequent replacement. Improved working techniques
and better materials have reduced these problems and given the prosthetist a wider choice of
options. The 3S socket design, including the Icelandic Roll-on Suction Socket (ICE-ROSS)
system, provides excellent suspension and minimizes the problem of excessive perspiration of
the residual limbs that is commonly encountered in bilateral prosthesis use.
Dynamic-response foot and ankle components have a profound impact on socket comfort and
the functional capabilities of all lower-limb prosthetic users. Amputees have noted
improvement in proprioceptive feedback; improved negotiation of inclines, declines, and
uneven terrain; as well as improved impact absorption and reduction of torque and shear
forces. All of these enhance stability and control of prostheses and improve gait. Special
foot alignment and resistance is required for the bilateral amputee for security and balance.
There is an abundance of knee joint components available that aid in stability and function.
For maximum durability, exoskeletal design has the advantage over endoskeletal systems.
For cosmetic appearance, the endoskeletal system has a distinct advantage and is therefore
favored by many females. Postfitting realignment procedures are performed much more
conveniently and expediently with endoskeletal designs than with exoskeletal systems that
require major labor-intensive reworking procedures to achieve alignment corrections.
Bilateral young transtibial amputees usually become excellent ambulators with a relatively
normal gait without the use of external aids. Similarly, persons with bilateral partial-foot
amputations, Syme ankle disarticulations, or a combination of these levels accomplish a
near-normal gait. Knee disarticulation or transfemoral amputees with contralateral transtibial
or more distal amputation also become accomplished ambulators but frequently prefer a cane
or other assistive device. Most bilateral amputees who have lost one knee limit their daily
ambulation activities and have sedentary jobs.
The simultaneously acquired bilateral knee disarticulation or transfemoral amputee requires

fitting with stubbies as the initial prostheses, as previously discussed. In our experience, most
adults with acquired bilateral transfemoral amputations fail to become consistent wearers of
full-length prostheses but continue the use of stubbies for their daily ambulation activities.
They may elect to wear the full-length prostheses for special events or cosmetic reasons
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 trans-
femoral 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.).
There are some possible variations in the rocker bottoms of stubbies. The use of SACH
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 24A-
18.). 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
walker. A particularly strong patient can also accomplish a swing-through gait with the aid
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
a 50-year-old and use prostheses accordingly. While the patient must be able to
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
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.).
SHOES FOR AMPUTEES

It is noteworthy that Kegel reports the recent development of special dress shoes for
amputees that are very lightweight, flexible, and have a soft compressible heel to dampen
impact at heel strike. The shoes are manufactured by Bally and look like any other regular
dress shoe. Kegel states that "there are shoes available for soccer, tennis, skiing and other
special requirements, but none for prostheses users." This new development remedies this
need.
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; 35:659-
664.
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; 4:97-
100.
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
amputee, in Moore WS, Mal-one JM (eds): Lower Extremity Amputation. Philadelphia,

WB Saunders Co, 1989, pp 229-245.
30. Harris RI: The history and development of Syme's amputations. Artif Limbs 1961; 6:4.
31. 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.
32. Huang C, Jackson JR, Moore NB, et al: Amputation: Energy cost of ambulation. Arch
33. Irons G, Mooney V, Putnam S, et al: A lightweight above-knee prosthesis with an
adjustable socket. Orthot Prosthet 1977; 31:35.
34. Jendrzrjezk DJ: Flexible socket systems. Clin Prosthet Orthot 1985; 9:27-30.
35. Keagy BA, Schwartz JA, Kotb M, et al: Lower extremity amputation: The control series.
J Vasc Surg 1986; 4:321-326.
36. 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.
37. Kegel W: The prosthetic shoe. Orthop Technik 1991; 00:449-451.
38. Kegel B, Moore AJ: Load cell, a device to monitor weight bearing for lower extremity
amputees. Phys Ther 1977; 57:652-654.
39. Kegel B, Webster JC, Burgess EM: Recreational activities of lower extremity amputees:
A survey. Arch Phys Med Rehabil 1980; 61:256-264.
40. Kokegei D, Dotzer R: Prosthetic management of the lower limb after traumatic
amputation. Orthop Technik 1991; 42:434-440.
41. 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.
42. Kruger LM: The use of stubbies for the child with bilateral lower-limb deficiencies.
43. 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.
44. Lambert CN, Hamilton RC, Pellicore RJ: The juvenile amputee program: Its social and
economic value. J Bone Joint Surg [Am] 1969; 51:1135-1138.
45. Lehneis HR: A thermoplastic structural and alignment system for below-knee
prostheses. Orthot Prosthet 1974; 28:23-29.
46. Lehneis HR, et al: Prosthetic Management for High Level Lower Limb Amputees. New
York, Institute of Rehabilitation Medicine, 1980.
47. Lippert FG III, Burgess EM, Starr TW: Physiologic suspension factors in below-knee
amputees evaluation. J Rehabil Res Dev 1983; p. 5.
48. Long IA: Normal shape-normal alignment (NSNA) above-knee prosthesis. Clin Prosthet
Orthot 1985; 9:9-14.
49. 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.
50. Malone JM, Moore W, Leal JM, et al: Rehabilitation for lower extremity amputation.
Arch Surg 1981; 116:93-98.
51. Malone JM, Moore WS, Goldstone J, et al: Therapeutic and economic impact of a
modern amputation program. Bull Prosthet Res 1979; 16:1.
52. Manella KJ: Comparing the effectiveness of elastic bandages and shrinker socks for
lower extremity amputees. Phys Ther 1981; 61:334-337.
53. Marquardt E: The multiple limb-deficient child, in American Academy of Orthopedic
Surgeons: Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. St. Louis,
54. Marshall K, Nitschke R: Principals of the PTS BK prosthesis. Orthop Prosthet
Appliance J 1967; 21:33.
55. Mauch HA: Stance control for above-knee artificial legs: Design consideration in the
S-N-S knee. Bull Prosthet Res 1968; 10:61-71.
56. 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.
57. 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.
58. Mensch G: Physiotherapy following through-knee amputation. Prosthet Orthot Int 1983;
7:79-87.
59. 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.
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
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. Inter-
Clin 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.
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.
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
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.
24B: Adaptations for Sports and Recreation | O&P Virtual Library
Search
GO
Special Considerations: Adaptations for Sports and Reproduced with

Recreation permission from
Bowker HK,
Michael JW (eds):
Bernice Kegel, R.P.T. Atlas of Limb
Prosthetics:
Do what you can, with what you have, where you are.
Theodore Roosevelt
Sports often improve the physically challenged persons attitude toward himself by changing a
negative attitude for what his body cannot do to pride in what it can do. This text is written to Much of the material in this text
facilitate the clinicians role in helping individuals with lower-limb amputation find the has been updated and published
appropriate sport for their level of ability. Fortunately, the prosthetic field has improved in Atlas of Amputations and Limb
extensively and is much more willing and able to accommodate the specialized needs of
todays amputee. Where appropriate, addresses are given for more detailed information. The (retitled third edition of Atlas of
information presented is based both on firsthand experiences of individual amputees, as well Limb Deficiencies), ©American
as research. While some of the adaptive procedures are widely applicable, others are not. Academy or Orthopedic Surgeons.
Every adaptation mentioned will not necessarily work for every individual. An overall physical Click for more information about
fitness program is essential before engaging in any new sport. this text.
WINTER SPORTS Funding for digitization

Prosthetics was
Snow Skiing provided by the
The concept of amputee skiing originated in Austria and Germany in 1948. The Swiss American Academy of Orthotists &
subsequently introduced "crutch skiing." In 1967, the National Amputee Ski Association was Prosthetists
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 You can help expand the
three-track skiing technique. The bilateral transtibial amputee skis with a four-track technique O&P Virtual Library with a
and uses two prostheses, two skis, and outriggers. The bilateral transfemoral amputee could tax-deductible contribution.
use short prostheses without knee mechanisms or can switch to a sled or monoski.
The Transtibial Skiing Prosthesis

To achieve skiing proficiency, it is important that the skier's center of gravity be located ahead
of the ball of the foot for proper balance, ease in turning, and adjustment of speed. While
individuals with two sound legs maintain balance by increased ankle dorsiflexion and a
forward lean, which most ski boots are designed to encourage, the skier with an amputation
may require certain adaptations.
A conventional prosthesis can be adapted by placing a 2.54-cm (1-in.) wedge under the heel
of the ski boot to achieve the desired forward cant. The resultant increase in socket flexion,
however, may raise the socket's posterior brim in relation to the patellar tendon bar, thus
causing excessive and painful pressure on the hamstring tendons. To relieve this excess
pressure on the hamstring tendons, the prosthetist can make a ski prosthesis. First, the
prosthesis is aligned in the conventional manner. The socket is then moved forward in a
linear manner so that the anterior part of the brim falls approximately 2.54 cm (1 in.) behind
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
end of the skis (Fig 24B-3.).
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
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 sit-
ski 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 sit-
skier 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 (1½
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.
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. Swimming without a prosthesis

2. Peg legs for use on the beach and possibly for swimming as well
3. Sockets attached directly to swim fins (Fig 24B-8.)
4. 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.
The Beach or Utility Prosthesis

This prosthesis is used for walking along the beach, standing in a pool, or wading through
streams while fishing. In addition, this prosthesis can be used in the shower, thereby
eliminating the need for a stool or grab bars. The prosthesis is waterproof and can be worn
with or without a shoe. If a SACH foot is used, some adaptations need to be made to the
heel to allow the amputee to walk barefoot. A removable "heel leveler" fabricated from
polypropylene molded over the SACH foot can be used. An alternative would be to use a
plantigrade postoperative foot (Kingsley), which would allow the amputee to change readily
from street shoes to tennis shoes for other activities.
The VAPC Swim/Walk Ankle

The Veterans Administration's Prosthetic Center (VAPC) of New York developed the swim-
walk ankle (Fig 24B-9.,A and B). The prosthetic ankle is constructed to lock at 90 degrees
(neutral) for walking and at 120 degrees (30 degrees plantar flexion) for swimming. Each
position is controlled by a spring-loaded pin that automatically locks in place. The swimmer
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.
Otto Bock-style Swimming Leg

The German firm provides technical information on how to construct the Otto Bock transtibial
swimming leg with an airspace between the two walls of the prosthesis shanks (Fig 24B-
11.). A hole drilled through the ankle block allows the airspace between the two walls to
partially fill with water during swimming and to drain when on land. The draining process is
rapid and does not cause any cosmetic problem. This filling process increases the weight of
the prosthesis and therefore reduces its buoyancy enough to permit effective swimming
action. The limb is weighted to facilitate proper balancing between the shank and the toe of
the prosthesis. When the airspace fills with water, the toe will point at the correct angle to
provide an effective swimming "kick." The swimmer may also wear a swim fin with this
device. Because of their increased strength characteristics, acrylic resins rather than
polyesters are generally used to fabricate the limb. If a supracondylar cuff is used, it should
be constructed of a pliable plastic material that is impervious to water.
A transfemoral swimming leg can be similarly designed. A quick-release knee lock

mechanism and a waterproof nylon axle are used. For convenient storage, the amputee may
disassemble the prosthesis into two parts by removing the axle. The knee mechanism, which
is completely functional in water, has a friction lock especially designed for walking or sitting
on the beach. For suspension, a light harness can be made out of waterproof material. Some
suction socket wearers manage to keep the limb on with no harness at all.
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
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
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 able-
bodied, 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
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
to allow them to be operated in a push-pull fashion with the sound leg.
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 bucket-
type 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.
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 leg-
strengthening 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 foot-
powered 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 two-
wheeled 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
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
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, flexible-
endoskeleton (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.
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.
BIBLIOGRAPHY
Aboulafia DI: In the beginning . . . Wheelchair sports in America. Rehabil World 1984; 8:22-
23.
Adams R, Hakala M, Oppelt R: Ice skating therapy. Physician Sports Med 1978; 6:71-81.
Aids to Make You Able. Self-Help Devices and Ideas for the Disabled. Don Mills, Ontario, W
Davis General Publishing Co Ltd, 1981.
Alexander MJL: The high jump technique of an amputee; the ideal technique? Cahper J
1981; 13-17.
Anderson B, Bornell DG: Stretch and Strengthen. Palmer Lake, Colo, Stretching Inc.
Axelson P: Adaptive Technology for Skiing. Palaestra 1986.
Brant MK: Kayaking with a prosthesis. Canoe 1976; 52:52-53.
Brenner RR: Bankshot basketball. Sports Spokes 1980; 6:8-9.
Brouwer BJ, Allard P, Labelle H: Running patterns of juveniles wearing SACH and single-axis
foot components. Arch Phys Med Rehabil 1989; 70:128-134.
Chadderton HC: Otto Bock Curling Limb. Fragment 1983; 141.
Collins VT: Soaring. Disabled USA 1982; 15-16.
Davis WN: Skiing, in Aids to Make You Able. New York, Beaufort Books, 1981.
Disabled Sport Resources Directory (DSRD). Mary Margaret Newsom, Education Services,
USOC, 1750 E. Boulder Ave, Colorado Springs, CO 80909-5760.
Donoho K, Leatherman J: Racquetball-wheelchair style. Sports Spokes 1984; 9:43-44.
Dummer G, Donnelly D: USMS Adapted Swimming Handbook. Avon, Conn, United States
Masters Swimming.
Enoka RM, Miller DI, Burgess EM: Below knee amputee running gait. Am J Phys Med 1982;
61:66-84.
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; 6:1-
4.
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
Saadah ESM: Rehabilitation of a below-knee amputee with a diving limb. Clin Rehabil 1989;
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) 378-
2961.
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
(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
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
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
Competitive Wheelchair Sports

Achilles Track Club 9 East 89th St New York, NY 10128 (212) 967-9300
International Wheelchair Road Racing Club Joseph M. Dowling, President 30 Myano Lane
Stamford, CT 06902 (203) 967-2231
National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs, CO
80909 (719) 635-9300
National Wheelchair Marathon c/o Bob Hall 15 Marlborough St Belmont, MA 02178 (717)
439-3246
United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown, PA
19057 (215) 945-1964
Wheelchair Athletics of America Judy Einbinder 8114 Buffalo Speedway Houston, TX 77025
(713) 668-5376
Cooperative Wilderness Handicapped Outdoor Group (C. Hog) c/o Thomas Whittaker Box
8118
Idaho State University Pocatello, ID 83209 (208) 236-391
The Counterpoint (or Sunburst)
Angle Lake Cyclery
Matt Dekker
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
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.
Hand Controls for Flying

Aircraft Inspection and Maintenance 2680 E Wardlow Rd Long Beach, CA 90807 (213) 595-
5738
Permanent hand controls.
Union Aviation, Inc. PO Box 207 Sturgis, KY 42459 (502) 333-5918
FAA-approved portable hand controls for certain
Cessna and Grumman aircraft.
Handbike
Rehabilitation R and D Center
Doug Schwandt
VA Medical Center
3801 Miranda Ave
Palo Alto, CA 94304
(415) 493-5000, ext. 4473
Two-wheeled cycle. Mr. Schwandt can also be contacted for information on the Counterpoint
or Sunburst bikes.
Handicapped Scuba Association Jim Gatacre
116 West El Portal, Suite 104 San Clemente, CA 92672 (714) 498-6128
Hein-A-Ken Skate Aid Hein-A-Ken, Inc 102 Fosse Ct
Thief River Falls, MN 56701 Skating boot.
Ice Sledding
Breckenridge Outdoor Education Center Mike Mobly, Executive Director PO Box 697
Breckenridge, CO 80424 (303) 453-6422
International Council on Therapeutic Ice Skating PO Box 13
State College, PA 16801 (814) 865-2563
International Foundation of Wheelchair Tennis Peter Burwash
2203 Timberloch Place, Suite 126 The Woodlands, TX 77380 (713) 363-4707
International Games for the Disabled c/o Tony Giustino Eisenhower Park East Meadow, NY
11554 (516) 542-4420
International Senior Amputee Golf Society, Inc c/o Dale Bourisseau 14039 Ellesmere Dr
Tampa, FL 33624 (813) 961-3275
International Sports Organization for the Disabled International Stoke Mandeville Games
Federation Stoke-Mandeville Spinal Injury Center Aylesbury England
International Sports Organization for the Disabled S-12387 RARSTA Sweden
International Wheelchair Aviators Mindy Desens, President Bill Blackwood, Secretary 1117
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) 280-
0464
National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs, CO
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) 796-
5084
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
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) 292-
2900
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
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
Ski Instruction Manuals

Alpine Manual by Jerry Johnston and Susan Clift, 1988 Canadian Association for Disabled
Skiing Box 307
Kimberly, British Columbia V1A2Y9 Canada
Bold Tracks: Skiing for the Disabled, by Hal O'Leary (1987)
Winter Park Handicap Program
PO Box 36
Winter Park, CO 80482
Ski Instruction Organizations

Canadian Association for Disabled Skiing (CADS) Box 307
Kimberly, British Columbia VIA 2Y9 Canada (604) 427-7712
52 Association, Inc
350 5th Ave, Room 1829 New York, NY 10118 (212) 563-9797
National Handicapped Sports 1145 Nineteenth St Suite 717
Washington, DC 20036 (301) 652-7505
Winter Park Handicapped Skier Program
Winter Park Sports and Learning Center
PO Box 36
Winter Park, CO 80482
(303) 726-4101, ext 179
These are some organizations that help the disabled individual get started or restarted in
skiing.
Skidiving Information
United States Parachute Assn Mike Johnston 1440 Duke St Alexandria, VA 22314 (703) 836-
3495
Ski-Eze
Ski-Eze USA, Inc
4401 Devonshire
Lansing, MI 48910
(517) 487-0924
(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,
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
Water Ski Information

American Waterski Association Disabled Ski Committee Phil Martin, Chairman 681 Bailey
Woods Rd Dacula, GA 30211 (916) 868-5733
Christian Family Ski School c/o Fred and Wanda Horrell PO Box 7425 Winter Haven, FL
33880 (813) 299-4044
Northwest Adaptive Water Skiers PO Box 1478 Granite Falls, WA 98252
Weight lifting Prosthesis
Nashville Orthotic and Prosthetic Services, Inc c/o Jim McElhiney, CPO 1904 Hayes St
Nashville, TN 37203 (615) 327-1546
Welsh Sports Association for the Disabled c/o E. Roberts Crosswinds 14 CAE GAM HEOL-Y-
CYW Bridgend, Mid-Glamorgan, Wales
Western Australia Disabled Sport Association PO Box 1162 East Victoria Park 6101 Western
Australia
Wheelchair Athletics of the USA Judy Einbinder 1475 West Gray, #161 Houston, TX 77019
(713) 522-9769
Wheelchair Bankshot Basketball

Rabcan Associates 485 5th Ave New York, NY 10017
National Wheelchair Basketball Association 110 Seaton Bldg University of Kentucky

Lexington, KY 40506 (606) 257-1623
Wheelchair Bowling
Wheelchair Bowling Association, Inc c/o Daryl Pfister, Chairman N54 W 15858 Larkspur Lane
Menomonee Falls, WI 53051 (414) 781-6876
Wheelchair Motorcycle Association Dr. Eli Factor 101 Torrey St Brockton, MA 02401 (508)
583-8614
Wheelchair Tennis
International Foundation of Wheelchair Tennis c/o Brad Parks, Director 3857 Birch St, Box
111 Newport Beach, CA 92660
(714) 851-1707
Peter Burwash International, Ltd 1909 Ala Wai, Suite 1507 Honolulu, HI 96815 (808) 946-
1236
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
24C: Emerging Trends in Lower-Limb Prosthetics: Research and Development | O&P Virtual Library
Search
GO
Special Considerations: Emerging Trends in Lower-Limb Reproduced with

Prosthetics: Research and Development permission from
Bowker HK,
Michael JW (eds):
Charles H. Pritham, C.P.O. Atlas of Limb
Prosthetics:
In the period beginning shortly after World War II, a revolution occurred in the provision of Surgical, Prosthetic, and
prosthetic care. While it is not appropriate to review this transformation in depth, a few major Rehabilitation Principles.
points will provide perspective about present circumstances and speculation regarding future
developments. 1992, reprinted 2002.
1. The new techniques and devices that appeared during that time were not necessarily Much of the material in this text
invented but rather synthesized from the ofttimes conflicting body of contemporary has been updated and published
practice and theory as reiterated in the light of fundamental studies of human gait. in Atlas of Amputations and Limb
Radcliffe and others showed that applying engineering concepts of rational analysis
and development to clinical problems would bear fruit many times over. (retitled third edition of Atlas of
2. As stated, many of the concepts now identified with the new practice of prosthetics Limb Deficiencies), ©American
were readily available to all. What reshaped the practice of prosthetics was the Academy or Orthopedic Surgeons.
dissemination of this now rationally ordered and internally logical body of knowledge. Click for more information about
Instructional courses were held, and from these, long-term courses of study in this text.
prosthetics were developed, thereby creating a new profession in the place of a craft.
Prepared in clinical practice and inspired with the example of past efforts, this new Funding for digitization
cadre of better-educated prosthetists embarked on research and development efforts of the Atlas of Limb
of their own. Prosthetics was
3. The standardization of prosthetic practice along with the education of a new generation provided by the
gave impetus to the development of a fledgling industry in the manufacture of Northern Plains Chapter of the
prosthetic components. Previously, a limb fitter would often custom-fabricate every American Academy of Orthotists &
Prosthetists
element of a prosthesis and use a minimum of purchased items. It took many years to
learn the requisite skills, it was labor-intensive, and the results varied widely. The new
generation of prosthetists was unequipped and unwilling to adopt this method of
practice. Their willingness to accept standardized manufactured components freed
them from bench work, gave them time to pursue new avenues of development, and
created a market. With the creation of a market and the revenue that it generated, it
became attractive for prosthetic suppliers to engage in research and development
efforts of their own. Today, competition among the suppliers ensures a continuous tax-deductible contribution.
process of innovation to allow not only growth but economic survival.
4. All of the above happened because the federal government provided leadership,
coordination, and funding. The result was an integrated process of innovation,
development, dissemination, and feedback. Many disparate groups with widely varying
interests were brought together in a common purpose through the intercession of this
outside agent with its independent base. Today, the federal government has
fundamentally abandoned its leadership, and the feedback loop has been disrupted.
Financial support of the schools of prosthetics and orthotics is gradually being
withdrawn. While the loss of central coordination and leadership is regretted, it is a
tribute to the excellence of the work done in the post-World War II period that
developmental efforts by clinicians, manufacturers, and others have continued. Present
and future efforts, as shaped by these four factors, promise to produce continuing
results in a number of different areas.
STRUCTURAL COMPONENTS
As prosthetists grow ever more willing to accept standardized components, manufacturers
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
other factors, has led manufacturers to respond to the need with new feet. One general
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 24C-
1.), Carbon Copy II Foot, and Flex-Foot, were originally envisaged as being most suitable for
younger amputees interested in athletic activities, they have found favor with geriatric
amputees as well. The other group of feet, including the stationary-ankle, flexible-
endoskeleton (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
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.
SOCKET DESIGN/FITTING METHODS

These various factors have interacted with growing expectations among amputees and a
concern with meeting the needs for extra-ambulatory activities to create an entirely new style
of interaction between prosthetists and amputees, including new fitting methods.
Regardless of amputation level, these new methods emphasize the use of multiple transparent
check socket fittings along with such aids as alginate and radiographic examination of the fit.
They also rely on the use of structural components that can be readily adjusted in
alignment and that can be set up with different feet and knee control units. When these tools
are used, various options and variations can be explored during the trial fitting stage. The net
result is a much greater level of patient involvement in the fitting process and presumably a
higher level of satisfaction.
Transparent check sockets have also given rise to innovative socket designs, most notably
for transfemoral (above-knee) amputees. While these various designs have been given a
variety of names such as normal shape-normal alignment (NSNA), contoured-adducted
trochanteric, controlled alignment method (CAT-CAM), and Sabolich contoured-adducted
trochanteric, controlled alignment method (SCAT-CAM), they all can be classified as ischial
containment Sockets.
The technology used in fabricating transparent check sockets is also being employed to
fabricate socket elements of other more durable thermoplastic materials such as copolymer
polypropylene. A variety of concerns motivate this switch in technique, including weight,
function, economics, and fabrication safety.
Thermoplastic techniques are particularly suitable for use with endoskeletal structural
components, thus leading to increasing reliance on such devices. This, in turn, has stimulated
manufacturers to develop new endoskeletal components such as the Endolite system
developed in England and the Carbon Copy III (Fig 24C-2.) system developed in the United
States.
Of particular importance among the efforts of clinical prosthetists are those of the Icelandic
prosthetist Os-surr Kristinsson. He has been responsible for such innovations as the
flexible socket concept and the use of silicone elastomer components to provide suction
suspension for levels at which it was not previously practical. In the United States, these
developments, or similar ones derived from his work, are variously known as the
Scandinavian flexible socket (SFS) or Icelandic-Swedish-New York (ISNY) in the case of
flexible sockets and Icelandic Roll-On Suction Socket (ICEROSS) or silicone suction socket
(3-S) in the case of suction suspension sockets. His work epitomizes a trend in the field: the
growing interest in exploiting the characteristics of elastomeric polymers, primarily silicone
or urethane, in socket fabrication in order to make more functional and comfortable devices.
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.
Automated production of prostheses has been sought for some 20 years. In the most basic
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.
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.
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
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 below-
knee 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
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
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 below-
knee 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.
25: Musculoskeletal Complications in Amputees: Their Prevention and Management | O&P Virtual Library
Search
GO
Musculoskeletal Complications in Amputees: Their Reproduced with

Prevention and Management permission from
Bowker HK,
Michael JW (eds):
John H. Bovvker, M.D. Atlas of Limb
Robert D. Keagy, M.D. Prosthetics:
Pradip D. Poonekar, M.B., B.S., M.S. (Gen. Surg.)
One of the primary aims of any surgical procedure, apart from obtaining primary healing at the
operative site, is the prevention of complications due to that procedure. Amputee 1992, reprinted 2002.
management has the added dimension of complications related to the amputation-prosthesis
interface. The complications of amputation surgery can therefore be divided into preprosthetic Much of the material in this text
and post-prosthetic problems. has been updated and published
In general, the frequency and degree of complications decrease remarkably when the Deficiencies: Surgical, Prosthetic,
surgeon is keenly interested in the challenge presented by properly designed and executed and Rehabilitation Principles
amputation procedures and keeps abreast of innovations. A casual or defeatist attitude
toward amputation surgery engenders many of the problems to be discussed. Academy or Orthopedic Surgeons.
this text.
PREPROSTHETIC COMPLICATIONS
Delayed Healing of the Atlas of Limb
Prosthetics was
Delayed healing may be related to several factors that can be operative singly or in provided by the
combination. These include inappropriate amputation-level selection, sub-optimal operative Northern Plains Chapter of the
technique, inadequate postoperative management, and infection. American Academy of Orthotists &
Prosthetists
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
mapping can yield valuable information (see Chapter 2C).
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 O&P Virtual Library with a
tension on muscle of questionable vascularity can result in ischemic changes leading to tax-deductible contribution.
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
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
be considered. In selected cases, readings can be taken in the hyperbaric chamber while
the patient is breathing 100% 0 2 at 2.4 atm. If Tcp02 levels are still borderline,
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
and cessation of smoking. HBO treatments are again a useful adjunct in management if
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.
Skin Adherence to Bone of the Residual Limb

The ideal closure of an amputation includes the construction of an adequate soft-tissue
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 split-
skin grafts once they have matured.
Problems in Shaping of the Residual Limb

Much can be done at the time of surgery to create an amputation stump that, by its
configuration, will assist in early prosthetic fitting. On the other hand, many problems that
lead to delayed application of a definitive prosthesis are a direct result of suboptimal operative
technique. While it is axiomatic that wound closure tension should be minimized by designing
ample myofasciocutaneous flaps, it is equally true that redundant skin and muscle can lead to
slow stump shrinkage with persistent distal edema despite adequate attempts at shrinkage
(Fig 25-4.,A-C).
In order to ensure optimal configuration, proper shaping of the bone end and adequate soft-
tissue coverage are important. Here the role of myodesis/myoplasty cannot be
overemphasized. The most structurally stable residual limbs are achieved with myodesis in
which the surrounding muscles and their fasciae are sutured directly to the bone through drill
holes (Fig 25-5.). In the case of transfemoral amputation, the additional advantages of
myodesis are stabilization of the femur in adduction by the adductor magnus, enhanced hip
flexion by the rectus femoris, and enhanced hip extension by the biceps femoris, all three
being muscles that cross the hip joint.
In myoplasty, on the other hand, opposing muscle groups are simply joined to each other by
sutures through the myofascia and investing fascia over the end of the bone. In a severely
dysvascular residual limb with marginal muscle viability, myoplasty is probably the preferable
method but should be done with little closure tension. In either case, tapering of the muscle
mass avoids excessive distal bulk (Fig 25-6.).
Following amputation surgery, there is a tendency for terminal swelling to occur. Control of
this edema will greatly reduce the tendency for wound complications and thus facilitate early
healing. This is a major benefit of rigid circumferential dressings of plaster of paris or
fiberglass. As postoperative swelling decreases, the rigid dressing may slip distally and
produce a circumferential constriction with distal choking and aggravation of distal swelling. If
the cast is changed promptly on loosening, this problem will not occur.
Whenever removal of a limb for malignancy is to be followed by chemotherapy, it is

recommended that nonabsorbable sutures be used to oppose the fascia and other deep
structures. Fascia and other soft tissues tend to heal poorly in the presence of
chemotherapeu-tic agents, and soft-tissue retraction occurs if absorbable sutures are used.
The overall conformation of the residual limb will then be altered, possibly leading to
difficulties in fitting.
The Syme ankle disarticulation presents a special case. If the heel pad is secure and well
centered, the patient will be able to tolerate a great deal of end bearing. If it is not properly
anchored to the end of the tibia, it may migrate posteriorly or to one side in the socket (Fig
25-7.). If passively correctable, however, it can be held in the proper weight-bearing position
by a carefully fabricated prosthesis. On the other hand, if the heel pad becomes fixed off
center by contracture of the triceps surae, other muscle groups, or a scar, it should be
surgically repositioned by division of the contracted tendons or scar and removal of an ellipse
of excess skin, including the incisional scar, opposite the original contracture. It may also be
necessary to remove a wafer of distal tibia and fibula to allow reduction of the heel pad. The
plantar fascia of the heel pad may then be firmly sutured to the distal-anterior portions of the
tibia and fibula through drill holes.
Prior vascular surgery may have resulted in a longitudinal scar beginning on the lower portion
of the abdomen and crossing the inguinal crease into the thigh (Fig 25-8.). This presents two
possible problems for the transfemoral amputee. One is scar irritation by the socket brim. The
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
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 range-
of-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.
Chronic Wound Sinus

The patient who appears with a small adhesive bandage on his wound with minimal drainage
has a problem that may or may not be related to one of the many conditions mentioned
above. This small opening may only lead to a superficial suture abscess, or it may be a sinus
related to a bone spur or low-grade, localized osteomyelitis. Since a sinus is likely to become
inflamed or infected, it is useful to know that it is present. A good way to determine this is to
probe the opening with a malleable metal probe or a flexible polyethylene intravenous
catheter after antiseptic skin preparation. Radiographs will help to determine bone
involvement. A sinus is best managed surgically during a benign, nonacute interval. A
sinogram followed by excisional surgery can be curative.
POSTPROSTHETIC COMPLICATIONS
Painful Residual Limb
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
hypermobility. Fusion of the proximal tibiofibular joint is a much simpler procedure that
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 distal-
anterior 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 extra-
periosteal 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 tendon-
bearing (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
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.
Adherence of Skin to Bone

In any residual limb, but especially at the transtibial level, the adherence of skin to bone or
the application of split-thickness skin grafts directly to bone may rapidly lead to pain and
ulceration when a prosthesis is used. This occurs because skin without underlying soft tissue
has little resistance to direct or shear forces imposed by the prosthesis. In an attempt to avoid
revision, the amputee can be taught to mobilize tissue by gentle persistent fingertip massage
on a daily basis over several weeks as a routine part of self-care. A gel socket may be
useful. A nylon sheath should be provided to reduce shear forces. If a transtibial amputation
stump continues to show skin breakdown despite competent socket adjustments, other
methods may be helpful. The addition of a rotator unit will decrease rotational shear forces.
Partial unloading of the transtibial level by the addition of knee joints and a long thigh corset
or the use of ischial weight bearing may be necessary to allow continued ambulation.
Surgical revision is done as a last resort and will usually require only a local wedge excision,
including a small length of bone. In the case of adherent split-thickness skin grafts, often a
relatively small area of adherent split graft can be excised, with primary closure effected by
advancement of surrounding skin and subcutaneous tissue once muscle atrophy has resulted
in relative skin redundancy at 10 to 12 months (Fig 25-17.,A and B). Amputation to a higher
anatomic level is rarely indicated.
Other sites where split-thickness skin grafts may not stand up to prosthetic use is over the
adductor longus tendon in the groin, at socket brims over the biceps tendon in the antecubital
fossa, and in the anterior axillary fold in relation to transhumeral sockets.
Skin stretching, either by traction or by tissue expanders, is probably the best way to develop
enough normal skin to eliminate large areas of split-skin grafts. To cover the adductor tendon
region in the groin, however, it is usually sufficient to swing a small flap distally from the
abdomen downward or proximally from the thigh.
Insensitive Skin
Amputees with diminished sensation in the residual limb are seen quite commonly. The
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.
Bony Overgrowth in Children

The traumatic transosseous child amputee may experience rapid growth in length of the
residual limb to the point where the bone grows through the skin. This is appositional bone
growth and is not related to physeal growth, even though bony overgrowth usually ceases
when physeal growth ceases. It is often seen in the humerus, fibula, tibia, and femur in that
order of relative frequency (Fig 25-18.). This may occur several times during childhood and is
easily treated by resection of sufficient bone to allow coverage with an adequate soft-tissue
envelope. Caps, plugs, chemical cautery, or electrocautery have not proved to be consistently
useful in controlling overgrowth. Proximal epiphysiodesis is con-traindicated since this has no
influence on distal appositional bony overgrowth and will lead to unnecessary shortening.
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. Weight-
bearing 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 intra-
articu-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.
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 wound-
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.
26: Skin Problems of the Amputee | O&P Virtual Library
Search
GO
Skin Problems of the Amputee Reproduced with

permission from
S. William Levy, M.D. Bowker HK,
Michael JW (eds):
Amputation is just the beginning and not the end of a treatment! The amputation surgeon and Atlas of Limb
Prosthetics:
prosthetist have joined together to become the lifelong advisors to the amputee who will wear
an artificial limb for the rest of his life. A dermatologist is capable of rendering valuable aid to Rehabilitation Principles.
not only the amputee but also other members of the rehabilitation team, for he is familiar with Rosemont, IL, American Academy
the problems of the skin that can result from the wearing of an artificial limb. Lower-limb of Orthopedic Surgeons, edition 2,
amputees are frequently involved with skin problems since many have been subjected to 1992, reprinted 2002.
anatomic loss of the lower limbs at widely varying levels, with each level subjected and
reacting to different pressures. Amputation at any level is accompanied by distinct problems of has been updated and published
functional loss, prosthetic fitting and alignment problems, and medical problems such as skin in Atlas of Amputations and Limb
disorders that are secondary to the use of the artificial limb. Partial or total loss of an upper Deficiencies: Surgical, Prosthetic,
limb can also be associated with similar complaints. Amputees require the continued care of a and Rehabilitation Principles
prosthetist who constructs the artificial limb on which the amputee must depend for (retitled third edition of Atlas of
locomotion and, to a larger degree, for social and economic rehabilitation. Skin lesions, Limb Deficiencies), ©American
however minute they may appear, are nevertheless of great importance since they can be the
beginning of an extensive skin disorder that may be mentally, socially, and economically this text.
disastrous to a given amputee. It is best to view any minor irritation as a potentially
dangerous symptom and to deal with it as early as possible. This is especially true in
diabetics. Once the skin problem has begun, it should not be ignored in the hope that it will Funding for digitization
heal of its own accord. Nothing can be more frustrating to the lower-limb amputee than to be of the Atlas of Limb
Prosthetics was
told to remain off his prosthesis or to go onto crutches because he has neglected a minor
provided by the
skin eruption. Northern Plains Chapter of the
This chapter is devoted to the common skin problems and danger signals associated with the Prosthetists
wearing of a lower-limb prosthesis. In working with numerous amputees over the years,
specific information regarding the various clinical problems has been assembled and
correlated in an effort to benefit the individual amputee. Stump and socket hygiene is
important in relation to several clinical disorders of the skin, and accordingly, a specific
hygienic program for care of the stump and socket has been developed. These will be
mentioned subsequently. Some amputees will go for months or years without any skin You can help expand the
complaint or irritation. In others, the skin is a weaker tissue for them, and frequent difficulties O&P Virtual Library with a
do arise. The orthopaedic surgeon, prosthetist, dermatologist, and other medical personnel tax-deductible contribution.
concerned with amputees should be aware of certain conditions and danger signals that are
frequently the forerunners of seriously incapacitating cutaneous disorders. Early recognition
and treatment of these conditions can avert much mental anguish and avoid loss of social or
economic activity. It should be remembered that once in a prosthesis, the amputee desires to
continue, and it is of vital concern to the physician and prosthetist to prevent any disorder that
may return the amputee to crutches or bed rest.
In the past decade there have been numerous advances in the development of prostheses for
transtibial (below-knee) and transfemoral (above-knee) amputees. The strongly expressed
desire of amputees to participate in sports with high physical demands has resulted in the
development of lighter-weight, stronger prostheses with more dynamic action than was
available in previous years. Many new designs are now reported to store energy during
stance and release energy as the body weight progresses forward, thus helping to passively
propel the limb. Numerous means to suspend prostheses have been developed, and diversity
has resulted from attempts to fit individuals of differing physical characteristics and life-styles.
The skin of an amputee who wears a prosthesis is subject to numerous abuses. Most leg
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.
STUMP EDEMA SYNDROME

When an amputee first starts to wear a prosthesis with suction suspension, his skin must
adapt to an entirely new environment. Similarly, a transtibial amputee wearing a total-contact
socket must adapt to the heat, rub, and perspiration generated within the socket. The
amputee can expect mild edema and a reactive hyperemia or redness when first becoming
accustomed to the prosthesis. These changes are the inevitable result of the altered
conditions that are now forced on the skin and subcutaneous tissues of the stump. In the
majority of instances, they are relatively innocuous, do not usually require therapy, and can be
minimized by gradual compression of the stump tissues postoperatively with an elastic
bandage or "shrinker" sock prior to use of the prosthesis. An incorrectly fitted socket may
predispose the leg amputee to these problems by imposing a pressure distribution that can
disturb local circulation.
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 upper-
limb 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
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 post-
traumatic epidermoid cysts, in the skin of amputees' stumps in association with the wearing
of an artificial limb. These occur most frequently in transfemoral amputees in the areas
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.
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.
BACTERIAL AND FUNGAL INFECTIONS

Bacterial folliculitis and furuncles or boils are often encountered in amputees with hairy, oily
skin, with the condition aggravated by sweating and rub from the socket wall. It is usually
worse in the late spring and summer when increased warmth and moisture from perspiration
promote maceration of the skin within the socket, which in turn favors invasion of the hair
follicle by bacteria. Ordinarily this process is not serious, but sometimes, especially in
diabetics, it can progress to furuncles, cellulitis, or an eczematous weeping, crusted,
superficial, impetiginized pyoderma (Plate 16. and Fig 26-1.). Folliculitis and furuncles can
also be the result of poor hygiene of the stump and/or the socket. In some of our amputees,
the skin bacterial flora of the residual limb was compared with the flora of the opposite
normal limb. All subjects wore prostheses and followed a satisfactory routine of skin hygiene.
The stump skin was found to harbor bacterial flora more abundant than that of the skin of the
intact leg. Chronic recurrent folliculitis can be cured by having an amputee adhere to the
routine hygienic program previously described. In still other patients, therapy may require a
wet compress, incision and drainage of boils after localization and oral or parenteral use of
antibiotics, and local application of bacteriostatic or bactericidal agents.
Superficial fungal infections such as tinea corporis and tinea cruris can appear on any part of
the residual limb enclosed by the socket. The diagnosis of a nonspecific scaling,
erythematous eruption can be confirmed through culture and/or microscopic demonstration of
the fungus filaments in scales or tiny vesicles removed from a given lesion (Fig 26-2.).
Chronic recurrent fungal infections are especially common on the stumps of individuals who
perspire freely and easily. Once the diagnosis has been made, therapy consists of the
application of fungistatic creams and powders for an extended period of time. The newer
antifungal agents, applied once nightly, can be curative. In those patients where topical
antifungal agents are not effective, oral antifungal antibiotics can be helpful and curative.
Griseoful-vin, ketoconazole, or fluconazole given orally for several weeks can be curative in
these resistant patients. It should be noted, however, that superficial fungus infections of the
stump skin may be difficult to eradicate completely because of continued moisture, warmth,
and maceration within the prosthetic socket.
At the present state of knowledge, bacterial and fungal infections are usually short-lived if the
diagnosis is made early and correct therapy is administered. Fortunately, the majority of
patients respond to topical medications.
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.
OTHER SKIN DISORDERS

Over many years numerous chronic dermatoses have been observed, and some have
localized on the stump skin. We have seen patients with acne vulgaris of the face and back
develop acne lesions on the stump. We have seen similar localization in patients with
seborrheic dermatitis, folliculitis, and eczema. Localization on the stump skin following a
generalizing eruption is not unusual. We have seen, and there are recorded instances of
psoriasis (Plate 17.) as well as lichen planus developing on the stump skin, with few lesions
being present elsewhere on the body. Here it is important to diagnose and treat the
generalized cutaneous disorder in order to improve the local process. An accurate diagnosis
is of utmost importance.
Diabetic skin is especially prone to chronic disorders that can be serious and disabling.
Bacterial and fungal infections are common in those amputees where the diabetic metabolic
process is uncontrolled. A high blood sugar content may be reflected as a folliculitis on the
stump skin or even elsewhere on the body of the diabetic. Ulcerations or erosions of the skin
in diabetics must be diagnosed and treated early to prevent serious infection. The painful
deep ulcers and edematous processes can be chronic and disabling. Candidal or yeast
infections are not uncommon in the groin and on the stumps of diabetic amputees following a
course of antibiotics for some other disorder. Diabetic dermopathy can be seen as bullae or
blisters from prosthetic rub against the skin and require several weeks for healing (Plate 18.).
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.
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, pros-
thetists, 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.
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.
27: Management of Pain in the Amputee | O&P Virtual Library
Search
GO
Management of Pain in the Amputee Reproduced with

permission from
Maurice D. Schnell, M.D. Bowker HK,
Michael JW (eds):
Wilton H. Bunch, M.D., Ph.D.
Atlas of Limb
Prosthetics:
The goal of amputation surgery is to remove an often painful, functionless limb and to
rehabilitate the amputee to a painless, functional state. The most common factor precluding Rehabilitation Principles.
successful outcome following lower-limb amputation is residual pain, which occurs in Rosemont, IL, American Academy
approximately 80% of patients at some point following a major extremity amputation. For of Orthopedic Surgeons, edition 2,
the majority of these patients, this pain will gradually resolve. However, a significant number 1992, reprinted 2002.
of amputees will have persistent limb pain that interferes with prosthetic usage.
Postamputation pain can be isolated to the residual limb or can occur as phantom pain. The
physiologic mechanism for intrinsic stump pain and phantom pain is similar. The presence Deficiencies: Surgical, Prosthetic,
of preamputation pain, especially in dysvascular amputees, corresponds with the incidence of and Rehabilitation Principles
phantom pain in the immediate postamputation period but does not correspond to chronic (retitled third edition of Atlas of
phantom pain. Limb Deficiencies), ©American
The treatment of chronic pain following an amputation is determined by the etiology of the Click for more information about
pain. Obvious pathomechanical sources of pain such as degenerative arthritis of the knee in this text.
a transtibial amputation, ischemia in the residual limb in a dysvascular amputee, or a painful
neuroma can be readily treated. Psychiatric factors may amplify amputee pain syndromes, yet Funding for digitization
personality disorders do not absolutely correlate with the incidence of phantom pain of the Atlas of Limb
syndromes. Prosthetics was
provided by the
A large variety of surgical and nonsurgical methods exists for the treatment of postamputation Northern Plains Chapter of the
pain. The survey of phantom pain treatment methods used by Veterans Administration American Academy of Orthotists &
hospitals, medical schools, and pain clinics showed that at least 50 different modalities are Prosthetists
currently utilized for the treatment of amputee pain. Only a few of these treatment methods
were even moderately successful at long-term follow-up. An appropriate treatment regimen
is dependent on a knowledge of the basic mechanisms involved in both central and
peripheral pain.

INTRINSIC CAUSES OF PAIN O&P Virtual Library with a
Pain Mechanisms
Pain is a phenomenon that consists of complex circuits of cellular communication and
integration elicited by stimulation of peripheral tissues such as skin, joints, tendon, ligaments,
and viscera. It is a personal experience, differing somewhat from one individual to another
as influenced by cultural experiences, personal attention, the importance of a specific
situation, and other cognitive activities. Although there is no evidence of control
mechanisms affecting the sensitivity of peripheral nerve receptors, pain is not simply a
transmission of a neural message, but rather a reaction that involves interpretative processes
within the central nervous system.
Several types of peripheral nervous receptors have been identified: mechanoreceptors,

thermoreceptors, and nociceptors, or pain receptors. Mechanoreceptors and
thermoreceptors consist of either free nerve endings or specialized capsulated receptors
(Pacini and Ruffini endings, Merkel spots, and Iggo corpuscles). Impulses from these low-
intensity receptors are carried by large myelinated fibers. The thermoreceptors and
mechanoreceptors are characterized by a low threshold for certain stimuli. For example,
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
appropriate stimulus and a relatively small field of reception. The two subclasses of
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 15°C) or high (above 50°C) 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
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
strongly excited by high-intensity thermal and mechanical stimuli. In contrast, lamina V cells
have a wide range of inputs from skin, subcutaneous tissue, muscle, viscera, and other deep
structures and are quite responsive to noxious stimuli in their respective field. Inhibition of
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
somatosensory tracts. The pyramidal tract, rubrospinal tract, and reticulospinal tract have
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.
Psychological factors play an important role in the total pain experience. Scientific data
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 ß) 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
the Civil War (1871), Silas Weir Mitchell wrote a classic essay on his experience with
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
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.
The causal mechanism of phantom pain remains controversial. Peripheral nerve irritation,
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 (ß-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
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 low-
level 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
peripheral nerve stimulators and dorsal-column stimulators, respectively. Although both of
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
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.
Reflex Sympathetic Dystrophy

Amputations as a result of trauma, particularly partial-hand and foot amputations, may be
followed by severe unremitting pain that is entirely out of proportion to the injury or the
apparent state of the limb. This burning pain, originally called causalgia, and its variants
may be considered together as reflex sympathetic dystrophy.
The cause is thought to be an abnormal prolongation of the normal sympathetic response to

injury. This produces vasospasm, hyperhidrosis, and erythema. The pain impulses to the
cortex are amplified, and this causes intense discomfort.
In the early stages the remaining dorsal portion of the limb is swollen, warm, and
erythematous. There is hyperesthesia, particularly to light touch, and extreme sensitivity to
cold. These symptoms make wrapping and wound care extremely difficult.
After about 3 months, the swelling in the remaining digits becomes fusiform. Palmar nodules
and fasciitis become evident. Fixed contractures are present because of the lack of active
motion.
By 6 to 9 months after the injury, the skin is pale, cool, and dry. The joints are fixed. If pain
is still a predominant feature, it is quite likely that it will be persistent indefinitely. One can
only hope that this stage of the process is prevented by prior treatment.
Radiographs of the distal bones will show patchy osteopenia, particularly in periarticular
areas. There is a loss of bone substance, with up to one third of the inner aspect of the
cortex being resorbed. If a technetium 99m etidronate sodium (ethane-1-hydroxy-l, 1-diphos-
phate [EHOP]) scan is performed, it will be positive before the bone resorption is visible on
plane films.
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 2.5°C rise in skin temperature with this technique. Nerve stimulation should be
strongly considered for those patients whose pain persists after a stellate ganglion block.
Bursitis and Tendinitis

Although uncommon as sources of pain in the amputee, bursitis and tendinitis must be
considered in the differential diagnosis of aggravating limb pain. Localized tenderness, slight
swelling with mild erythema of the overlying skin, increased localized skin temperature, and
occasional soft-tissue crepitation are signs of possible bursitis or tendinitis. Passive stretching
of the suspected involved tendon should increase the pain significantly if tendinitis is present.
Radiographs of the affected limb segment may demonstrate a calcific deposit in some cases
of tendinitis.
Treatment may consist of any combination of several of the following modalities: (1)
elimination of any activity that has produced overstress to the involved tendons or localized
trauma to affected bursae, (2) rest through reduced use of the involved limb, (3) temporary
discontinuance of the prosthesis, (4) possible rigid dressing immobilization for 14 to 21 days,
(5) compression of swollen bursae by elastic wraps, (6) application of heat modalities to
involved structures, (7) injection of bursae or tendon sheaths with local anesthetic agents
combined with steroid preparations, (8) appropriate analgesic drugs, and (9) modification of
the prosthetic socket to alleviate local pressure to the stump.
Pain Not Associated With an Amputation

The prosthesis draws the amputee's attention to the involved limb. Thus any pain in the limb
may be immediately associated in the patient's mind with the amputation and the prosthesis.
This is not always the case. A large number of upper-limb referred-pain syndromes are
entirely independent of the amputation or the prosthesis. These need to be remembered and
eliminated as the cause.
Referred pain from the neck may masquerade as limb pain. This may be due to cervical disk
disease or osteoarthritis and foraminal narrowing. Similarly, lumbar disk disease may produce
referred pain to an amputated lower limb. The various vascular and nerve compression
syndromes in the neck and axilla are occasionally the cause of pain in an amputee. Cardiac
pain may be referred to the limb after an amputation as well as before.
Finally, not all pain has an organic basis. Pain on the basis of a neurotic syndrome or
unresolved anxiety may persist long after the wound is healed and the physician has
assumed that the patient has completed the acceptance of amputation.
EXTRINSIC CAUSES OF PAIN
Lower Limbs
Syme Ankle Disarticulation

Two common problems that arise in the management of the Syme ankle disarticulate are (1)
hamstring pressure when the patient is seated and (2) pain with or without associated skin
breakdown over the anterodistal portion of the stump.
The stumps of some Syme ankle disarticulates cannot tolerate full end bearing in the
prosthesis. In such cases the proximal portion of the socket can be modified similar to a
patellar tendon-bearing (PTB) socket with resultant distribution of partial weight bearing proxi-
mally. With faulty socket design patients may complain of soreness and pressure over the
posterior aspect of the knee. Usually the patient is relatively comfortable in the upright
position but has significant discomfort when sitting with the prosthetic foot resting squarely on
the floor.
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.
Transtibial (Below-Knee) Amputation

Common causes of prosthetic pain in the transtibial amputee are (1) excessive end bearing,
(2) uneven skin pressure, (3) frictional skin loss, (4) loss of total contact, (5) hammocking
phenomenon, and (6) inlet impingement. Evaluating the complaint of pain is simply a
systematic process of ruling out each of these causes and then applying the appropriate
solution for its correction.
Excessive End Bearing.-If end bearing is a source of limb discomfort, commonly specific
physical signs are present on examination of the stump. Often a callus is located over the
distal end of the tibia and/or fibula. Also, there may be palpable bursae over the distal end of
the tibia or fibula as further evidence of end bearing.
When the prosthesis is applied, the stump descends too deeply into the socket. The addition
of an appropriate number of stump socks to raise the stump from the distal portion of the
socket should provide prompt symptomatic relief.
If a physical examination is inconclusive and the possibility of end bearing warrants further
evaluation, other techniques will aid in the diagnosis. The simplest method is to put a small
ball of clay in the bottom of the socket and ask the patient to walk. Clay that is severely
compressed is a crude indicator of excessive load bearing at the distal end of the stump.
A more informative test is the use of a Brand micro-capsular stocking. This system is
composed of cotton fabric with a polyurethane lining into which encapsulated blue dye has
been sprinkled. A stump sock is constructed from the basic material and then placed carefully
over the stump. Next, the prosthesis is applied, and the patient is asked to walk. With
increasing gradients of pressure, the microcapsules of dye are ruptured, and there is a color
change from light yellow to various hues of green to deep blue. The use of this stocking
locates any area of pressure quite precisely, but the amount of pressure is only grossly
quantified.
Other careful tests include radiographs of the stump through the socket, with or without dye
contrast medium injected around the stump; thermography; thermistor studies; and the use of
a transparent check socket. Although radiographs provide information solely in a static
loading condition, they are helpful in determining the adequacy of total contact of the socket.
This is particularly true if a contrast medium is injected between the interface of the stump
and the socket wall.
The use of a clear check socket gives similar information, but under conditions of both static
and dynamic loading. A clear check socket can be made from a plaster positive mold of the
existing socket, and then the degree of end bearing can be analyzed by direct visualization
and probing the stump surface through multiple holes drilled in the socket distally. If evidence
exists of excessive loading of the distal end of the stump, a new cast should be taken of the
stump from which a new transtibial prosthesis is fabricated. This can be preceded by the use
of a second clear check socket to confirm total contact in the new socket.
Positive thermograms will demonstrate an increased skin temperature in the area of end
bearing. Repeat thermograms after appropriate prosthetic adjustment should show a reversal
of the temperature gradient toward normal at the end of the stump. Such evidence
corroborates the resolution of excessive end bearing as a source of stump pain.
The most frequent reason for end bearing is a reduction in stump volume. Although this
problem may be temporarily alleviated by adding more socks, there is a limit to which this
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.
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
against the stump by proper coordination of knee and body action. If a prosthetic foot with
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 re-
establishment 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
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.
Transfemoral (Above-Knee) Amputations

Prosthetic causes of pain in the transfemoral amputee include (1) excessive pressure on the
ischial tuberosity, (2) adductor roll, (3) choking, (4) malalignment, (5) inlet impingement, (6)
excessive end bearing, (7) pressure from a high anterior wall, and (8) a high medial wall. As
in the transtibial amputee, one must systematically eliminate each of these problems as the
cause of the patient's complaint.
Excessive Pressure on the Ischial Tuberosity.-Improper design of the ischial seat may
result in significant discomfort with either standing or walking. Any decrease in stump
volume that allows greater distal displacement of the stump results in increased compression
and shear forces over the ischial tuberosity. The patient often finds that he can obtain
transient relief of his discomfort by sitting or lying down. However, if the ischial seat is too
wide, even sitting may produce ischial symptoms.
Localized tenderness and skin changes ranging from hyperemia to frank skin breakdown are
the hallmark of ischial seat pressure. If the increase in pressure is gradual, the involved skin
will respond by forming a typical callus.
Checkout of the socket fit reveals no obvious problems except firm contact of the ischial
tuberosity against the ischial seat. When the patient is asked to stand with full weight bearing
on the contralateral limb and then to shift the weight gradually onto the prosthetic side, the
degree of compression against an examining finger between the tuberosity and the ischial
seat is obviously high. Further corroboration of ischial seat pressure can be demonstrated
with the use of a microcapsular stocking or thermography.
When the pressure over the tuberosity is marginal, the addition of more stump socks will
elevate the stump slightly and distribute some of the load bearing to the surrounding gluteal
musculature. In the case of a suction socket the prosthetist may apply a liner pad along the
interior of the posterior wall that will tighten the anteroposterior diameter and accomplish the
same purpose. Lowering the ischial seat or increasing its radius may produce effective results
for some patients. If these simpler measures fail, a new total-contact transfemoral suction
socket should be prescribed.
Adductor Roll.-With improper stump wrapping, increased stump volume, or unsatisfactory
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.
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 2½
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
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..
Upper Limbs
Partial-Hand Devices
Strict adherence to the surgical dogma of preserving all possible segments of an injured hand
may result in chronic pain compounded by significant functional problems. For example, digits
afflicted with post-traumatic vasomotor changes secondary to altered sympathetic innervation
can be detrimental to patients because of episodic pain associated with increased cold
sensitivity. Should reflex sympathetic dystrophy or cau-salgia develop, the recovery of hand
usefulness is obstructed, and the difficulty of fitting the patient with an appropriate orthotic or
prosthetic device is definitely magnified. Massive damage to joints and their related tendons
may virtually ensure extensive permanent functional loss and pain since associated vascular
and neurologic recovery of the hand is marginal at best. Unfortunately, insufficient venous and
lymphatic drainage creates chronic swelling of the hand, thus adding another factor that
enhances hand impairment. Worse yet, poor skin coverage and diminished epicritical
sensation further complicate functional retraining of an injured hand with or without a special
device.
To maximize the rehabilitation process of an injured hand, critical decisions regarding the
preservation of those segments of the hand that have a reasonable likelihood of regaining
nonpainful, useful function must be made by the attending surgeon during initial treatment. If
the patient fails to make satisfactory progress during the rehabilitative period, consideration
should be given to secondary reconstructive surgery that would involve a higher functional
amputation. Removal of part or all of a painful, functionless hand with subsequent
replacement by a well-designed prosthesis is welcomed by most patients.
In general, partial-hand prostheses have satisfied neither the cosmetic nor the functional
needs of the hand amputee. Faulty design, poor material properties (weight, thermal
conductivity, surface friction characteristics, strength, durability, etc.), inadequate device
suspension, reduction of sensory feedback, and possible restriction of proximal joint motion
are only a few of the reasons for prosthetic failure.
If, after prosthetic fitting, the patient with a hand amputation complains of discomfort, every
effort should be directed toward evaluation and elimination of all potential pain sources.
Assessment of the adequacy of skin coverage is simple but absolutely essential. A tethered,
noncompliant scar is unyielding to shear forces that produce definite skin tenderness and
discomfort with possible associated skin breakdown. Careful inspection and palpation of the
involved hand provide sufficient information to estimate the probable skin tolerance to
compression and shear stress from a proposed prosthetic device. If it is questionable whether
the skin can tolerate such forces directly, the device should be lined with Plastazote, Pelite,
polyurethrane, or comparable materials that will protect the damaged skin surfaces.
The painful hand with increased cold sensitivity often manifests coolness, cyanosis, edema,
and excessive sweating. These vasomotor and sudomotor disturbances are similar to those of
sympathetic reflex dystrophy. Characteristic signs of Raynaud's phenomenon may be elicited
by exposure of the hand to a cold environment. These amputees should be instructed to
avoid any exposure of the hand to environmental temperatures below 10°C without an
insulated glove. Furthermore, all partial-hand devices used in a cold environment should be
constructed of material with poor thermal conductivity and lined with a synthetic substance
with excellent insulation properties.
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
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.
Transradial (Below-Elbow) Amputation

Three frequent causes of pain in the transradial prosthetic wearer are (1) pressure over the
anterodistal end of the stump, (2) choking of the stump, and (3) inlet impingement.
Amputees with acquired short transradial stumps are vulnerable to high compression and
shear forces across the anterodistal aspect of the stump when lifting heavy loads with the
elbow in a flexed position. Conditions are only made worse by (1) poor total contact of the
socket distally as a result of stump shrinkage, (2) inadequate soft-tissue coverage over the
distal end of the radius and ulna, and (3) osteophyte formation or apposi-tional bone growth
of the forearm bones.
Whatever the cause, the symptoms and signs are similar-localized stump pain, tenderness of
the distal end of the stump, reactive hyperemia of the skin, possible presence of an
underlying bursa, and occasionally a skin ulcer. A lack of total contact may result in edema
and induration of the distal portion of the stump as well.
Careful inspection of the stump localizes the area of increased skin pressure. With the
artificial limb applied, strong resistance during elbow flexion will usually produce discomfort at
the distal end of the stump. Seldom is it necessary to use a microcapsular stocking, socket
radiographs, or thermography to determine the nature of the patient's complaints.
Roentgenograms of the stump are valuable, however, in the detection of offending
osteophytes or excessive appositional bone growth in the juvenile amputee.
Treatment should be directed initially toward healing the skin ulceration and reduction of
stump edema if present. Next, socket relief distally or foaming the end of the socket with
Silastic may eliminate skin pressure. In certain patients, a new total-contact socket is
required.
The juvenile amputee is faced with periodic loss of socket fit as a result of musculoskeletal
growth. With increased circumference and length of the stump, the socket is too small to
accept the entire stump. As a result, increased forces over the distal end of the stump create
painful pressure symptoms that reduce the functional efficiency of the amputee. Recognition
of an improper socket necessitates replacement with a properly fitted one.
Transradial amputees with stump soreness will often increase the number of stump socks to
relieve pressure against the end of the stump. This leads to elevation of the distal portion of
the stump from the end of the socket and obstructs venous and lymphatic outflow from the
stump because of constriction of the proximal portion of the stump. The resultant choking of
the stump is painful and may produce skin changes of the distal end of the stump.
Inspection of the stump reveals an absence of sock markings over the distal portion of the
stump. The lower portion of the stump is swollen and tender. There may be generalized
reactive hyperemia of the skin of the stump. The proximal portion of the stump may have
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.
Transhumeral (Above-Elbow) Amputation

As in the transradial prosthesis wearer, the magnitude of forces applied to the anterodistal
aspect of the transhumeral stump is significantly increased with progressive loading of the
prosthesis. If the stump is quite short, total contact is poor, or soft-tissue coverage of the
stump is less than optimal, the symptoms and physical findings of the involved stump are
identical with high soft-tissue forces over any bony prominence. Careful physical examination
is usually adequate to identify the cause of the problem. If necessary, confirmatory tests with
a microcapsular stocking, thermography, or radiographic studies can be performed. Prosthetic
solutions include relief of the distal portion of the socket, foaming of the distal end of the
socket to regain total contact, or fabrication of a new socket. Stump revision may be required
in the presence of poor skin coverage, bony overgrowth of the humerus, or extreme soft-
tissue redundancy.
In the short transhumeral amputation, the anteroposterior walls of the socket must be
extended medially over a large portion of the shoulder joint to provide rotational stability.
Excessive tightness of the anteroposterior diameter of the medial portion of the inlet will
produce pressure against the skin along the edges of the socket brim. Altering the trim lines,
heating and rolling the brim edges, or increasing the anteroposterior diameter of the inlet will
eliminate the pressure problem.
Children with acquired transhumeral amputations are plagued by troublesome appositional

bone growth of the humerus. The gradual lengthening of the humerus compresses the skin
over the distal end of the bone against the bottom of the socket. Associated pain when
wearing the prosthesis interferes with its optimal use. Soon skin changes appear and may be
accompanied by a swollen bursa over the end of the bone. As discomfort increases, the child
periodically removes the prosthesis or refuses to wear it at all.
Early in the evolution of the problem, removal of an existing socket liner and/or deepening of
the end of the socket will provide temporary help. However, with further bony overgrowth, the
amount of stump change exceeds the improvement obtained with socket adjustments. Now
the treatment of choice is surgical revision of the stump, which includes excision of the bony
overgrowth and removal of any bursa. Since appositional bone growth is unrelated to
epiphyseal growth, epiphy-siodesis is absolutely contraindicated. This condition tends to recur
periodically so that the child is likely to have several surgical procedures until reaching
skeletal maturity when general bone growth ceases. A Silastic bone plug has been
recommended to prevent recurrence of appositional bone growth. However, its use has not
been widespread.
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
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
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 169-
217
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
28: Psychological Adaptation to Amputation | O&P Virtual Library
Search
GO
Psychological Adaptation to Amputation Reproduced with

permission from
John C. Racy, M.D. Bowker HK,
Michael JW (eds):
Atlas of Limb
*Portions of this chapter appeared previously in Racy JC: Psychological aspects Prosthetics:
of amputation, in Moore WS, Malone SJ (eds): Lower Extremity Amputation. Surgical, Prosthetic, and
Philadelphia, WB Saunders, 1989, chap 26. Used with permission. Rehabilitation Principles.
Amputation is a triple threat. It involves loss of function, loss of sensation, and loss of body of Orthopedic Surgeons, edition 2,
image. The wonder of it is that so many adapt so well, thanks to their resilience and the 1992, reprinted 2002.
ingenuity and dedication of those who care for them. The experiences of many people at the Much of the material in this text
University of Arizona College of Medicine and elsewhere have been incorporated into this has been updated and published
chapter. Reference will be made to an amputee self-help group in the Tucson area, and in Atlas of Amputations and Limb
quotes from its members will be inserted into the text to illustrate points under consideration. Deficiencies: Surgical, Prosthetic,
DETERMINANTS OF PSYCHOLOGICAL RESPONSE Limb Deficiencies), ©American
The observed psychological response to amputation is determined by many variables. These Click for more information about
can be conveniently grouped into psychosocial variables and medical variables reflecting the this text.
premorbid health and the medical and surgical management of the amputee.
Psychosocial Variables
Prosthetics was
provided by the
Age Northern Plains Chapter of the
The degree of psychological difficulty associated with amputation generally increases with Prosthetists
age, all other considerations being equal. Infants born with a congenially missing limb
adapt adequately as they learn to make compensatory use of their remaining faculties.
Children adapt well to the loss of function and manipulate prostheses and other limbs with
great agility. They are particularly sensitive to peer acceptance and rejection. Amputation in
the preadolescent or adolescent age group is a great threat to emerging sexual identity. For
example, a 13-year-old member of the Tucson self-help group interviewed for this report You can help expand the
reacted to the news that a leg amputation was necessary to cure her osteogenic sarcoma
with the statement, "No boy is going to look at me."
Among young adults, the response to limb loss depends on its causes and the degree of
disability and disfigurement. They do enjoy the advantages of an established identity, physical
resilience, and social confidence. Hence, they tend to adapt well.
Among the elderly, ill health, social isolation (especially after the death of a spouse), financial
stringencies, and occupational limitations may all conspire to complicate adjustment to the
limb loss. There is some controversy in the literature over the correlation of age and long-
term emotional consequences of amputation. Several early studies suggested that elderly
amputees were at greater risk for psychiatric disturbances such as depression. More recent
studies find just the opposite. In either case, the greatest challenges for the young
amputee are in terms of identity, sexuality, and social acceptance, and for the elderly, in
terms of livelihood, functional capacity, and interpersonal deal-ings.
Personality Style
Individuals who are narcissistically invested in their physical appearance and power tend to
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.
Economic and Vocational Variables

It stands to reason that individuals who earn their living from motor skills that are lost with the
amputation are especially vulnerable to adverse reactions. Others who have a wide range of
skills or whose main line of work is not particularly dependent on the function of the lost limb
may experience less emotional difficulty. Of course, no amputee is completely insulated from
the emotional consequences of discriminatory practices, subtle or otherwise, in the workplace,
the prohibition of which by federal law notwithstanding. Unemployment is associated with a
greater degree of psychological stress and may be a predictor of phantom pain.
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.
Medical Factors
Health
Healthy, young individuals who lose a limb traumat-ically have many advantages over older,
frail individuals. Among the elderly-who, in fact, constitute the vast majority of amputees-the
surgery usually comes after a prolonged period of treatment for peripheral vascular disease,
often combined with at least two other medical disorders. These disorders are likely to set
a limit on functional restoration and the return to an active life-style.
Mental health problems can easily enter into the picture through a complicated series of
psychosomatic and somatopsychic responses to the loss. Shukla and coworkers studied 72
amputees prospectively in India and found that nearly two thirds manifested postoperative
psychiatric symptoms, the most common of which was depression, followed by anxiety, crying
spells, insomnia, loss of appetite, and suicidal ideation. In this regard, depression-with its
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, self-
consciousness, low intelligence, senility, anger, resentment of the need to rely
on others, and secondary gain.
Reason for the Amputation

Much of the earlier work on amputation in this century centered on wartime casualties. The
current situation is quite different in that the amputation affects a much older age group and
follows either trauma or chronic illness rather than combat. A wartime situation in which the
injury to the limb might lead to evacuation, honorable discharge from the service, and
rehabilitation to civilian life is not often seen today. Adults suffering a traumatic or
accidental limb loss tend to react with varying forms of denial and bravado. Those who
undergo an elective amputation for the cure of a malignancy benefit from the availability of
time for preparation and exploration of alternatives. The reaction is usually one of realistic
acceptance and cooperation with the treatment team. Such individuals seem to make an
excellent adjustment, assuming of course that the malignancy has been cured.
For the elderly, surgery usually occurs after a long period of suffering resulting from diabetes
and peripheral vascular disease. Most accept the surgery with relief since it often signals the
end of suffering and the return to improved functioning. Some react indifferently or negatively
and view the surgery as proof of failure. Amputation necessitated by the negligent or
malicious behavior of others is likely to produce persistent feelings of resentment and self-
doubt. Litigation can easily complicate the process of rehabilitation and recovery.
Preparation for the Amputation

There is little doubt that those individuals who have had adequate warning and preparation
fare better in the immediate postsurgical period, whereas those who do not receive such
preparation tend to react negatively or with massive denial. It is less clear whether these
differences persist, given that adaptation is governed ultimately by many other variables
preceding and following the amputation.
In general, the greater the loss, the greater the difficulty in adjustment. There are, however,
instances of massive psychological reaction to small physical losses- for example, the loss of
a toe or a thumb -and of minimal reaction to severe loss of several limbs. It is not clear
whether lower-limb loss is harder to accept than upper-limb loss, as had been suggested.
Above-elbow (transhumeral) amputation brings with it great anxiety and frustration, and
bilateral transhumeral amputation is perhaps the most difficult situation of all. Contrarily,
amputation of one leg below the knee allows relatively good adjustment, with restoration of
both function and body image.
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.
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.
The Team Approach

Because adaptation to amputation is so multifaceted and because it is an evolving process
requiring different kinds of attention at each stage, the team approach has emerged as the
standard approach to rehabilitation.
The range of skills and points of view represented in a team increases the probability that all
aspects of rehabilitation will be addressed and none overlooked. The team may include
members of the family and successfully treated amputees. Amputee self-help groups are
further extensions of this approach.
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
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."
Immediate Postoperative Stage

The period between the surgery and the start of rehabilitation may last a matter of hours or
days, depending, among other things, on the reason for the amputation, the extent and
condition of the residual limb, and the kind of rehabilitation thought to be feasible.
Psychological reactions noted in this phase are concerns about safety, fear of complications
and pain, and in some instances, loss of alertness and orientation. In general, those who
sustain the amputation after a period of preparation react more positively than do those who
sustain it after trauma or accident. Most individuals are, to a certain degree, "numb," partly as
a result of the anesthesia and partly as a way of handling the trauma of loss. For those who
have suffered considerable pain before the surgery, the amputation may bring much-needed
relief. This was true for four of the eight members of the self-help group interviewed for this
report.
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
vocational adjustment. Some individuals in this phase experience and express various
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
limited. Parkes describes the response as similar to that seen in widows. He lists four
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 in-
hospital 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
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
talk." Some resent any pressure put upon them to resume normal functioning. Others may
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.
SPECIAL AREAS OF CONCERN
Phantom Limb Sensations

The feeling that the amputated limb is present and moving is so common as to be regarded
as a universal occurrence after surgery. It tends to abate rapidly, however, so only a few
individuals continue to perceive their limbs as still present and active a year after surgery.
Many, however, continue to have occasional experiences of itching or locomotion, sometimes
after residual-limb stimulation. Phantom limb experience has not been noted in those who are
born congenially missing a limb and in those who sustain the limb loss at a very early age.
In general, phantom limb sensations present no particular problem. The members of the self-
help group had all experienced them at one time or another. Some of them still do, 10 or 15
years after amputation, in the form of an intermittent itch that, curiously, is relieved by
scratching the prosthesis.
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
versa. The typical psychological profile of the amputee suffering phantom pain does not
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
missing limb larger than the opposite limb or with increased markings. Similarly, dreams
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
adjustment. Related to the issue of revised body image is concern with social appearances
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
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
the prime of life. Concern arises from the following sources: (1) fear that the body would
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
preparation is highly desirable. Such preparation must include a clear explanation of the
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
with limb-sparing treatments. In connection with this, it has been suggested that the term
"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
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."
Early Prosthetic Fitting and Mobilization

There is little doubt that the earlier the prosthesis is applied, the better are the results in
terms of functional capacity and psychological adaptation. As Bradway and associates
wrote, "Early prosthetic fitting and rehabilitation enable the patient to incorporate all of his
physical and emotional efforts into recovery from the earliest possible moment, rather than
allowing the patient to focus only on disabilities and pain." Introducing the patient to a
successfully rehabilitated amputee may be of great assistance in this effort. Of paramount
importance to patients, and perhaps a predictor of prosthetic use, is the comfort and
usefulness of the device. The level of the amputation also seems to be a significant
determinant in the ultimate use of appliances. Sturup and colleagues found a higher rate of
prosthetic use among below-elbow (transradial) amputees than among transhumeral
amputees and a clear tendency toward nonuse among younger amputees and among those
whose amputation was of the nondominant arm. Durance and O'Shea report that amputees
are least likely to use prostheses during leisure activities.
The Team Approach

A team approach is optimal in amputee rehabilitation and should include the surgeon, surgical
nurses, pros-thetist, physical therapist, occupational therapist, social worker, vocational
counselor, and if indicated, a psychiatrist or psychologist. With this variety, each member of
the team is in a position to address one aspect or another of the patients needs. As these
needs evolve, flexibility and adaptation to new realities are required not only of amputees but
also of those who help them. To the extent that it is possible to do so, the involvement of
members of the family at all of these stages can be of tremendous help. Perhaps the most
valuable contribution of the team approach is the facilitation of a more rapid return to familiar
surroundings and to independence. The prospective study by Ham et al. of 223 British
amputees found that team management reduced hospital stays significantly and increased the
long-term effectiveness of rehabilitation. No less important, as Dise-Lewis points out, is the
role of the team in validating the amputee's right to be in control of his own rehabilitation and
in providing a safe haven for emotional expression.
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
capacity that can now be enjoyed. This is an issue to be approached with an open mind.
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
do not seek paid employment." Several workers have attempted to find predictors of
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
for rehabilitation outcome. But as Mendelson and colleagues point out, any psychological
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
a particular moral or behavioral value system." Whether a trained person leads the group
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
been noted as manifestations of body image disturbances. With the possible exception of
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
psychoactive medicine appear to be of efficacy in treating phantom pain. Psychological
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 self-
help 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
and phantom limb pain: Cross-legged correlation data from six-month pain logs. J
Psychosom Res 1990; 34:71-77.
2. Atkins D: Personal communication, 1984.
3. Bowker JH: Amputation rehabilitation: Critical factors in outcome. J Ark Med Soc 1981;
78:181.
4. Boyle M, Tebbi CK, Mindell ER, et al: Adolescent adjustment to amputation. Med
Pediatr Oncol 1982; 10:301-312.
5. Bradway JK, Malone JM, Racy J, et al: Psychological adaptation to amputation: An
overview. Orthot Prosthet 1984; 38:46.
6. Caine D: Psychological considerations affecting rehabilitation after amputation. Med J
Aust 1973; 2:818.
7. Datta D, Psychology of limb loss, letter. Br Med J 1989; 299:1526-1527.
8. Dise-Lewis JE: Psychological adaptation to limb loss, in Atkins DJ, Meier RH III (eds):
Comprehensive Management of the Upper Limb Amputee. New York, Springer-Verlag
NY Inc, 1989, pp 165-172.
9. Durance JP, O'Shea BJ: Upper limb amputees: A clinical profile. Int Disabil Stud 1988;
10:68-72.
10. English AWG: Psychology of limb loss. Br Med J 1989; 299:1287.
11. Ewalt JR, Randall GC, Morris H: The phantom limb. Psychosom Med 1947; 9:118.
12. Frank RG, Kashani JH, Kaslani SR, et al: Psychological response to amputation as a
function of age and time since amputation. Br J Psychiatry 1984; 144:493-497.
13. Freierson RL, Lippmann SB: Psychiatric consultation for acute amputees.
Psychosomatics 1987; 28:183-189.
14. Friedmann LW: The Psychological Rehabilitation of the Amputee. Springfield, Ill,
15. Gingras G, Mongreau M, Susset V, et al: Psychosocial and rehabilitative aspects of
upper extremity amputees. Can Med Assoc J 1956; 75:819.
16. Grunert BK, Smith CJ, Devine CA, et al: Early psychological aspects of severe hand
injury. J Hand Surg [Br] 1988; 13:177-180.
17. Ham R, Regan JM, Roberts VC: Evaluation of introducing the team approach to the
care of the amputee: The Dulwich Study. Prosthet Orthot Int 1987; 11:25-30.
18. Hamilton A: Rehabilitation of the leg amputee in the community. Practitioner 1981;
225:1487.
19. Hansen ST: The type-Ill C tibial fracture-salvage or amputation (editorial). J Bone Joint
Surg [Am] 1987; 69:799-800.
20. Hovgaard C, Dalsgaard S, Gebuhr P: The social and economic consequences of
failure to replant amputated thumbs. J Hand Surg [Br] 1989; 14:307-308.
21. Hughes J, White WL: Emotional reactions and adjustments of amputees to their injury.
US Naval Med Bull, suppl, March 1946, p 157.
22. Kerstein MD: Group rehabilitation for the vascular disease amputee. J Am Geriatr Soc
1980; 28:40.
23. Kessler HH: Psychological preparation of the amputee. Ind Med Surg 1951; 20:107.
24. Kolb L, Brodie K: Modern Clinical Psychiatry, ed 10. Philadelphia, WB Saunders Co,
1984, pp 574-576.
25. Kohl S: Personal communication, 1984.
26. Kohl S: The process of psychological adaptation to traumatic limb loss, in Krueger DW
(ed): Emotional Rehabilitation of Physical Trauma and Disability. New York, SP Medical
& Scientific Books, 1984, pp 113-148.
27. Kullman L: Evaluation of disability and of results of rehabilitation with use of the Barthel
index and Russek's classification. Int Disabil Stud 1987; 9:68-70.
28. Lipp M, Malone SJ: Group rehabilitation of vascular surgery patients. Arch Phys Med
Rehabil 1976; 57:180.
29. MacBride A, Rogers J, Whylie B, et al: Psychosocial factors in the rehabilitation of
elderly amputees. Psychoso-matics 1980; 12:258.
30. Malone JM, Moore WS, Goldstone J, et al: Therapeutic and economic impact of a
modern amputation program. Ann Surg 1979; 189:798.
31. Marks L: Lower limb amputees: Advantages of the team approach. Practitioner 1987;
231:1321-1324.
32. May CH, McPhee MC, Pritchard DJ: An amputee visitor program as an adjunct to
rehabilitation of the lower limb amputee. Mayo Clin Proc 1979; 54:774.
33. Mendelson RL, Burech JG, Polack EP, et al: The psychological impact of traumatic
amputations-A team approach: Physician, therapist and psychologist. Hand Clin 1986;
2:577-583.
34. Noble D, Price D, Gilder R Jr: Psychiatric disturbances following amputation. Am J
Psychiatry 1954; 110:609.
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.
29: Critical Choices: The Art of Prosthesis Prescription | O&P Virtual Library
Search
GO
Critical Choices: The Art of Prosthesis Prescription Reproduced with

permission from
John H. Bowker, M.D. Bowker HK,
Michael JW (eds):
Atlas of Limb
GENERAL FACTORS Prosthetics:
The prescription of a prosthesis no longer involves simply matching a particular level of Rehabilitation Principles.
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 1992, reprinted 2002.
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, Much of the material in this text
including heat-mold-able plastics, lightweight metals, and carbon fiber-reinforced plastics. has been updated and published
Before discussing factors involved in prescription, it is useful to review the reasons for not Deficiencies: Surgical, Prosthetic,
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 Limb Deficiencies), ©American
useless to prescribe one. The mental status of the patient must be such that he can learn its Academy or Orthopedic Surgeons.
use and limitations. At the highest levels of amputation in both the upper and lower limbs, Click for more information about
useful function decreases directly in relation to progressive loss of limb length. In addition, in this text.
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
Prosthetics was
one examines all the parameters of a given patients life. First and foremost, the prosthesis provided by the
should meet the needs and desires of the patient, both vocationally and avocationally, insofar Northern Plains Chapter of the
as possible. Prosthetic services should be readily available, not only for the provision of the American Academy of Orthotists &
initial prosthesis but also for its maintenance, repair, and replacement at suitable intervals. Prosthetists
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 You can help expand the
play an important role. In areas of excessive humidity, metal parts will tend to corrode and O&P Virtual Library with a
wood to rot. In areas of extreme aridity such as the desert regions of the world, fine sand tax-deductible contribution.
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
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.
SPECIFIC FACTORS RELATED TO LOWER-LIMB

PROSTHETIC PRESCRIPTION
The basic reasons for fitting a lower-limb prosthesis are to enhance ambulation by decreasing
the excess energy requirements of crutch walking and improving the patients balance with
restoration of bilateral proprioceptive feedback through the residual limb-prosthesis interface.
Very importantly, the hands are freed for activities other than handling a walker or crutches.
In short, the goal is to restore as much functional capacity to the lower-limb amputee as
possible. This will vary widely from returning him to all activities that he had previously
engaged in, including active sports, to the minimum acceptable rehabilitation goal of assisted
transfer activities that aid the care-giver as much or more than the amputee. The other
benefit to any amputee is the cosmetic restoration provided by the prosthesis.
There are also cogent reasons for not fitting lower-limb prostheses. The fitting of bilateral
dysvascular transfemoral amputees with articulated prostheses, for example, is rarely
successful. These devices, in addition to being expensive and extremely difficult to walk with,
are quite uncomfortable to sit in for prolonged periods. These patients find transfers much
easier without the impediment of these almost nonfunctional prostheses. If the patient
requests some form of cosmetic restoration, however, lightweight cosmetic prostheses can be
provided, or a pair of panty hose can be filled with properly sculpted foam to give a pleasing
appearance with slacks or skirt and shoes.
If these patients insist on some form of household ambulation and can demonstrate sufficient
cardiac reserve clinically, they may be given a trial on stubbies. These are basic
nonarticulated transfemoral sockets with rocker bottoms and appropriate suspension (Fig 29-
1.). Young traumatic bilateral transfemoral amputees, on the other hand, will almost always
demand a trial of ambulation but should also start with stubbies. After a variable period of
training, during which they are able to assess the energy costs of such walking and the team
evaluates their motivation, they may be given articulated limbs. Eventually, however, most
abandon these prostheses for a wheelchair because of its greater efficiency in speed and
energy consumption. Even the unilateral dysvascular transfemoral amputee may not be able
to muster the cardiopulmonary reserve to manage mere household ambulation and will prefer
a wheelchair.
At the hip disarticulation or transpelvic levels, the amputee, typically a younger trauma or
tumor patient, often becomes a long-term community ambulator. Some, however, may find
that the decreased speed of prosthetic walking is the overriding factor in rejecting prosthesis
usage for most occasions. If these high-level amputees require two external aids such as
canes for prosthesis use, there is little, if any, functional advantage over crutch walking
without a prosthesis.
Patients should not be rejected for fitting of unilateral or bilateral lower-limb prostheses solely
on the basis of age. Many very elderly patients can be successfully fitted at the transtibial or
Syme ankle disarticulation levels provided that they are physiologically sound and have
sufficient mental capacity to comprehend the subtleties of sock adjustment for changes in
residual-limb volume (Fig 29-2.). In borderline cases, lower-limb transtibial amputees should
be fitted with inexpensive preparatory prostheses to realistically assess their potential for
ambulation.
Delaying prosthetic fitting and training of the unilateral dysvascular amputee in order to
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.
SPECIFIC FACTORS RELATED TO UPPER-LIMB

PROSTHETIC PRESCRIPTION
The key to successful fitting of the upper-limb amputee is largely based on the amputees
motivation. It should also be remembered that prosthetic fitting is entirely optional at the
discretion of the amputee, although most bilateral upper-limb amputees find that prostheses
enhance their function. The motivation of the unilateral amputee for prosthetic fitting is usually
highest immediately after amputation, before one-handedness develops. In fact, successful
fitting of the unilateral upper-limb amputee is unusual after the amputee has become fully
functional with one hand.
It is very useful, therefore, to fit an immediate postoperative prosthesis (IPOP) whenever

possible to provide a prehensile tool to assist the intact hand and prevent the development of
complete one-handedness (Fig 29-3.). Behaviorists should be enlisted in an early stage to
assist the amputee in starting to work through the grieving process.
In approaching the upper-limb amputee, it is important to note that there are significant
differences in the impact of hand vs. foot loss. Awareness and use of the hand for grasping
occur much earlier in infancy than the use of the lower limb for walking. The hand is of
greater significance than the foot, both physically and psychologically. It is also important to
realize that function and cosmesis of the upper limb are much less completely replaced by a
prosthesis than are foot function and cosmesis by a lower-limb prosthesis. Because of these
factors, prosthetic services can best be provided by a specific upper-limb prosthetic team.
The team should be both interdisciplinary and interactive, in other words, operating in close
conjunction rather than independently. Although the surgeon cannot be expected to carry out
the activities of other team members, the amputee expects the surgeon to be fairly
knowledgeable in all areas of prosthetic rehabilitation so that he can effectively coordinate the
limb-fitting program by synthesizing the findings and recommendations of the team.
The first step in prescription is eliciting the amputee's expectations while realizing that every
upper-limb amputee feels that he should receive a prosthesis with a hand and elbow that look
real, functions like the hand and elbow that were lost, and is low in cost and easily
maintained. It is therefore necessary to give a fairly detailed explanation of what is realistically
available. This discussion should include the basic differences between body-powered and
myoelectric limbs, as well as the limits of prosthesis function vs. that of the intact upper limb.
The complexity of various prostheses must be explained, and the tolerance of the individual
amputee for these should be ascertained. Despite the obvious attractions of myoelectric
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.
30: Special Considerations- Rehabilitation Without Prostheses: Functional Skills Training | O&P Virtual Library
Search
GO
Special Considerations- Rehabilitation Without Reproduced with

Prostheses: Functional Skills Training permission from
Bowker HK,
Michael JW (eds):
Joan E. Edelstein, M.A., P.T. Atlas of Limb
Prosthetics:
Prosthetic technology does not serve all the needs of every person with amputation. Even Surgical, Prosthetic, and
those who wear prostheses perform some activities such as bathing and donning Rehabilitation Principles.
undergarments without the device. Some individuals, particularly those with very proximal or
very distal amputations, may choose to forego prostheses altogether. Although a trial fitting 1992, reprinted 2002.
may demonstrate some functional or cosmetic value of a prosthesis, the patient, family, and
clinicians may decide not to proceed with definitive fitting. Other clients, particularly those with Much of the material in this text
multiple disorders, cannot cope with the physical demands of prostheses. A few individuals has been updated and published
do not wear prostheses simply because they are unaware of current componentry and in Atlas of Amputations and Limb
funding sources.
The nonuser challenges scientists to improve the prosthetic armamentarium so that future
devices can enable the wearer to obtain greater function at less physiologic and financial Academy or Orthopedic Surgeons.
cost. Nevertheless, the clinical responsibility is to guide each patient to achieve the highest Click for more information about
degree of personal, vocational, and recreational independence. The intent of this chapter, this text.
therefore, is to delineate means to accomplish representative activities. Physicians and
prosthetists should be familiar with the function that can be achieved by people with particular
amputations who do not wear prostheses. Therapists can incorporate the suggestions in this
discussion when training children and adults to enhance their quality of life, even if a Prosthetics was
prosthesis is not used. provided by the
SKILLS FOR PATIENTS WITH UPPER-LIMB AMPUTATIONS Prosthetists
Clothing Selection and Dressing
Unilateral Amputation
Many garments and modifications suitable for patients with hemiplegia also serve the needs O&P Virtual Library with a
of individuals with unilateral amputation. Adaptations should be as inconspicuous as tax-deductible contribution.
possible, with accessories such as loops and pressure-sensitive tape the same color as the
garment. Loosely fitting clothing is more convenient than snug apparel. Larger buttons are
easier to manipulate with one hand than are small ones ; alternatively, pressure-sensitive
tape can be sewn under buttons to preserve the appearance of a buttoned front yet facilitate
dressing. Snaps and magnetic closure are even less cumbersome than buttons. Slippery
fabric is more manageable than knitwear. Front rather than back or side openings simplify
dressing. Step-in skirts and dresses are easier to don than those that must be pulled on
overhead. Slip-on shoes are recommended, although styles with pressure-sensitive flaps are
readily available. Some individuals replace regular laces with elastic ones. Many people,
however, have no difficulty in tying shoe laces with one hand; lacing without crossing the ties
aids tightening the laces because the end of the lace can be readily fashioned into a slip
knot.
A button hook and a zipper pull may be handy. A dressing stick held in the antecubital
fossa enables the user to don and remove coats and shirts rapidly. The stick has a large
hook at one end.
Donning slacks is easiest if they are placed on a bed near a wall. The client inserts one leg
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 the shirt with a tie clasp. A pretied, clip-on necktie is another option. To don a glove, rub
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
garment. An alternative for donning both underpants and outer pants is placing them on
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
continues to the back of the garment. With a reacher, a stick with a hook at one end, the
client can lower and raise the pants. Some girls and women find that underpants modified
with a split crotch facilitate toilet activity. Undergarments designed for incontinence are
another option to augment security.
Grooming and Hygiene
Although little difficulty should be encountered, some people like the convenience of scrub
and denture brushes, nail file, and clipper each equipped with suction cups. One can also
stabilize a nail file or emery board between the thighs. Shaving is speeded by filling the
cheeks with air to make the skin taut.
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 one-
self.
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
placed over the heel; the patient then rocks over the foot. Others drape paper over the rim
of the toilet and straddle the bowl to wipe themselves. A bidet or special toilet seat
equipped with a water spigot and warm airflow is suitable for the home.
Kuhn described a vaginal tampon applicator for women with bilateral amputation. Other
hygienic aids can be constructed easily.
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.
Dining
A commercial fork clip secures the utensil to the plate so that the sound hand can cut. A
snap-on plate guard is useful for the beginner and serves as a stable area against which one
can push food. The rocker knife facilitates one-handed cutting; one model has prongs so
that the user can spear food morsels. Alternatively, the diet can omit meats and other
foods that one would have to cut. Techniques for buttering bread and opening a milk carton
are easy to learn. Chopsticks are another mode of one-handed dining.
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
fork. If the amputation limbs are long enough, the patient does not need any device to hold
eating utensils; he or she merely stabilizes the fork or spoon with both limbs.
Communication
The person with amputation of the right hand will find that writing with the left hand is easier
with a table rather than a right-armed writing desk. The client should slant the paper in the
opposite direction from that used by right-handers to avoid twisting the left arm into a
cramped posture. One-handed touch-typing methods devised for individuals with cerebral
palsy can be used by the person with unilateral amputation. Paper insertion is aided if the
typewriter has a lever that positions the paper on the platen automatically. A self-correcting
feature helps the one-handed typist. Special typewriters for one-handers are available, as
are computer keyboards designed for unimanual use. For telephone dialing, the patient can
place the receiver on the desk or use a commercial holder that eliminates the need to
stabilize the receiver against the shoulder with one's head while writing a message.
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
use both limbs to stabilize a pencil, pen, or crayon for writing and drawing. The beginner
will find that a felt-tipped pen makes writing easier.
Homemaking and Other Vocations
A full range of cooking can be achieved by the one-handed person. An apron with a semirigid
plastic clip rather than fabric ties can be slipped onto the waist with one hand. A board with
stainless steel holding pins secures potatoes and other firm vegetables so that one can peel
with the sound hand. One-handed jar openers, beaters, mashers, and choppers are readily
available. Lightweight bowls and pans can be lifted single-handed. A mixing bowl can be
stabilized by placing it on a rubber mat or setting it into a bowl holder or into a drawer that
is closed snugly against the bowl. Eggs can be broken one-handed, or the novice can use
an egg separator.
Some chores such as folding laundry are aided by using the teeth as a holder. Other activities
such as those involved in child care can be managed efficiently by using one hand while
securing the infant against one's torso with the amputated limb or relying on the crib or other
flat surface for stability.
Sewing begins with threading the needle, which can be secured by slipping it into one's shirt
sleeve, skirt, or trouser leg, or one can use an automatic needle threader. Left-handed
scissors are sold in most needle-craft shops. Embroidery and extensive sewing are less
arduous if one uses an embroidery hoop on a floor stand, which frees the hand to sew. One-
handed knitting is expedited by a knitting holder clamped to a table.
The amputation limb makes an effective stabilizer in many carpentry and office tasks. The
technique of setting nails with one hand relies on the force one can obtain from the hammer
head against which the nail is held. Farm equipment and work site modifications enable
the client with unilateral amputation to accomplish most tasks efficiently. Because farming
and many other vocational and avocational pursuits involve operating a vehicle, the use of a
spinner knob on the steering wheel should prove helpful.
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.
Recreation: Games and Sports
One can shuffle cards one-handed or use a bowl or hat to hold them; commercial playing
card shufflers are inexpensive alternatives. Simple devices aid the golfer, gardener,
carpenter, and fishing enthusiast. For example, a one-hand fishing vest holds the rod so
that the user can cast and retrieve. An alternative is a broad waist belt fitted with a pocket to
hold the pole. The camera tripod can be modified to support a bow for the archer who has
unilateral amputation. Cameras designed for one-handed operation feature a pistol grip, a
trigger to snap the shutter, and an automatic focus mechanism. The billiards player can use a
mobile bridge to support the cue stick; mounted on two wheels, the bridge has a hole for the
stick. Wrist disarticulation does not preclude a career as a major league baseball pitcher.
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.
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.
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.
SKILLS FOR PATIENTS WITH LOWER-LIMB AMPUTATIONS

The functional problems that attend lower-limb amputation differ from those associated with
loss of the upper limb. The foregoing section indicates that the patient with unilateral upper-
limb amputation who does not wear a prosthesis can accomplish daily and vocational
activities rather easily, often without using assistive devices; basic skills are, however, much
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.
Dressing and Clothing Selection
The individual who intends to ambulate with a pair of crutches should select a low-heeled
shoe for the sound foot. The shoe should also have a laced or strap fastening high on the
dorsum of the foot to prevent the shoe from slipping off the foot when the patient swings the
leg while walking.
Bathing
Unilateral and Bilateral Amputation

A bath chair with a plastic seat and rubber-tipped legs contributes to safety in the shower or
bath. Some models of chair have an extension that fits over the edges of the tub to aid
transfer. Strategically placed wall-mounted bars increase safety during transfers. A survey of
500 patients indicated that 80% sat on the shower floor to bathe; those who stood or used a
stool, predominantly those with bilateral amputations, relied on grab bars to assist balance.
Locomotion
The patient who does not wear a prosthesis may be able to manage with a pair of axillary or
forearm crutches. Some individuals in good physical condition, with particular regard to the
upper limbs, heart, and lungs, walk smoothly and efficiently for long distances with crutches.
Young adults with hip disarticulation or transpelvic amputations are likely to opt for crutches
rather than wear a relatively cumbersome prosthesis. For those who rely on a wheelchair,
crutch walking may facilitate maneuvering in small or crowded rooms. Occasional use of
crutches counteracts the negative consequences of prolonged sitting, such as the formation
of contractures and pressure sores.
Crutches must be the proper length. The hand piece should be set at a point that permits the
user's elbow to be slightly flexed. A rubber hand cover reduces the risk of the patients hand
slipping, especially if the hand is wet with perspiration. Alternatively, some individuals prefer
to wear gloves to increase control of the crutches. The top of the axillary crutch should be
two finger widths from the axilla to avoid compression of the superficially located radial nerve.
A rubber cover increases the friction of the axillary piece, which should be kept next to the
chest. For both styles of crutch, the tip should be a large suction one to increase traction on
the floor.
Good posture requires that the crutches be kept parallel to the trunk to minimize pressure on
the chest. The body should progress forward in a continuous manner. The patient should
move the amputation limb in the opposite direction from the sound leg rather than maintaining
the residuum flexed in order to create a rhythmic, swinging gait.
Walking with crutches without a prosthesis is stressful and associated with markedly elevated
heart rates for those with amputations, whether for vascular disease or trauma. Waters and
colleagues found that heart rates were elevated to an average of 130 beats per minute
among crutch users, comparable to the stress that jogging imposes on nondisabled persons.
Consequently, for most individuals, crutches should be considered only for traveling short
distances.
Forearm crutches are safer on stairs and uneven ground than are axillary crutches. Among
subjects with above-knee (transfemoral) amputation, the use of forearm crutches resulted in a
freely selected speed that was 15% to 40% slower than that chosen by nondisabled persons;
energy cost per unit distance ranged from 48% to 70% greater. When the same subjects were
tested with their prostheses, walking speed was 12% to 33% slower than control subjects, at
a metabolic cost 30% to 40% greater than normal.
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
energy on stair ascent with axillary crutches than did nondisabled control subjects. Ten
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
prosthesis, they could climb step over step. Young adults with transtibial amputation were
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.
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
pastimes.
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
crutches. Swimming provides superb recreation as well as good exercise. Agile individuals
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.
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 re-
entry, 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.
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,
19. Ganguli S: Analysis and evaluation of the functional status of lower extremity amputee-
appliance 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,
30. Kessler HH: Three cases of severe congenital limb deficiencies: Twenty-year follow-
up. 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.
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
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.
50. Youll WJ: Toilet aid for people with lower limb disabilities. Techn Aid Disabled J 1983,
pp 13-15.
31: Introduction to the Child Amputee | O&P Virtual Library
Search
GO
Introduction to the Child Amputee Reproduced with

permission from
John R. Fisk, M.D. Bowker HK,
Michael JW (eds):
This Atlas is about prosthetics, but the needs of the limb-deficient child are not merely those Atlas of Limb
Prosthetics:
of replacement parts. Even in the discussion of surgical principles, there is a different set of
rules to follow when working with children. The disabled child missing all or part of one or Rehabilitation Principles.
more limbs is a growing, developing, and learning individual. Equally important, the child has Rosemont, IL, American Academy
parents and siblings who are growing and learning along with them. Thus, when we work with of Orthopedic Surgeons, edition 2,
the limb-deficient child, we have many different considerations beyond those involved with 1992, reprinted 2002.
treating adults. The chapters that follow address many of these unique concerns.
The child is not just a small adult. In addition to the obvious differences brought about by
growth, children react differently to disabilities than do adults. There are two major categories Deficiencies: Surgical, Prosthetic,
of pediatric patients with limb deficiencies. Those who were born with them, i.e., congenital and Rehabilitation Principles
deficiencies, and those who acquired them after birth, i.e., amputations. In the first instance, (retitled third edition of Atlas of
the child has no sense of loss and nothing new to get adjusted to. Anything of a prosthetic Limb Deficiencies), ©American
nature is an aid, not a replacement, and if it is not truly an aid, the child will reject it. Those Academy or Orthopedic Surgeons.
who lose a limb due to trauma or disease, unless their amputation occurred when they were Click for more information about
this text.
very young, will have a profound sense of loss and undergo a period of readjustment. How
well they manage this change greatly affects their acceptance of replacement prosthetic
limbs. Funding for digitization
The motivations of the two groups are different. In the first instance, congenitally limb- Prosthetics was
deficient children will try to do whatever other kids do. We find that their only limitations are provided by the
those placed upon them by adults. Left to their own devices, they are very adaptable. Northern Plains Chapter of the
Acquired amputees, on the other hand, want to be as they were prior to the amputation. They American Academy of Orthotists &
Prosthetists
will mourn the loss of their limb; they will be angry and resentful. Their motivation will be
greatly influenced by their ability to resolve this inner turmoil.
The two groups of children have parents and relatives involved in their care. Whether of
congenital or acquired etiology, their child's limb deficiency is a great source of guilt for them.
They will proceed through the universal grief response. We are greatly indebted to Kubler-
Ross for her work in helping to clarify the stages of the grief process. Initially there will be You can help expand the
shock, and then denial and anger. There will be a great sense of disappointment because of O&P Virtual Library with a
lost dreams and expectations not able to be met by their disabled child. With resolution and
acceptance, new, more realistic expectations will be set so that in the end, if all goes well,
the child will receive the support and nurturing that are doubly necessary to assist growth
with the disability. Health care professionals involved with a family working through these
stages must learn to recognize the changes as they occur and be prepared to alter their
approach accordingly.
Rev. Harold Wilke, born completely without arms and well known for his work with the
disabled, once said that the most important action that his parents took while he was growing
up was to decide to have another child. That gesture showed him that they loved him for who
he was sufficiently to risk having another child. There are many of our patients' families who
never reach this point of adjustment; they never completely resolve their grief. The pediatric
limb deficiency clinic team therefore not only has the patient to be concerned with, but also
the parents and relatives.
As these children grow, they proceed through the same stages of development as anyone
else. In infancy, the accomplishment of normal motor milestones should be facilitated. A
passive arm may offer balance or a prop for sitting and crawling. A prosthetic leg becomes
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.
There have been several studies of rejection of upper-limb prostheses by children. Few
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.
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
are disappointing. Marquardt in Germany suggests transplanting a cartilaginous apophysis
from the ilium or preserving an epiphysis from the amputated portion of the limb. Usually
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
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 myoelectric-
powered 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,
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.

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.
32: Acquired Amputations in Children | O&P Virtual Library
Search
GO
Acquired Amputations in Children Reproduced with

permission from
Robert E. Tooms, M.D. Bowker HK,
Michael JW (eds):
Annual surveys of specialized child amputee clinics in the United States have repeatedly Atlas of Limb
Prosthetics:
shown that approximately 60% of childhood amputations are congenital in origin and 40% are
acquired. In contrast, a survey of prosthetic facilities has revealed that significantly more Rehabilitation Principles.
children with acquired amputations receive prosthetic services than do those with congenital Rosemont, IL, American Academy
limb deficiencies. This discrepancy suggests that children with the more complex of Orthopedic Surgeons, edition 2,
congenital limb deficiencies are referred to specialized child amputee clinics, whereas most 1992, reprinted 2002.
acquired childhood amputations are managed in less specialized settings. In either case, the
number of children with acquired amputations is relatively small but represents a significant has been updated and published
segment of the pediatric population with major orthopaedic problems. in Atlas of Amputations and Limb
Acquired amputations are secondary to either trauma or disease, with trauma causing roughly and Rehabilitation Principles
twice as many limb losses as disease. Although there are obviously many traumatic (retitled third edition of Atlas of
incidents that may result in childhood amputations, power tools and machinery are the worst Limb Deficiencies), ©American
offenders, followed closely by vehicular accidents, gunshot wounds and explosions, and Academy or Orthopedic Surgeons.
railroad accidents. In the older child, vehicular accidents, gunshot wounds, and power tool Click for more information about
this text.
injuries are the most frequent causes of limb loss. In the 1- to 4-year-old group, power tools
such as lawn mowers and household accidents account for most amputations (Fig 32-1.).
Of the disease processes necessitating amputation in children, malignant tumors are of the Atlas of Limb
responsible for more than half, the highest incidence occurring in the 12- to 21-year-old Prosthetics was
group. Vascular malformations, neurogenic disorders, and a wide variety of miscellaneous provided by the
disorders are responsible for the remainder of amputations due to disease (Fig 32-2.). Northern Plains Chapter of the
In over 90% of acquired amputations a single limb is involved, and it is a lower limb that is Prosthetists
involved in 60% of the cases. Males outnumber females in incidence of acquired limb loss in
a ratio of 3:2, most probably because males tend to engage in more hazardous activities.
SURGICAL PRINCIPLES
The well-established surgical principles for amputation surgery in the adult are just as O&P Virtual Library with a
applicable to amputations performed in children. The cardinal dictum in children is to tax-deductible contribution.
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
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
prevent this problem by epiphysiodesis have not been successful. Terminal overgrowth
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
reported large series of acquired amputations in children. Once surgery becomes
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
stress at the stump-socket interface. Minor modifications in the prosthetic socket will
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 weight-
bearing 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.).
Neuroma formation in amputation stumps of children is seldom symptomatic enough to

warrant surgical treatment. In reviewing a large series of acquired childhood amputations,
Aitken found that only 4% required surgical treatment for neuromas, most being
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
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; 45:1735-
1741.
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; 25:659-
664.
6. Brand PW, Ebner JD: Pressure sensitive devices for de-nervated hands and feet. J
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; 9:30-
47.
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.
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.
[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.
33: The ISO/ISPO Classification of Congenital Limb Deficiency | O&P Virtual Library
Search
GO
The ISO/ISPO Classification of Congenital Limb Reproduced with

Deficiency permission from
Bowker HK,
Michael JW (eds):
H.J.B. Day, M.R.C.S. (Eng.), L.R.C.P. (Lon.) Atlas of Limb
Prosthetics:
In order to facilitate scientific communication about congenital limb deficiency, a logical, Surgical, Prosthetic, and
accurate system of classification and nomenclature is needed, and this must be capable of Rehabilitation Principles.
translation into all languages. The lack of a suitable system has allowed the use of the term
"congenital amputation"-implying that a limb segment has been lost before birth-to be used for 1992, reprinted 2002.
cases that are patently failures of formation. The use of terms derived from Greek or Latin
roots may sound impressively scientific but are both inaccurate and ambiguous and are often Much of the material in this text
misused, none more frequently than "phocomelia," which has been used to describe every has been updated and published
level and type of deficiency. The history of classifications devised since 1961, including the in Atlas of Amputations and Limb
work of the International Society for Prosthetics and Orthotics (ISPO) "Kay" committee, has
been described previously by Kay, Swanson, and Day. Some further minor modifications, (retitled third edition of Atlas of
made more recently, have enabled the ISPO classification to be drafted and accepted by the Limb Deficiencies), ©American
participating nations as an international standard. Academy or Orthopedic Surgeons.
this text.
8548-1:1989 "METHOD OF DESCRIBING LIMB
DEFICIENCIES PRESENT AT BIRTH" Funding for digitization
The standard is reproduced here with the permission of the International Organization for Prosthetics was
Standardization (ISO). Copies of this standard are available from the ISO Central Secretariat, provided by the
Case Postale 56, CH-1211 Geneva 20, or from any ISO member body. Northern Plains Chapter of the
It has three constraints: Prosthetists
1. The classification is restricted to skeletal deficiencies, and therefore the majority of

such cases are due to a failure of formation of parts.
2. The deficiencies are described on anatomic and radiologic bases only. No attempt is
made to classify in terms of embryology, etiology, or epidemiology.
3. Classically derived terms such as hemimelia, peromelia, etc., are avoided because of You can help expand the
their lack of precision and the difficulty of translation into languages that are not related O&P Virtual Library with a
to Greek. tax-deductible contribution.
Deficiencies are described as transverse and longitudinal. The former resemble an

amputation residual limb in which the limb has developed normally to a particular level
beyond which no skeletal elements are present. All other cases are classed as longitudinal: a
reduction or absence of an element or elements within the long axis of the limb.
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.
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.
34A: Surgical Management | O&P Virtual Library
Search
GO
Upper-Limb Deficiencies: Surgical Management Reproduced with

permission from
Terry R. Light, M.D. Bowker HK,
Michael JW (eds):
The birth of a child with an upper-limb deficiency leads to a myriad of confusing parental Atlas of Limb
Prosthetics:
emotions. Parental concerns and expectations must be dealt with in an honest and forthright
fashion by both the physician and the prosthetist caring for the child. Most parents have Rehabilitation Principles.
feelings of guilt and grieve that their infant is not as perfect as they had anticipated through Rosemont, IL, American Academy
the course of the pregnancy. Many parents feel an intense need to "do something," either of Orthopedic Surgeons, edition 2,
surgical or prosthetic, to make their child "normal" and whole. Conflicting advice from well- 1992, reprinted 2002.
meaning friends and relatives may create further parental tension and confusion.
Initially, many parents seek a cosmetic prosthesis that will conceal their child's abnormality
without regard to its functional impact. The predictable lack of success when a purely Deficiencies: Surgical, Prosthetic,
aesthetic prosthesis covers sensate skin in the hand should be openly discussed. As parents and Rehabilitation Principles
observe their growing child functioning without a prosthesis, they gradually understand the (retitled third edition of Atlas of
potential encumbrance of a purely cosmetic prosthesis. Although an aesthetic prosthesis may Limb Deficiencies), ©American
aid the rehabilitation of the traumatic amputee, it is usually a hindrance to the congenital Academy or Orthopedic Surgeons.
amputee. If prosthetic wear becomes a source of conflict between parent and child, the child Click for more information about
this text.
may even express the thought that the prosthesis is to be worn merely to please parents who
cannot accept them as they really are-without a prosthesis. If an active prosthesis is to be
successfully integrated into the child's life-style, it must provide the child with the ability to Funding for digitization
either accomplish otherwise impossible activities or to carry out activities more easily or more of the Atlas of Limb
rapidly. At times, cosmetic restoration, particularly in partial hand and foot loss, may be Prosthetics was
considered a functional improvement. provided by the
The hand allows the child to explore his environment and manipulate objects within that American Academy of Orthotists &
Prosthetists
environment. The hand should be able to maneuver in space under volitional control and
should be able to reach the body as well as the area in front of the body. The child must be
able to aim the hand so that it can precisely approach an object by using visual as well as
tactile clues. The object is then grasped by the closing fingers and supporting thumb. The
hand must also be capable of releasing the object from its grasp.
The two major types of grasp are precision prehension and power prehension. Precision You can help expand the
prehension is used to hold relatively small objects with modest force, while power prehension O&P Virtual Library with a
is used to hold larger objects, often with somewhat greater force. In precision prehension, the
object is secured between the distal phalanx of the thumb and the index finger or between
the thumb, index, and middle fingers. The fingers are usually extended at the interphalangeal
joints while the metacarpophalangeal joints are partially flexed. The object itself usually does
not contact the palm.
The three most common forms of precision grasp or pinch are palmar pinch, lateral pinch,
and tip pinch. In palmar pinch the flat palmar pads of the thumb and fingers secure opposite
sides of the object being grasped. In lateral pinch the palmar surface of the thumb's distal
phalanx is brought against the radial border of the index finger. Since this posture is often
employed to grasp and twist a key, this pattern is also known as key pinch. Tip pinch
provides contact with the distal end of the distal phalanx of the thumb with the distal phalanx
of the index or of the index and middle fingers. Tip pinch is used to pick up a small coin from
a table top.
Power prehension involves the ulnar digits (most often ring and little fingers), while the radial
digits (index and middle fingers) are primarily used in precision prehension. Power grasp
usually results in contact of the object against three surfaces: the palmar aspects of the
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 single-
hand 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 self-
conscious 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
require surgical revision. Consultation between the surgeon and prosthetist allows the
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
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
the child's platelet count has increased to at least 60,000/mm before considering elective
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.
SHORT TRANSRADIAL AMPUTATION

This common level of terminal deficiency is effectively treated prosthetically. Surgical
reconstruction is rarely indicated. Initial prosthetic management begins with a passive hand.
The sophistication of the prosthesis is increased as the child matures.
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 full-
thickness 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
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 dark-
skinned 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
Polydactyly is less common than either preaxial or postaxial Polydactyly. Polydactylous
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 Bilhout-
Cloquet 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
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.
Central Polydactyly often presents in combination with syndactyly. Frequently an

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
border of the hand with seven or eight digits and two ulnae. Neither the thumb nor the
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
limb. When the radius is absent or severely dysplastic, the unsupported carpus will rest
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
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
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.
CONGENITAL CONSTRICTION BAND SYNDROME

Congenital constriction band syndrome has many manifestations (Fig 34A-9.). These include
band indentation, distal edema, acrosyndactyly, and/or amputation of distal parts.
Bands that encircle a limb or digit may result in distal edema. Surgical treatment requires
excision of the indented skin and of any deep fascial constricting tissue. The skin is closed
after Z-plasty flap transposition.
Syndactyly release is described in the preceding section on syndactyly. Although a sinus with
a web space floor is often present, this web space floor is situated too distally and will require
formal release to bring the web space to the appropriate proximal level. Syndactyly usually is
the result of a failure of normal interdig-ital web space resorption during embryonic
development. When syndactyly occurs in association with congenital constriction band
syndrome, however, a sinus is usually evident proximal to the area in which the skin is
joined. This form of syndactyly is termed ac-rosyndactyly or fenestrated syndactyly. In
developmental syndactyly, adjacent digits are joined side to side in a fashion similar to the
intrauterine embryonic paddle form. In acrosyndactyly, however, noncontiguous digits may be
joined. The index finger might be joined to the ring finger, while the middle finger is forced
palmar or dorsal to the distally webbed digits.
When amputation occurs as a result of congenital constriction band syndrome, the amputation
may occur at the joint, metaphyseal, or diaphyseal level. Diaphyseal amputations usually
occur through hand or foot phalanges or through the tibia. The resultant tapered ends may
require revision in adolescence or adulthood because of the propensity of these amputations
to appo-sitional overgrowth.
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
functional value and subject to repeated infection. In some instances these hands may be
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; 14:6-
17.
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.
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, Mosby-
Year 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 non-
functioning 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; 65:584-
598.
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.
Search
GO
Upper-Limb Deficiencies: Prosthetic and Orthotic Reproduced with

Bowker HK,
Michael JW (eds):
Terry Supan, A.A.S., C.P.O. Atlas of Limb
Prosthetics:
The function and design principles of prostheses for children are similar to their adult Surgical, Prosthetic, and
counterparts. Whether the child has an acquired amputation or a congenital anomaly, our goal Rehabilitation Principles.
should be to provide the most functional and cosmetic design possible when and if the
rehabilitation team and the family decide that the child should be fitted with a prosthesis. The 1992, reprinted 2002.
key difference is that children's prostheses must also be developmentally appropriate.
Age guidelines for optimum fitting have changed as we have gained more experience. No has been updated and published
longer must we wait until the teenage years to fit a myoelectric prosthesis. Nor do we wait in Atlas of Amputations and Limb
until the child has lived a year before fitting after tumor surgery. Traumatic amputees now Deficiencies: Surgical, Prosthetic,
receive their first prosthesis in a matter of days, not months. and Rehabilitation Principles
RECENT DEVELOPMENTS Academy or Orthopedic Surgeons.
During the 1980s, a plethora of new components, materials, and techniques were developed this text.
for the adult or geriatric amputee. A specific attempt was made at the end of the decade to
redirect this effort toward the pediatric patient. Myoelectric hands, elbows, and controls were Funding for digitization
miniaturized and simplified (Fig 34B-1.). The lighter-weight, stronger new materials could be of the Atlas of Limb
used for children. Thermoplastic socket designs allowed for more adjustability and adaptability Prosthetics was
for growing limbs. Redesigned lower-limb components also became available for the younger provided by the
amputee. Northern Plains Chapter of the
In a break with the past, the U.S. government did not underwrite this developmental cost. Prosthetists
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 You can help expand the
parts into the child's next prosthesis. The preschool amputee may need a new socket O&P Virtual Library with a
annually because of growth, but the expensive myoelectric hands and electronics should be tax-deductible contribution.
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.
WHEN TO FIT AND WITH WHAT

The key questions are when a child should be provided with a prosthesis and what the best
type is. There are no simple answers. "How soon?" is probably best answered by "when
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
of bimanual activities. The child with a congenital condition may be provided with a passive
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 single-
function 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
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 I½
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.
SPECIAL NEEDS OF CHILD AMPUTEES

Children are not just small adults. Their life-styles and attitudes are different. They want to be
independent, but they also want to fit in with their peers. They need to belong to the group
and not feel like an outsider.
A child with a congenital anomaly or amputation will experience the reaction of others to their
"difference." The more cosmetic the prosthesis is, the greater the chance of a positive
reaction to the child. "Captain Hook" still conveys a negative image for most of our
population. Therefore, cosmetic appearance does become an issue for both child and family.
The physical changes that children normally go through must be considered when designing
their prostheses. The rapid growth of their limbs requires replacement of all or part of the
prosthesis annually. The use of multilayered sockets or thick limb socks will delay the
replacement. The use of thermoplastics that are adjustable will also help.
As noted above, the more expensive parts of electric prostheses can be reused in the next
device. Several centers use the concept of "limb-banking" electric components to help reduce
the cost of the prostheses. This only works if there is technical and financial support to
maintain the parts.
Children can be very destructive in their normal active life-style. The prosthesis must be
designed to take as much abuse as possible. They also should be provided with the adaptive
equipment to have as normal a childhood as possible. The use of terminal devices designed
for recreation should be encouraged (Fig 34B-7.).
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.
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.
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
34C: Externally Powered Prostheses | O&P Virtual Library
Search
GO
Upper-Limb Deficiencies: Externally Powered Prostheses Reproduced with

permission from
Francis J. Trost, M.D. Bowker HK,
Michael JW (eds):
Dan Rowe, C.P.O.
Atlas of Limb
Prosthetics:
Externally powered prostheses were first discussed by Reiter in a publication shortly after
World War II. Further work in this field, however, was not actively pursued until the late 1950s Rehabilitation Principles.
and 1960s. Rosemont, IL, American Academy
At that time, fueled by technological advances and the need created by the thalidomide 1992, reprinted 2002.
disaster, attention was again focused on the possibility of producing externally powered
prostheses. Efforts to accomplish this were undertaken in the Soviet Union, England, Much of the material in this text
Canada, Italy, and Germany.
Efforts to improve and refine these devices have resulted in the development of a valuable
adjunct used in the treatment of amputees. While much has been accomplished in this field, (retitled third edition of Atlas of
many problems remain to be solved, and at this time, external power is not the complete Limb Deficiencies), ©American
solution for all of the amputees' problems but, rather, is a valuable additional tool in the Academy or Orthopedic Surgeons.
prosthetic armamentarium. Click for more information about
this text.
Because of the complexity of factors and components used in externally powered prostheses
and because of the considerable cost involved, it is felt that most of these prostheses are
best prescribed in specialty clinics composed of team members from the various disciplines
concerned with the treatment of child ampu-tees. Prosthetics was
provided by the
Initially, externally powered prostheses were fabricated for the adult amputee, and the Northern Plains Chapter of the
components were frequently too large for children. Because of the needs of the juvenile American Academy of Orthotists &
amputee and the influx of thalidomide babies, various modifications, including miniaturization Prosthetists
of components, allowed children to be fitted with externally powered prostheses.
For unilateral amputees any prosthesis will always be an assistive device. Tasks requiring fine
manipulation, unless bimanual, will always be accomplished by the normal or nonamputated
limb. In the case of bilateral and high-level amputees (Fig 34C-1.), who have the greatest
need for prosthetic assistance, externally powered prostheses still fall far short of meeting You can help expand the
their needs in regard to spatial placement of the prosthesis and reliability. In view of this, it O&P Virtual Library with a
is not surprising that the most common externally powered prosthesis used clinically is the tax-deductible contribution.
unilateral transradial prosthesis (Fig 34C-2.).
EXTERNAL POWER COMPONENTS

In discussing external power components, emphasis will be placed on the child amputee
and the differences and special considerations that have to be given to them as children.
Powered components for the adult are discussed in Chapter 6A. It should also be noted that
teenagers who have reached adult size will have adult components available to them. Initially,
components for small children were simply downsized adult components, but currently, in
addition to downsizing, some components have been redesigned to meet the needs of the
child amputee.
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
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
gives an optimum response as determined by a myotester or, in the case of young
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
limb. They are not used nearly as often as hands and elbows. Without them, rotational
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
elbow with a body-powered terminal device. Another possibility is a powered hand on one
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
as possible. In long transradial amputees it may have to be placed in a pod that protrudes
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.
ADVANTAGES OF EXTERNAL POWER

The major advantage of externally powered prostheses for below-elbow (transradial)
amputees is the ability to combine cosmesis with function (Fig 34C-7.). This feature
appears to be of major importance to the parents of young children where the child has little
or no input into the selection of the prosthesis. Another major benefit in these prostheses is
the lack of harnessing straps and control cables. Beside being uncomfortable at times, the
straps and cables detract from the appearance of the prosthesis. Additional advantages
claimed by amputees are ease of operation, comfort, the ability to operate the prosthesis in
any position, and superior grip strength, especially when compared with voluntary-opening
devices.
With above-elbow (transhumeral) prostheses using an externally powered elbow, "live lift" is
possible. In children with limited shoulder or chest excursion, an externally powered elbow
allows the available excursion to operate a body-powered terminal device.
Patients have shown a tendency to prefer the externally powered hand when grasping larger
objects but to prefer the body-powered terminal device when handling small or flat things.
This may be related to a number of factors including the larger grasping surface of the hand,
the greater friction of the glove, the ability to use visual cues, and the bulk of the hand.
An uncommon but definite advantage of the powered prosthesis is found in the fitting of
amputees whose residual limb is extensively scarred, particularly in areas where suspension
straps or a control cable can exert excessive friction or pressure, as in the axilla. These can
be eliminated if electrode placement can be successfully carried out. The same rationale
applies to the amputee who lacks the body excursion or strength to operate and control a
body-powered prosthesis but can activate a switch or electrode in an externally powered
component. The externally powered prosthesis will provide a superior prehension force,
which is particularly useful in high-level amputees who lack the power to operate a terminal
device successfully (Fig 34C-8.). It should be noted that operation of externally powered
components requires less energy expenditure than operation of body-powered components
does, which is, again, especially important for the high-level amputee.
DISADVANTAGES OF EXTERNAL POWER

Many of the advantages of externally powered prostheses are subjective and dependent on
amputee response. The disadvantages, on the other hand, are more objective and specific.
One of the biggest problems still to be solved in externally powered prostheses is that of
durability of the various components. Through years of research and improvement, the
transradial myoelectric system has achieved a high degree of reliability and durability. The
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
year, and this group included only a few very young children. Very young children do not
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
the repairs are being made. Many of the powered elbows are not available in children's
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
shoulder motion. These are passive only. This is not an indictment of powered limbs since
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
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
patients. Other investigators, however, have not been able to reproduce those results, and
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.
CONSIDERATION OF AMPUTATION LEVEL

The majority of externally powered prostheses have been fitted to transradial amputees. One
reason for this is that there are many more child amputees in this category than there are at
higher levels, whether acquired or congenital. Another reason is that the externally powered
transradial prosthesis is functionally a better prosthetic device than the prosthesis for high-
level amputees. The reasons for this relate to the available components and particularly to the
residual-limb characteristics and the number of functions that need to be replaced.
Unfortunately, the amputees with the greatest need (i.e., the higher-level amputees) are the
least served by external power due to technological shortfalls. Because of this, the rejection
rate and incidence of failure to use these prostheses are highest in this group. It is hoped that
future research will solve these shortcomings and provide these amputees with a better, more
useful assistive device. Initially, the following observation will be directed at unilateral
amputees. Bilateral amputees will be specifically discussed later.
Historically, the transmetacarpal level of amputation has been a difficult level to fit with any
type of prosthesis. The incidence of rejection is high. In amputees of this level, length
usually is not a significant problem because the amputated limb is almost as long as the
nonamputated limb. In addition, they retain that marvelous sense that any prosthetic device
eliminates, namely, sensation. With retained carpal and metacarpal segments, they have
some wrist and hand motion and lack only finger prehension. This function is usually
accomplished with the opposite hand. Externally powered prostheses have practically no use
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
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.).
TRAINING THE CHILD AMPUTEE WITH EXTERNALLY

POWERED PROSTHESES
It has been well demonstrated that children of all ages, including toddlers, can be trained to
operate externally powered prostheses.
The training method comprises several phases. These include testing for controllable
myoelectric signal and training in the care, maintenance, control, and finally, the functional
use of the powered prosthesis.
Although very young children can be taught to operate an externally powered prosthesis,
much of the responsibility for care, maintenance, and actual training will fall to the parents,
who have to be motivated to accept this role. In fact, it has been our experience that the
motivation of a very young child with any prosthesis generally resides primarily in the parents,
gradually giving way to the amputee as he incorporates the prosthesis into his normal living
patterns. In addition to this, certain concessions have to be made to the very young child
because of his age, attention span, and conceptual abilities. These will be referred to
specifically as the process is described. The format followed is similar to that followed in the
training of an amputee with any type of prosthesis, except that location and control of the
switching device is unique to external power.
In fitting with a myoelectric prosthesis, location of control sites and muscle training is done by
the pros-thetist, therapist, or both. A myotester is used to accurately locate the optimum
control sites. The muscles to be used are palpated, and then the test electrode is moved
until a maximum response is obtained on the myotester. In very young children, the use of
toys that move when activated by the myoelectric activity of the child should be substituted for
the myotester.
The amputee must learn independent contractions of muscle groups and, in the case of one
site-two function controls, differential or graded muscle contraction. This can be facilitated by
the use of movements of the phantom hand, although this is not available in very young or
congenital amputees. One site should be taught at a time, and after they are all learned,
combined function can be taught.
Training sessions should be kept to 30 minutes or less, depending on the attention span and
endurance of the child. These sessions may have to be very short for the young child but can
be supplemented later by watching the child play and encouraging him to use the prosthesis
in his play activities. Short training sessions avoid muscle fatigue and soreness.
Other factors to consider are the developmental age of the patient, his ability to follow
instructions, and the complexity and speed of the prosthetic components. While terminal
devices can be fit at a very early age, elbow function, when needed, is usually added
somewhat later.
Training time will vary, although most amputees can be taught to generate signals, and this
does not seem to depend on the length of time since the amputation. In the young child the
parents should be incorporated into the training program at the onset since their participation
and cooperation is essential to a favorable outcome.
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.
RESULTS OF FITTING WITH EXTERNAL POWER

Fitting amputees with externally powered prostheses has previously been more prevalent in
Europe and Canada than in the United States, although it has become much more common
here in recent years.
In one study in a group of 40 children using transradial prostheses with external power, only
2 children rejected the powered prosthesis and preferred the split hook. It should be noted
that all these children are unilateral amputees and that half of them have been monitored for
1 to 3 years. No one else has shown this high rate of success. More typically, acceptance
rates for transradial powered prostheses is from 60% to 90%. Many of these studies are
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
prostheses and the rest wore the prostheses passively. Fishman and Kruger's study had
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 Children-
Springfield 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.
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
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.
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
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: 174-
181.
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.
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.
34D: Developmental Approach to Pediatric Upper-Limb Prosthetic Training | O&P Virtual Library
Search
GO
Upper-Limb Deficiencies: Developmental Approach to Reproduced with

Pediatric Upper-Limb Prosthetic Training permission from
Bowker HK,
Michael JW (eds):
Joanna Grace Patton, B.S., O.T.R. Atlas of Limb
Prosthetics:
*This chapter is adapted from material presented in Comprehensive
Management of the Upper Limb Amputee, published by Springer-Verlag. Rosemont, IL, American Academy
Chapters in that book by Joanna Grace Patton entitled "Developmental of Orthopedic Surgeons, edition 2,
Approach to Pediatric Prosthetic Evaluation and Training" and "Upper-Limb 1992, reprinted 2002.
Prosthetic Components for Children and Teenagers" are used as a basis for this
format. The author wishes to express appreciation to Springer-Verlag for Much of the material in this text
permission to use the selected content.
THE CHILD WITH A UNILATERAL TRANSVERSE FOREARM and Rehabilitation Principles
DEFICIENCY Limb Deficiencies), ©American
Child Development-Foundation For Early Prosthetic Fitting and this text.
Treatment
Principles of child development are important as a foundation for evaluating, prescribing of the Atlas of Limb
prostheses, and training children who have limb deficiencies or acquired amputations. The Prosthetics was
staff at the Child Amputee Prosthetics Project (CAPP) at both the University of California at provided by the
Los Angeles and Shriners Hospital for Crippled Children, Los Angeles Unit, adhere to this Northern Plains Chapter of the
philosophy of care. They feel that pediatric prosthetic treatment is not and should not be a American Academy of Orthotists &
duplication of adult treatment. Prosthetists
Sypniewski reviewed the literature in 1972 and reported on the various rationales for early
upper-limb prosthetic fitting for children. Early fitting is clearly cited as an important concept.
However, there is and always has been a difference of opinion about which developmental
milestones are most appropriate as a basis for planning treatment. Clinicians still debate what
is meant by "early fit." In a 1976 article by Fisher, she discussed both the definition and You can help expand the
practice of early fitting. She cited research that supports the belief that the development of O&P Virtual Library with a
visually guided reaching is dependent on the opportunity to see the limb moving in space. tax-deductible contribution.
She questioned whether fitting the baby before 3 or 4 months of age would aid visually
guided reaching and thus influence future prosthetic wearing and use patterns.
These same questions concerning when to fit, what to fit, and how to do training will continue
to have an impact on both health professionals and the general public in the 1990s. For
example, the development of myoelectrically operated components for children in the 1970s
and the manufacture of lightweight electric hands and miniature circuits are changing
the prescription and training process. In selected centers that have well-established
myoelectric programs, babies between 4 and 15 months of age are receiving their first
myoelectric prosthesis. The approach has gained media attention and generated much
interest and controversy among professionals and families who have limb-deficient children.
At CAPP, the first prosthesis with no active control is fit when the baby achieves independent
sitting balance. Since the baby has progressed beyond the stage of rolling, the prosthesis
is less likely to hamper movement. The practice at CAPP is based on clinical experience as
well as a study by Brooks and Shaperman that identifies the developmental period prior to
2 years of age as a good time to fit the first prosthesis. In fact, children who received the
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.
Family's Introduction to the Prosthetic Program

Early intervention and support are most important for families. They are encouraged to see
the clinic team as soon after the baby's birth as possible. Some parents are totally
overwhelmed by the birth of their child with a limb deficiency, while others seem more able to
cope with the birth crisis. The early opportunity to discuss feelings and concerns is most
valuable to the family. They also need to receive appropriate information about the baby's
limb deficiency and future treatment. Parents are asked to bring siblings and extended family
members so that the CAPP staff may provide the following types of information:
1. Reassure the family that the baby with a transverse forearm deficiency has the
potential to develop normally unless there are other medical or neurologic problems
unrelated to the limb deficiency.
2. Explain that the child will be able to perform most activities of daily living, including
self-help, school, recreational, vocational, avocational, and household tasks with or
without a prosthesis. Skills will develop because of the child's natural abilities and
interests.
3. Reassure the family that the child should be treated the same as other siblings or
children in terms of performing daily tasks, receiving discipline, and enrolling in regular
school.
4. Provide accurate information about prostheses, and clarify misconceptions about state-
of-the-art technology. Explain how the child performs activities with and without a
prosthesis.
Parents frequently ask whether a prosthesis has a real value. Certainly a child can use
substitute grasp patterns like clasping an object under the arm or against the body with the
residual limb. With the prosthesis, the child can hold the object away from the chest and at
the midline of the body. Then he is able to complete the more complex part of the task with
the sound hand.
Families need time to assimilate the information provided by the team because they are the
ones who must make informed decisions concerning the prosthesis for the child. When
parents have the opportunity to select the type of terminal device they want, they may be
more committed to the total program. Even though the team provides information, support,
and training, the parents must follow through on a day-to-day basis. They help the child
develop both a consistent wearing and use pattern when performing daily activities.
Infant Prosthesis/No Active Controls

At CAPP, the prosthesis for the infant is a lightweight endoskeletal or exoskeletal
transradial (below-elbow) prosthesis with a nonactive terminal device. An infant chest harness
is used instead of the traditional figure-of-8 harness (Fig 34D-1.). A polyvinylchloride (PVC)
gauntlet covers the socket to provide a friction surface. It prevents the baby from sliding when
the prosthesis is used for support on a hard surface. Parents are given the choice of a CAPP
Terminal Device No. 1 (CAPP TD), a Dorrance 12 P hook, a Steeper foam-filled infant hand,
or a Centri infant hand. The advantage provided by the CAPP TD and hook is that they are
both able to hold an object. In addition, the CAPP TD with its large grasping surface and
good friction cover provides a secure hold on objects. Even though the little passive hands
provide no grasp function, families do request them because of appearance.
Evaluation of and Training With the New Prosthesis

The prosthesis should be evaluated when it is delivered to the patient to make sure that it
conforms to the prescription and standards of the clinic. The occupational therapist observes
fit, comfort, and function of the prosthesis during normal use. By watching the baby move and
play, the therapist evaluates the stability of the socket and harness. Any signs of restriction or
discomfort are reported to the prosthetist so that the necessary changes and adjustments can
be made.
The therapist sees the baby and family two or three times during the first month to provide
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 prosthesis becomes pinned under the baby's body or caught in furniture. The baby is
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
child learns to clasp between the sound arm and the prosthesis (Fig 34D-3.). Parents are
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
behavior. Gesell and Ilg describe a similar developmental activity in which babies learn to
place cubes in and out of a cup. This adaptive behavior becomes more meaningful and
engrossing as the baby gets closer to 18 months of age. To make it easy for the toddler to
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.
Readiness to Activate the Terminal Device-The CAPP Approach

At CAPP the control line or cable is added to the transradial prosthesis when the child
demonstrates certain developmental behaviors that indicate the ability to learn how to use an
active terminal device. The readiness criteria are as follows:
1. The child is able to follow simple directions that have no more than two steps.
2. The child demonstrates an attention span of at least 10 minutes.
3. The child demonstrates an awareness that the terminal device can hold an object and
attempts to open it with the sound hand.
4. The child shows an interest in activities that require the use of two hands.
5. The child shows some willingness to be handled by the parent or therapist.
Some of these behaviors become apparent near the child's second birthday and are based on
principles of development. Pulaski says "the child at two makes a transition from sensory
motor experience to mental activity." The mental activity is demonstrated by the child's
ability to follow simple directions and to understand cause and effect. According to Gesell
et al., the 2- to 2½-year-old has the beginning of interest in constructive activity such as
building with blocks and fitting simple toys together. He also has an elementary interest in
imaginative play. It is therefore appropriate to capitalize on this period of cognitive and
motor development by introducing the active control line or cable. The child integrates the
opening of the terminal device with fine motor bimanual activities and then relates it to
everyday play. However, these cognitive and motor skill changes do take place during the
middle of the "terrible twos" when the child may resist being handled. Sometimes after the
control line is added and everyone gears up for the training, the child is no longer
cooperative. No harm is done if the therapist and family remain flexible. They may postpone
the training time or pursue alternative nonstruc-tured training methods.
Evaluation of the Prosthesis With the Active Terminal Device

The control line and figure-of-8 harness are added to the current prosthesis, or a new
prosthesis may be fabricated. The terminal device may be a CAPP TD No. 1, a 10X
Dorrance hook, or a child's size mechanical hand.
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.
Control Motion Training

Controls training or initial training is conducted by the occupational therapist to teach the child
to open the terminal device. The therapist sits behind the child or next to the arm with the
prosthesis. The child holds a toy in the sound hand while the therapist moves the shoulder on
the side of the prosthesis into humeral flexion (Fig 34D-4.). Pressure is exerted by the
harness under the axilla on the sound side. The child usually moves the shoulder or upper
part of the body to avoid the pull of the axilla loop. The result is slack in the control system,
which prevents ease of operation of the terminal device. To counteract the problem and
minimize frustration, the therapist stabilizes the shoulder on the sound side and encourages
the child to reach forward to place a toy in the terminal device. The therapist helps with the
secure and correct placement of the toy and extends the child's shoulder to relax tension on
the control line to close the terminal device. Once the child has completed the activity, he
may remove the item with the sound hand.
If the child is less inclined to sit at a table to learn the controls, the control attachment strap
may be tightened. When the child bends over or reaches forward toward a toy, the terminal
device opens. The therapist or parent then calls attention to the open terminal device.
The therapist definitely provides "hands-on" assistance during this period. Two or three short
training sessions a week for 2 to 3 months are reasonable to reinforce learning the control
motion and to provide a successful experience for the child. The parents must be included in
the therapy sessions in order to assist the child at home.
Although the focus is on learning the control motion, the child does not respond well to
"drills." It is best to use developmentally appropriate bimanual toys and games in order for the
child to relate the control motion to purposeful play. At CAPP we do not ask the child who
has a unilateral limb loss to use the prosthesis to perform dominant hand skills, but rather to
assist the sound hand in two-handed tasks. Appropriate activities that provide repetitive
opening and closing of the terminal device may be used for this phase of training.
1. Use threaded nesting barrels such a "Kitty in the Kegs" or small jars and bottles with
toys or treats inside. (Hold the barrel or the jar in the terminal device. Remove and
replace the top with the sound hand).
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 34D-
5.).
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 34D-
6.).
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
sound hand to grasp a stationary object in space. It is best to avoid "one-handed drills"
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.).
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
more independently in the classroom (Fig 34D-11.).
1. Hold paper to cut with scissors.

2. Open and close glue bottles and jars.
3. Open a milk carton and package of cookies.
4. Stabilize clothing to zip a jacket or button a shirt.
5. Don and doff the prosthesis independently.
6. 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
to developing more spontaneity. Although some children become more spontaneous than
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 self-
help, recreational, athletic, and avocational activities. Therefore the youngster should always
have access to the prosthetist, therapist, or other appropriate team member.
Functional Need and Prosthetic Options

As the child grows and develops, function, cosmesis, interests, and skill levels change. The
therapist is usually aware of these needs and may be in a position to introduce different
prosthetic components or recommend changes to existing ones. Early in the use-training
period, the therapist or child will identify a need for more prehension force. The child may
become repeatedly more frustrated when he is not able to hold an object securely in the
terminal device as resistance is applied by the sound hand. The child who has the CAPP
TD No. 1 will need to replace the soft spring (Hosmer 71622) with the regular spring (Hosmer
71623). This exchange is made as soon as the child has enough operating force to pull
against the increased resistance. A third and much harder spring is available for the older
school-aged child.
The CAPP TD No. 2 with its automatic thumb-locking mechanism and heavy-duty closing
spring provides excellent grip force and function. This component is appropriate for the
teenager and adult and will soon be commercially available.
The Hosmer-Dorrance voluntary-opening hook uses rubber bands to provide grip strength.
For the young child, a quarter to half of a band may be added at a given time according to
the youngster's available excursion and operating force. Some preteen and teenage boys
may actually switch to a hook from some other device because they like the configuration,
the fine tip prehension, and the option of adding rubber bands to increase grip strength.
The hook is especially versatile for grasping the handle bars of a bike, for tool use, and for
heavy-duty work.
Voluntary-closing Adept terminal devices from Therapeutic Recreation Systems (TRS) also
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
appearance and may be acceptable as an alternative to other devices (Fig 34D-13.).
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
usually required to remove the prosthesis for body-contact sports. For certain activities, the
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.
THE CHILD WITH BILATERAL UPPER-LIMB AMELIA
Support and Guidelines for the Family

When a child is born with bilateral upper-limb ame-lia or other severe limb deficiencies, the
family needs emotional support, guidance, and information. As one CAPP mother so
poignantly said, "We were in so much shock we did not know how to act or what to do." An
experienced, sensitive team can share the family's fears and concerns and, over time, help
them to refocus on the child's abilities.
The occupational therapist evaluates the infant's development and explains what to expect as
the baby matures. Guidelines for handling the baby's special needs are also presented. For
example, babies with severe limb loss have less skin surface from which to disperse body
heat. They are frequently very hot and perspire excessively around the head and neck.
Parents are instructed to use lightweight clothing and allow the baby's lower limbs to be
exposed. The benefits are twofold. The baby remains cooler, and the feet are free to touch
and explore the environment.
The Baby's Ability to Adapt
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
arms. Schmid says "that the foot skills of these children develop in a sequential pattern
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.
Rationale for Prosthetic Fitting

For the child with bilateral upper-limb amelia, use of prostheses is presented as an option or
an alternative way to perform selected activities. The team provides the family with
information on appropriate components and discusses the real function of prostheses. Before
a prosthesis is prescribed, the following questions must be addressed:
1. Does the child have a functional need for a prosthesis? Will the prosthesis interfere
with the child's development?
2. Is the child able to use the components and control systems currently available?
3. Do the parents want a prosthesis for the child? Are they ready to commit to the
training process?
If at all possible, the baby should receive the first prosthesis before the developmental period
of the "terrible twos." It may be prescribed when the baby achieves independent sitting
balance as long as it does not interfere with the ability to move freely. At CAPP we
sometimes wait until the child is walking. When the feet are used for ambulation, the child
may be more enthusiastic about wearing the prosthesis.
One or two shoulder disarticulation prostheses may be suggested for the first fitting. One
socket covers less of the chest area and may keep the weight, bulk, and heat to a minimum.
However, it may be easier to suspend two sockets on the body and give the child a greater
sense of balance. These options depend on the child's size as well as the contour and
muscle mass of the chest and trunk. Essentially, the clinic team must determine which fitting
will provide the best comfort and meet the child's functional needs.
The First Infant Prosthesis With No Active Controls

At CAPP the prosthetic fitting of choice for the child with no arms is an endoskeletal shoulder
disarticulation prosthesis. It may include an aluminum frame or vented laminated socket and
a 10X hook or CAPP TD with no control cable. The elbow joint is usually assembled from
CAPP components, but a new push-button elbow joint is commercially available from the
U.S. Manufacturing Company. The forearm and humeral segment lengths are made of pieces
of PVC tubing (Fig 34D-15.). These segments must be the appropriate length to allow for the
following functions:
1. The terminal device must reach the mouth at the midline of the body when the elbow
is fully flexed.
2. The forearm must clear the table top when the elbow is flexed at 90 degrees.
The Training Period

After the prosthesis is evaluated for fit, comfort, and function, the parent must learn how to
encourage the child to use it. The daily wearing pattern may be full-or part-time, but the
prosthesis should not interfere with foot use or the development of other gross motor skills.
The key, however, is a consistent wearing pattern. As the parents repeatedly place toys and
finger food in the terminal device, the child will learn about the holding function. Parents will
need to assist the child with many of the activities such as unlocking the elbow to bring food
to the mouth.
Since children without arms do not have active shoulder motion, they cannot reach out and
clasp large or small objects between the segment lengths. It is possible, however, to carry
a large lightweight toy that is wedged between the forearms. Likewise, the child must use
body motion to push or move an object with the prosthetic forearm or terminal device.
Because the toddler can perform most age-level play activities with the feet, it takes creativity
and perseverance on the part of the therapist and parent to encourage use of the prosthesis.
When the child wears shoes so that his feet are not accessible, the following types of
activities may be used in the training process (Fig 34D-16.):
1. Scribble with a crayon that is secured in the hook.

2. Push or maneuver cars, trains, or other toys on a table surface.
3. Pull a toy with a string that is secured in the hook.
4. Paint in a "Paint with Water Book." Secure a brush in the hook.
5. Hit a drum or xylophone with a mallet secured in the hook.
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
without arms may also show signs of readiness to perform this task with the feet. It is
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.
Activating the Terminal Device and Learning the Control Motion

The passive prosthesis provides only minimal function for the child without arms. The need to
do selected dominant-hand activities with the prosthesis prompts the activation of the terminal
device as soon as the youngster has the cognitive ability to learn the controls. The terminal
device of choice for the active prosthesis is a Dor-rance 10X hook because it provides fine tip
prehension, nonprehensile hooking action, and a clear view of the objects to be grasped.
The terminal device may be activated with either a Michigan External Power System (electric
hook) with a push-switch control or a body-powered single control cable and a thigh strap.
Each system has its advantages and disadvantages. The team must decide which one will
meet the individual patient's needs and abilities. The Michigan External Power System can be
used with the endoskeletal type of prosthesis and retain the manual elbow unit. The push-
button control is placed inside the top of the socket, and the child hits the button to open the
hook. When the child relaxes away from the switch, the hook closes by rubber band action.
This method allows the terminal device to open and close in a stationary position.
Unfortunately, this system provides limited pinch force because the motor tolerates only about
three fourths of a rubber band. If more bands are applied, the motor usually malfunctions.
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
the hook instead of asking the child to actively grasp it. With practice the child learns to
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
the object before closing the terminal device. Rubber tubing applied to the stationary finger
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.
Activities of Daily Living and Alternative Methods of Performance

The concept of adapted performance is essential to the child with severe upper-limb loss. The
prostheses never provide total independence and were never meant to replace foot skills (Fig
34D-20.) and other problem-solving methods. Celikyol describes adapted performance
"as encouraging the patient to approach and solve tasks by using the entire body adaptively
and to look beyond conventional methods of arm and hand use to stabilize, grasp, and move
objects in space." The occupational therapist helps the child to participate in activities of
daily living by demonstrating adapted techniques and experimenting with adapted equipment
(Fig 34D-21.). An activity may be introduced during the same time frame in which an able-
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 4-
6, 8, 10.
15. New Products Bulletin. Liberty Mutual Research Center, Hopkinton, Mass, 1989, pp 1-
3.
16. Patton J: Developmental approach to pediatric prosthetic evaluation and training, in
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, Springer-
Verlag 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.
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, 212-
237, 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 Sciences-
National 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
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.
Search
GO
Lower-Limb Deficiencies: Surgical Management Reproduced with

permission from
Leon M. Kruger, M.D. Bowker HK,
Michael JW (eds):
Atlas of Limb
BASIC PRINCIPLES Prosthetics:
The physiologic differences between children and adults have already been discussed, as Rehabilitation Principles.
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 1992, reprinted 2002.
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 Much of the material in this text
child will become ambulatory promptly, whether the deficiency is distal or proximal. By the has been updated and published
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 and Rehabilitation Principles
procedures can be carried out in one stage. The child should be brought to independent (retitled third edition of Atlas of
walking as early as possible, with surgical intervention and resultant scarring kept to a Limb Deficiencies), ©American
minimum and with the best physiologic restoration available. Academy or Orthopedic Surgeons.
Surgical intervention on the limb-deficient child, particularly on those with longitudinal this text.
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 of the Atlas of Limb
seen on any recurring basis in the office practice or general hospital. Prosthetics was
provided by the
While in the past, limb lengthening for congenital longitudinal deficiencies has been Northern Plains Chapter of the
considered and largely abandoned (with the possible exception of the congenital short femur), American Academy of Orthotists &
the introduction of the Ilizarov technique of limb lengthening by callus distraction has once Prosthetists
again appealed to some orthopaedic surgeons. It should be pointed out that prior to
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 You can help expand the
be either in the lengthening apparatus or immobilized or braced after healing; and that if over- O&P Virtual Library with a
lengthened he will require a lift on the normal side. This cycle will probably be repeated as he tax-deductible contribution.
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.
Early Communication With Parents and Pediatricians

Those clinics caring for limb-deficient children should attempt to establish rapport with
pediatricians and obstetricians so that when such a child is born, the clinic chief will have the
opportunity to examine the child in the newborn nursery. Recognition of the shock, grief, and
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 35A-
1.,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
consultation is mandatory. Should pregnancy occur, parents should also be encouraged to
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.
Maintenance of Muscular Development in the Residual Limb

A congenital limb deficiency may not be simply the absence of a long bone or the peripheral
joint distal to the deficiency; it may also include inadequacy of the proximal musculature
and deficits in the skin, nails, and nerves. Torode and Gillespie as well as Johansson and
Aparisi have reported on the missing cruciate ligaments in patients with congenital short
femur and fibula deficiency. Recognizing the deficits in the proximal musculature at the
initial evaluation is important if progressive deformity is to be prevented. To this end a
program must be developed that includes not only institutional physical therapy but also
education for the parents in the techniques of development and maintenance of muscle
strength. The parents should be brought into the physical therapy department for instruction
by the therapist in setting up a home program.
Prevention of Progressive Deformity

Prevention of deformity in the child with a lesser deficiency may pose no problem. In fact,
even with a major deficiency such as an amelia, there is no concern with progressive
deformity. However, in the more complicated limb deficiency such as proximal femoral focal
deficiency (PFFD) and longitudinal deficiency of the tibia and fibula, an exercise program for
strengthening or stretching of the remaining musculature may be inadequate to prevent
deformity of the remaining joints. Orthotic management for the control of foot, ankle, and knee
deformities can be pursued until the child is ready for definitive surgical conversion (Fig 35A-
2.). In many patients, particularly those with PFFD, orthotic management without revision may
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.
Retention of All Long-Bone Growth Plates

The percent contributions to the longitudinal growth of the distal femoral, proximal tibial, and
distal tibial growth plates have been determined (Fig 35A-3.). Unnecessary sacrifice of any of
these three longitudinal growth centers in the infant or very young child may result in major
prosthetic problems in adult life. In some instances, the sacrifice of such an epiphysis in the
very young child can be catastrophic. As an example, the patient with a longitudinal
deficiency of the tibia should be treated by disarticulation at the knee level, with the distal
femoral epiphysis left intact. Assuming normal growth in the distal and proximal femoral
growth plates, in adult life the patient would have a slightly shortened knee disarticulation,
which is ideal for prosthetic fitting. Should the surgeon elect to carry out a transfemoral
(above-knee) amputation with sacrifice of the distal femoral growth plate, it would deprive the
child of 70% of the eventual length of the femur, and in adult life the patient would have a
very short transfemoral residual limb. Disarticulation ensures a long residual limb with all of its
advantages in adult life.
Similarly, in a longitudinal deficiency of the tibia, it is important to determine by ultrasound

or magnetic resonance imaging (MRI) the possibility of a nonossified proximal epiphysis of
the tibia, which would indicate a partial deficiency. In such a case, disarticulation should not
be carried out so that the below-knee segment of the limb can be preserved.
Preservation of Proximal Joints

Particularly in transverse deficiencies of the leg in the upper quarter or higher, preservation of
the knee joint is important. Functional restoration of the trans-tibial (below-knee) amputee is
far superior to what can be expected of the transfemoral amputee. The sacrifice of a knee
joint in the small child may severely limit his ability to climb stairs, manage ramps, and take
part in many physical and sports activities. By the same token, efforts to preserve such a very
short tibial segment (Fig 35A-4.) may be rewarded in adult life with a competent, functional
knee joint and a good, sturdy, sufficiently long transtibial stump.
Patients with classes A and B PFFD are recognized as having a hip joint at birth. It is not
possible at the time of birth to be sure of the integrity or the stability of that joint. Although
Lloyd-Roberts and Stone had recommended early exploration of all of these joints, they
later conceded that it may not be necessary and that early exploration may damage the joint.
Stabilization of Proximal Joints Where Necessary

Stabilization of proximal joints is particularly applicable to patients with PFFD. Steel et al.
have described iliofemoral fusion for PFFD-fusing the femoral segment to the pelvis so that
the femoral segment will be parallel to the floor. The knee is thereby flexed at a right angle
when the patient stands. Extending the knee would then, in effect, flex the hip. We have
not used this procedure. When hip instability is present due either in type A to the
subtrochanteric defect or in type B to the lack of contact between the head, neck, and shaft
fragments, osteotomy and bone grafting or osteosynthesis between the two fragments will
stabilize the hip. In Aitken types C and D, when the femoral segment is quite short, knee
fusion may be necessary in order to have a good prosthetic result. These procedures will
be described in more detail in the section on PFFD.
Bilateral Limb Deficiencies
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 split-
thickness 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
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.
Partial or Complete Metatarsal Deficiencies

As in transverse deficiencies of the phalanges, revision surgery is not usually necessary for
metatarsal deficiencies. Occasionally, it is necessary to remove vestigial phalanges that have
either no bony component or insufficient bony component for functional value. These may
present not only cosmetic and hygienic problems but also a serious problem in shoe insert
fitting. The vestigial phalanges may become irritated and even ulcerate. With such problems,
excision is recommended. When the residual metatarsal elements are extremely small,
whether short or atrophied, shoe fitting problems are the major concern. If there is insufficient
residual foot on which to fit a shoe with an insert, consideration must be given to other
prosthetic restoration. Those patients with very short remaining metatarsal elements and
those with complete transverse metatarsal deficiencies must be treated as though they have a
tarsal deficiency.
Complete or Partial Tarsal Deficiencies

For the patient with a complete transverse tarsal deficiency (apodia or congenital ankle
disarticulation), the deficit may be managed by prosthetic restoration. No surgical intervention
is necessary.
Partial tarsal deficiencies with a normal distal tibial epiphysis and no length discrepancy may
require conversion surgery. In the very early years, these children may walk with a high-top
laced shoe. Prosthetic devices are available, but function and cosmesis are less than ideal
(Fig 35A-10.). Proximal revision for functional as well as cosmetic reasons will be considered
(Fig 35A-11.), with Syme ankle disarticulation as the procedure of choice. This procedure is
frequently referred to as a modified Syme's amputation because the articular cartilage is
left intact. The Boyd amputation may also be considered as an alternative to disarticulation.
In the very small child, up to 3 years of age, the malleoli may be left intact and will present
no problem in prosthetic fit or restoration. In the older child, the malleoli may be transversely
sectioned at the level of the tibial articular surface to provide a broad, flat, end-bearing stump.
Care must be taken not to damage the distal tibial epiphysis in this procedure. In an older
child in whom the epiphyses have closed, one may have to model the stump or shave the
malleoli to achieve acceptable cosmetic result in a Syme-type prosthesis. Patients so treated
are left with an end-bearing stump that is the most functional type. The patient may walk
without the prosthesis. There is no concern for the phenomenon of bony overgrowth so
frequently observed when transtibial amputation is performed.
Procedure for Syme Ankle Disarticulation

The procedure for Syme ankle disarticulation should be carried out with tourniquet control.
The incision starts anteriorly at the tip of the medial malleolus and is carried directly across
the ankle joint to the lateral side. The second half of the incision is then carried from these
two points across the plantar surface of the foot in a slight arc to carry the incision just distal
to the calcaneocuboid level (Fig 35A-12.). The anterior part of the incision is carried down
through the subcutaneous tissue and the superficial vessels clamped and ligated. The
anterior tibial tendon and toe extensors are divided and held with a clamp or suture for later
attachment. The dissection is carried medially, and the posterior tibial vessel and nerve are
identified and traced distal-ward to preserve the circulation of the plantar flap. The anterior
ankle capsule is opened, and the medial and lateral ligaments are divided. The plantar portion
of the incision is carried directly down to the bone and the plantar flap dissected off the
inferior aspect of the os calcis by sharp and blunt dissection. With the foot pulled forward, the
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, Partial
Upper Third
A partial transverse leg deficiency (congenital transtibial amputation, partial transverse
hemimelia) may occur as a true deficiency or in association with Street-er's dysplasia
(congenital constriction band syndrome). When it is associated with Streeter's dysplasia,
surgical attention to other constriction bands may be necessary, either above the level of
amputation or on other limbs. In those true deficiencies, vestigial digits may be present, and
these may require surgical removal. Such appendages may range from one metacarpal or
metatarsal ray to five vestigial digits.
The deficiency is apparent at the time of birth, and attention should be directed to the
maintenance of range of motion in the proximal joints, particularly the knee joint. If the child is
born with a flexion contracture of the knee joint, it may be necessary to surgically relieve this
condition prior to considering prosthetic restoration. If the knee joint extends completely at the
time of birth, implementation of a range-of-motion program should be maintained until the
child is ready for the prosthesis.
Until recently it was thought that these congenital amputations were not subject to the
phenomenon of bony overgrowth. Pellicore et al. have now reported the observation of
bony overgrowth in the remaining tibia of these children; this phenomenon has been observed
through the period of symptomatic overgrowth until surgical revision was required.
Children with transverse deficiencies of the leg in the proximal portion will demonstrate good
standing balance on their sound limb somewhere between 9 and 15 months of age. They are
ready for prosthetic restoration at this time (Fig 35A-13.).
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.).
Transverse Deficiency of the Thigh, Total (Amelia)

Children with total transverse deficiency of the thigh (amelia) (Fig 35A-14.) should be fitted
with their first prosthesis as soon as they are standing independently on the normal opposite
side. As with other deficiencies, there may be a vestigial digit attached. This usually is not a
problem since the vestige has no rigidity and, hence, can be incorporated into the socket
without difficulty. Surgical intervention is seldom indicated.
The infant with bilateral amelia will require a plastic "bucket-type" socket fitted to a firm base
to achieve sitting or "standing" balance. As he grows older, he may progress to the swivel
walker. If the child has normal upper limbs, bilateral articulated hip disarticulation prostheses
may be prescribed at about 4 or 5 years of age.
LONGITUDINAL DEFICIENCIES
Longitudinal Deficiency of the Fibula, Partial
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.
Longitudinal Deficiency of the Fibula, Total

Because of the frequency of its occurrence, longitudinal deficiency of the fibula has received
a great deal of attention in the literature. The titles are varied- congenital absence of the
fibula, fibular deficiency, paraxial fibular hemimelia, dysgenesis, etc. O'Rahilly reported on 296
cases of this deficiency that he had reviewed in the literature prior to 1935. Since that time
several hundred cases have been reported. In 1952, Coventry and Johnson reported 29
cases of congenital absence of the fibula and mentioned amputation as a form of treatment
but stressed the reconstructive approach. Since Aitken's report of 1959, most authors
have emphasized amputation and prosthetic restoration. Although O'Rahilly was able to find
only 296 cases in the literature prior to 1935, by 1991 there were over 2,200 cases in the
Shriners Hospitals for Crippled Children. Our experience at the Springfield Unit increased
from 60 patients in 1961 to 120 in 1991.
Clinical Picture
As with other longitudinal limb deficiencies, one is impressed by the fact that fibular deficiency
is a true limb deficiency, not simply the absence of a single bone (fibula). The tibia may be
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
lateral rays. The classic clinical picture is a foreshortened limb with an equinovalgus foot,
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.
Treatment of Unilateral Longitudinal Fibula Deficiency, Total

Leg length discrepancy is the major problem in the patient with total unilateral longitudinal
deficiency of the fibula. Experience has shown that this is a progressive discrepancy and
that the progress of this discrepancy can be predicted on growth charts. Efforts at equalizing
the discrepancy by tibial lengthening have generally been unsatisfactory.
With the advent of the Ilizarov technique of lengthening by callus distraction, there has been a
reappearance of interest in preserving the foot and lengthening these limbs. As mentioned
earlier, if, in fact, an effort is made to lengthen the tibia in such a child, he will have to wear a
lift to compensate for his discrepancy until he is old enough for his limb to be lengthened. He
then has a protracted period of wearing the lengthening apparatus and protecting the limb,
and this process will probably have to be repeated a second time in order to obtain adequate
equalization. Efforts at equalizing discrepancies in excess of 7.5 cm (3 in.) by contralateral
growth arrest or shortening are contraindi-cated because this amount of loss in overall height
of the patient is too great a price to pay. Therefore, it would appear that only in the unusual
patient can leg length equalization, by a combination of lengthening and growth arrest, be
accomplished. To consider an effort at leg length equalization the patient should have a
straight tibia with no anterior bow, as well as a normal or near-normal foot and a length
discrepancy that is not expected to exceed 7.5 cm. In our experience, if the child has a 5-cm
length discrepancy at birth and an abnormal foot, with or without shortening of the femoral
segment, then the treatment of choice remains ankle disarticulation (Syme type) and
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.
Bilateral Longitudinal Fibula Deficiency, Total

There are two major considerations for patients with complete bilateral longitudinal deficiency
of the fibula and a normal femur: (1) the condition of the feet and (2) the anticipated overall
height of the patient.
Patients with five-rayed feet that are reasonably aligned beneath the tibia will have no
problem in shoe wear. On the other hand, those patients with a three-or four-rayed foot and
associated severe equinus and valgus may require considerable surgery to align the foot
plantigrade, Even after repeated surgical procedures, normal shoe wear may be precluded by
the shape and deformity of the foot. Severe foot deformity may then be an indication for
amputation and prosthetic restoration.
With fibular deficiency there may be a deficiency of the distal end of the tibia and its growth
plate. When the tibia at birth is disproportionately short as compared with the femur or when
there is a severe anterior bow in the tibia, one can anticipate that the discrepancy will be
progressive. In these patients early ankle disarticulation at the age of 1 year to 18 months is
indicated.
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.)
and prosthetic restoration to provide normal stature. When length discrepancy between the
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.
Longitudinal Deficiency of the Tibia

Longitudinal deficiency of the tibia may occur either unilaterally or bilaterally, and it may be
either partial or complete. Its occurrence is much less frequent than fibular deficiency. There
have been several reports of the association of longitudinal deficiency of the tibia with
deficiency of the first metacarpal (absent thumb), as well as with Polydactyly. Although
Eaton and Mc-Kusick in reporting their four cases stated that "no familial cases have been
recorded," Clark has cited 13 case reports of familial occurrence of tibial deficiency that she
found in the literature. She added to it her report of a patient with nine affected descendants
in three generations.
The characteristic clinical picture of tibial deficiency can usually be recognized at birth (Fig
35A-22.). Gross instability of the knee is evident, with or without flexion contracture and
lateral displacement of the fibula. Severe varus of the foot is present, with the sole of the foot
facing toward the opposite leg or even toward the knee or perineum. The knee joint is so
unstable that the foot can almost be brought up against the medial portion of the thigh.
Length discrepancy is the most obvious part of this deficiency. Several patients have an
exostosis or osteochondroma of the femur (Fig 35A-23.). The deficiency may be total or
partial, but at birth it is difficult to be sure of this differential diagnosis. A pterygium may be
present.
Partial Tibial Deficiency

Since the presence or absence of a proximal segment of the tibia is crucial in the treatment
decision, it is important to ascertain this knowledge early in life (Fig 35A-24.). If there is a
suggestion that a proximal tibial segment is present, even though it is not visualized on a
radiograph, it is important to rely on the clinical examination. Ossification of a proximal tibial
segment may not occur for months or even up to 2 years of age. In such patients,
arthrography and other techniques may be of assistance in making a diagnosis. Grissom et al.
have described the use of sonography in the management of tibial deficiencies since
ultrasound examination can define the cartilaginous anlage of the proximal tibial segment that
cannot be visualized radiographi-cally at birth. MRI may also be used, but ultrasound is a
simpler and less expensive examination and does not require the sedation necessary for the
small child who is to have an MRI examination. Partial deficiency of the tibia should be
treated with an orthosis or an orthopros-thesis until one is certain of the ossification of the
proximal fragment and of the presence of the knee joint.
Having established the presence of a proximal fragment and knee joint, the size of this tibial
fragment is the next concern. If the tibial segment is short, less than one third the length of
the normal tibia, the procedure of choice is synostosis of the fibula to the tibia and
disarticulation of the foot (Fig 35A-25.). This produces a long transtibial residual limb. On
occasion, the fibula may migrate proximally above the knee joint (Fig 35A-26.). In our
experience, this has occurred in only one patient. Resection of the proximal half of the fibula
was carried out, and stability of the knee joint was maintained. Tibiofibular synostosis should
prevent this from occurring if it is done early enough.
Procedure for Tibiofibular Synostosis
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
the ankle is then accomplished in the usual fashion. Marquardt has described implantation
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 transtibial-
type 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.).
Longitudinal Deficiency of the Tibia, Complete

With complete longitudinal deficiency of the tibia, the clinical picture is the same as just
described.
In 1965, Brown first reported his experience with construction of a knee joint in patients with
complete longitudinal deficiency of the tibia. His experience dated back to 1957, when he
first implanted the fibula beneath the femur and disarticulated the foot. The residual limb was
fitted into a "transtibial" socket with outside hinges. A limb deficiency that had always been
considered for transfemoral amputation was converted into a "transtibial" prosthetic
restoration. Since that time, many of these procedures have been accomplished. However,
at a long-term review,[*Cooperative Clinic Chief's Meeting, Seattle, 1975.] the high incidence
of recurrent deformity and the need for repeated operative intervention was such that only a
few centers continue to perform this procedure. On occasion, the picture is altered by the
presence of a pterygium between the femur and the fibula. This pterygium may determine the
incision location for surgical intervention.
The treatment of choice is disarticulation at the knee. Resection of the fibula may also be
necessary when there is a severe pterygium. In those patients with unilateral deficiency, this
procedure may be considered as soon as the individual is standing on the normal limb.
Prosthetic restoration and good functional rehabilitation should be anticipated.
Procedure for Knee Disarticulation

In the procedure for knee disarticulation, a skin incision is marked out with a long anterior
flap, which is also wide at its distal portion, and carried to well below the level of the femoral
condyles. The posterior portion of the incision should be marked out at or just below the
popliteal crease. The anterior incision is made and carried down through the subcutaneous
tissues. The anterior capsular structures are divided to enter the knee joint. There may not be
a patellar tendon. Posteriorly, the incision is made and deepened, and the hamstring tendons,
if identifiable, are divided somewhat long and tagged for later suture. The great vessels are
clamped and doubly ligated and the nerves drawn distally, divided, and allowed to retract.
The gastrocnemius origin (if discernible) is severed from the femoral condyles. The capsule
and ligaments are divided and the limb removed. At this point, the tourniquet is released and
all bleeding controlled. The hamstring tendons are sutured to the capsule or ligamentous
structure as available. If a patella and its tendon are present, the patella is left in place, and
the tendon is sutured to the hamstring tendons or posterior capsule. The capsule is closed
over the cartilage of the femoral condyles. Drainage with either a soft-tissue drain or suction
is instituted, and the closure is completed. It should be noted that the long anterior flap
provides good coverage of the femoral condyles and good weight-bearing skin for
subsequent prosthetic wear. The postoperative care may be with rigid dressing or soft
dressing according to the surgeon's preference.
Disarticulation in the presence of a pterygium may pose a surgical dilemma for placement of
the incision. We have resolved this problem by making an L-shaped incision from the base of
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.
Longitudinal Deficiency Femur, Partial (Proximal Femoral

Focal Deficiency [PFFD])
In 1939, Langston described a "congenital defect of the shaft of the femur." Aitken
recognized "the existence of a group of partial deficiencies of the proximal femur involving the
iliofemoral joint" and, since no appropriate terminology existed, used the designation
"proximal femoral focal deficiency." Amstutz has defined PFFD as the "absence of some
quality or characteristic of completeness of the proximal femur, including stunting or
shortening of the entire femur." Aitken described four classes (Fig 35A-29.). In class A there
is an acetabulum. The head of the femur is within the acetabulum, and there is a
subtrochanteric deficit. Class B presents with an acetabulum and a capital fragment within the
acetabulum. There is a short shaft fragment with no bony connection between the two. In
class C there is no acetabulum. One finds a short femoral fragment with a tuft on top. In
Class D there is also no acetabulum. A very short triangular femoral segment is present.
Amstutz further expanded this classification and developed five types. His type 1 included
those patients with what has been described by Aitken as a congenital short femur or coxa
vara with bowing. His other four types approximate the Aitken classes A, B, C, and D. These
morphologic classifications offer assistance in treatment decision primarily with regard to the
hip.
Most reports of PFFD have included only small numbers of cases. Prior to Jan 1, 1968, the
Area Child Amputee Center in Grand Rapids, Michigan, had only 35 cases. In his report,
King was able to review over 100 cases of PFFD collected from various juvenile amputee
clinics throughout the United States. In 1968, Westin and Gunderson were able to gather
165 cases collectively recorded from Shriners hospitals. More recent reports have included
a larger number of patients.
Westin and Gunderson reported a 65% incidence of other defects, with 50% of the patients
having deficiency of the fibula in the same limb. Amstutz and Ait-ken noted a high incidence
of fibular deficiencies in the same limb, as well as other skeletal deficiencies. Kruger and
Rossi reported 31 of 38 patients to have other limb abnormalities, with fibular deficiency in
50% of their patients. Koman et al. described their 50-year experience in the management of
PFFD. Sen-Gupta and Gupta reported four patients with PFFD in one family and stated,
"In the absence of a history of maternal diabetes; premature child birth; exposure to known
teratogenic factors such as irradiation, toxic chemicals, and drugs; mechanical trauma; or
maternal viral infection, the defects appear to be genetic in origin." Only male members
were affected.
Shatz and Kopits reported that "A review of radiographs obtained on one patients maternal
great aunt showed that she had a PFFD with absence of the ipsilateral fibula." Hillmann et
al. reported that a review of 49 patients showed no genetic basis for the diagnosis. Steel et
al. in 1987 suggested iliofemoral fusion for stabilization of the hip in PFFD. However,
others have not been pleased with this procedure since fusing the femoral segment to the
ilium at 90 degrees and permitting the knee to act as a hip joint puts the weight-bearing line
of the limb anterior to the body.
In his early description of the biomechanical losses of lower-limb skeletal deficiency, Aitken
has stressed four points: (1) inequality of leg length, (2) malrotation, (3) inadequacy of
proximal musculature, and (4) instability of proximal joints. PFFD has all four of these
elements of biomechanical loss. Although malrotation, inadequacy of proximal musculature,
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.
Amstutz and Wilson recognized this progressive discrepancy in the length of limbs thus
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.
The Hip Joint

As described by Aitken classes A and B PFFD have an acetabulum present by
radiographic examination at birth, which indicates the presence of a femoral head within the
acetabulum. Types C and D have no acetabulum present by radiographic examination at
birth, which suggests that no femoral head will develop. It is usually impossible to distinguish
between types A and B at birth. As ossification of the capital epiphysis, femoral neck, and
trochanteric portion occur, the distinction can be made.
Class A PFFD can be recognized by radiographic examination when the cartilaginous anlage
of the head and neck have ossified. The head and neck will be connected to the shaft
fragment with a subtrochanteric varus deformity that may be progressive. This subtrochanteric
varus may be associated with subtrochanteric pseudoarthrosis. Correction of the deformity by
subtrochanteric valgus osteotomy may be carried out, and if a pseudoarthrosis, is present,
resection and bone grafting are indicated. If correction is deferred, the subtrochanteric valgus
may increase to such magnitude that it will be difficult to correct it completely at a single
stage, and a two-stage procedure may be necessary. In the first stage the deformity is
partially corrected, and then after 1 or 2 years the operation is repeated to complete the
correction. The goals should be the creation of a neck shaft angle of between 120 and 135
degrees.
The Aitken class B PFFD is characterized by the presence of a head and neck fragment that
has no continuity with the shaft fragment that rides proximal to it. Lloyd-Roberts and Stone
and Lange et al. have found a connection either by fibrous tissue or cartilage between the
two fragments. In either case, between the ages of 3 and 6 years osteosynthesis is indicated
to create a stable hip (Fig 35A-31.). These efforts should be delayed until there is adequate
evidence of bone in the neck fragment so that with grafting, a firm union between the shaft
and neck fragment can be attained. On the other hand, if osteosynthesis is delayed too long,
there is a possibility that the capital fragment may fuse to the acetabulum; in this case,
osteosynthesis should not be carried out since an unstable mobile hip is preferable to a rigid
hip.
Procedure for Osteosynthesis

A lateral incision is made over the proximal shaft of the femur with extension proximally to
the anterosupe-rior spine of the ilium, as with the Watson-Jones approach. The femoral shaft
is exposed subperiosteally and osteotomized at the level of the head-neck fragment. Muscle
insertions, especially if abductors are attached to the proximal fragment, are left intact. The
neck is now exposed, and the capsule is opened to inspect the hip joint. The lateral portion of
the neck is usually covered with fibrous tissue and/or a cartilaginous cap. This lateral aspect
of the neck is nibbled away with a small rongeur to expose a raw bony base in the center of
the cartilage. If the patient is very young, only a small area of bone is available. The shaft
fragment is now brought into opposition with the exposed neck by wide abduction and fixed to
the neck fragment with Kirschner wires. In the case of the older child in whom advanced
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
PFFD, with success in four patients. In their technique, the femoral segment is fused to the
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.
Unilateral Partial Longitudinal Deficiency of the Femur

(PFFD)
Since length discrepancy is the major factor in patients with unilateral PFFD, they may be
divided into three groups: (1) femoral segment less than 20% of the normal side, (2) femoral
segment 20% to 70% of the normal side, and (3) femoral segment greater than 70% of the
normal side.
Short Femoral Segments

Patients with PFFD whose femoral segment is less than 20% of the length of the normal side
are usually either in the Aitken class C or class D. No hip joint is present, and even though
the discrepancy may be moderate at birth, it will become progressive with growth. Definitive
treatment in these patients will be disarticulation at the ankle level and prosthetic restoration
(Fig 35A-32.). As with other limb deficiencies, if the parents have been prepared and
especially if they have attended a clinic and had the opportunity to observe other children
with similar problems, acceptance of this recommendation can be expected. If the parents are
reluctant to accept ablation, then as an alternative an articulated extension prosthesis can be
prescribed. This may be either a temporary measure or permanent if the parents so desire.
As a further option, the Van Nes rotation-plasty, described below, may be considered
Medium-Length Femoral Segments

There are many options available in the treatment of patients with PFFD who have a femoral
segment measuring 20% to 70% of the length of the normal femur. A treatment plan should
be developed with the emphasis on early management for the prevention of deformity at the
hip and the knee. Orthoses may be prescribed, as well as a stretching and exercise program.
If the parents are resistant to surgical intervention or if surgical intervention is to be deferred
beyond the time of expected ambulation, the child may be fitted with a platform orthosis or an
extension prosthesis without amputation.
When the femoral segment approaches 70% of the length of the femur on the normal side
and full knee extension and quadriceps power have been maintained, disarticulation at the
ankle and prosthetic restoration with a Syme-type prosthesis are indicated (Fig 35A-33.).
Although knee levels are unequal and therefore stride length is unequal, these patients
manage very well.
Children with shorter femoral segments may have developed a flexion-external rotation
deformity of the hip and associated knee flexion deformity. The weight-bearing line is
therefore anterior and lateral to the weight-bearing line of the body, and these children do not
do well. Knee fusion, which should be carried out in full extension, will establish a single
skeletal lever. King and Marks have pointed out that with knee fusion, the flexion-abduction-
external rotation deformity at the hip will spontaneously correct without surgical intervention.
The single skeletal lever then comes into the weight-bearing line, and not only does the
gait improve, but also the strength of the muscles about the hip. Recurrent flexion may later
appear through the epiphyses. King and Marks have attributed this reoccurrence to the
Hueter-Volkmann law. Recurrent flexion deformity through the knee fusion should be
corrected by osteotomy (Fig 35A-34.).
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 Nes rotation-plasty may be considered in conjunction with knee fusion. The Van
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.
Procedure for Van Nes Rotation-Plasty

Tourniquet control is optional in the Van Nes rotation-plasty, but preferred. After the usual
preparation and draping, an incision is made from the anteromedial proximal portion of the
tibia slightly obliquely to the anterolateral aspect of the ankle level. The diaphysis of the tibia
and fibula (when present) are exposed. Short segments of Kirschner wire may now be
inserted into the proximal and distal ends of the tibia to be used as a reference point for
rotation, or if desired, the tibia can be marked prior to resection for this purpose. According to
the prior plan, depending on the age of the patient and the amount of shortening desired, 5
to 7.5 cm of tibia is resected and approximately 2.5 cm more of the fibula. The fibula may be
reserved to use as a central bone graft for added stability. The tourniquet is released and
bleeding controlled.
If adequate bone has been resected, rotation of the distal segment 180 degrees poses no
circulatory problem, and fixation of the tibial fragments may be accomplished with a
compression plate and screws. If there is any question of circulatory impairment, either
additional tibia may be resected, or parallel Kirschner wires may be used above and below
the osteotomy resection site for control of the fragments and the reserved fibula used as a
central bone graft to prevent displacement. The skin wound is closed, with no effort made to
close the deep structures. Again, circulation of the foot is observed, and if satisfactory, the
limb is immobilized in plaster.
Long Femoral Segment

Patients with femoral segments greater than 70% of the length of the normal side usually
have a variation of coxa vara with bowing, or what Aitken terms a congenially short femur. He
does not include either of these conditions in the PFFD category, even though they are a
manifestation of a deficiency in the proximal end of the femur. These patients must be
observed and growth charts maintained, and as a rule they may be treated as having a
length discrepancy problem. Options to be considered include (1) lengthening of the short
femur, (2) growth arrest at the normal knee epiphyses, (3) shortening of the normal femur, or
(4) a combination of lengthening and growth arrest. If there is no reasonable hope for
equalization of leg lengths, disarticulation at the ankle and a Syme-type prosthesis are
considered as a method of leg length equalization rather than resorting to excessive
shortening of the patient's overall height.
Although patients with coxa vara and bowing of the femur or a congenitally short femur
appear to benefit from subtrochanteric valgus osteotomy, development of the acetabulum
must be carefully observed. If acetabular dysplasia is present, valgus osteotomy is
contraindicated.
Bilateral Partial Longitudinal Deficiency of the Femur (PFFD)

Patients with bilateral PFFD may be divided into two groups : the symmetrical, in which the
length of the limbs is approximately equal, and the asymmetrical, in which there is a
discrepancy in length between the two limbs so that to stand on the feet the patient is
required to excessively flex one hip and knee while the other is extended. Asymmetry may
result from a difference in length of the remaining femoral segment or from a concomitant
fibular or tibial deficiency on the short side.
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
management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly.

Washington, DC, National Academy of Sciences, publication no 1734, 1969.
4. Aitken GT: Tibial hemimelia, in Aitken GT (ed): Selected Lower Limb Anomalies.
Washington, DC, National Academy of Sciences, 1971.
5. 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.
6. 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.
7. Badgley CE, O'Connor SJ, Kudner DF: Congenital ky-phoscoliotic tibia. J Bone Joint
Surg [Am] 1952; 34:349-371.
8. Bevan-Thomas WH, Miller EA: A review of the proximal femoral focal deficiencies. J
9. Bohne WHO, Root L: Hypoplasia of the fibula. Clin Or-thop 1977; 125:107-112.
10. Borggreve J: Kniegelenksersatz durch das in der Bein-langsachse um 180 gedrehte
Fussgelenk. Arch Orthop Chir 1930;28:175-178.
11. 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.
12. Brown FW: The Brown operation for total hemimelia tibia, in Aitken GT (ed): Selected
Lower Limb Anomalies. Washington, DC, National Academy of Sciences, 1971.
13. Clark MW: Autosomal dominant inheritance of tibial meromelia. J Bone Joint Surg [Am]
1975; 57:262-264.
14. Corner EM: The clinical picture of congenital absence of the fibula. Br J Surg 1913;
1:203-206.
15. Coventry MB, Johnson EW Jr: Congenital absence of the fibula. J Bone Joint Surg
[Am] 1952; 34:941-955.
16. Doig WG: Proximal femoral phocomelia. In proceedings of the Australian Orthopaedic
Association. J Bone Joint Surg [Br] 1970; 52:394.
17. Eaton GO, McKusick VA: A seemingly unique Polydactyly-syndactyly syndrome in four
persons in three generations. Birth Defects 1969; 5:221-225.
18. Epps CH Jr: Current concepts review. Proximal femoral focal deficiency. J Bone Joint
Surg [Am] 1983; 65:867-870.
19. Farmer AW, Laruin CA: Congenital absence of the fibula. J Bone Joint Surg [Am] I960;
42:1-12.
20. Fixsen JA, Lloyd-Roberts GC: The natural history and early treatment of proximal
femoral dysplasia. J Bone Joint Surg [Br] 1974; 56:86-95.
21. Frankel VH, Gold S, Golyakhovsky V: The Ilizarov technique. Bull Hosp J Dis Orthop
Inst 1988; 48:17-27.
22. Friscia DA, Moseley DF, Oppenheim WL: Rotational osteotomy for proximal femoral
focal deficiency. J Bone Joint Surg [Am] 1989; 71:1386-1392.
23. Gillespie R, Torode IP: Classification and management of congenital abnormalities of
the femur. J Bone Joint Surg [Br] 1983; 65:557-568.
24. Grissom LE, Harcke HT, Kumar SJ: Sonography in the management of tibial
hemimelia. Clin Orthop 1990; 251:266-270.
25. Hillmann JS, Mesgarzadeh M, Revesz G, et al: Proximal femoral focal deficiency:
Radiologic analysis of 49 cases. Radiology 1987; 165:769-773.
26. Hootnick DR, Levinsohn EM, Packard DS Jr: Midline metatarsal dysplasia associated
with absent fibula. Clin Orthop 1980; 150:203-206.
27. Jayakumar SS, Eilert RE: Fibular transfer for congenital absence of the tibia. Clin
Orthop 1979; 139:97.
28. Johansson E, Aparisi T: Missing cruciate ligament in congenital short femur. J Bone
Joint Surg [Am] 1983; 65:1109-1115.
29. 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; 60:31-
39.
30. Kalamchi A, Cowell HR, Kim KI: Congenital deficiency of the femur. J Pediatr Orthop
1985; 5:129-134.
31. Kalamchi A, Dawe RV: Congenital deficiency of the tibia. J Bone Joint Surg [Br] 1985;
67:581-587.
32. King RE: Providing a single skeletal lever in proximal femoral focal deficiency. A
preliminary case report. Inter-Clin Info Bull 1966; 6:23-28.
33. 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.
34. King RE, Marks TW: Follow-up findings on the skeletal lever in the surgical
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. Inter-
Clin 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.
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;
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; 47:1159-
1169.
75. Yelton CL: Certain congenital limb deficiencies occurring in twins and half-siblings.
Search
GO
Lower-Limb Deficiencies: Prosthetic and Orthotic Reproduced with

Bowker HK,
Michael JW (eds):
Daniel G. Oglesby, Jr., C.P.O. Atlas of Limb
Carmen Tablada, C.P. Prosthetics:
Providing prosthetic and orthotic care for the limb-deficient child involves more than simply Rehabilitation Principles.
supplying the proper componentry. The psychological impact on the parents and family must
also be considered. In most cases the very young child has no awareness of being different 1992, reprinted 2002.
from his peers. It is only from the reactions of his parents and others that he learns about his
disability. Much of the material in this text
The prosthetist is often able to help the family deal with these issues by discussing their in Atlas of Amputations and Limb
concerns openly and calmly and by providing prosthetic care that encourages a normal Deficiencies: Surgical, Prosthetic,
developmental sequence for the child. Fitting and delivery of new devices must be timely to and Rehabilitation Principles
avoid adding to the child's feelings of being unable to keep up with his family and friends.
Referral to a local support group can often help the family faced with the new challenge of Academy or Orthopedic Surgeons.
limb deficiency. Only occasionally is referral to a professional for counseling necessary. Click for more information about
this text.
For the child with an acquired limb loss due to tumor or accident, there may be the added
factors of fear of death or guilt over the circumstances of the amputation. The emotional
scars can be even more devastating than the physical loss. The prosthetist's role is to help Funding for digitization
keep the child actively involved in normal daily activities. A well-fitted fully functional of the Atlas of Limb
Prosthetics was
prosthesis can help keep the child and the family focused on constructive adaptation.
provided by the
DEVELOPMENTAL STAGING OF COMPONENTRY American Academy of Orthotists &
Prosthetists
The basic principle in pediatric prosthetics is to provide components that are appropriate to
the child's developmental stage. Although sophisticated mechanisms have a role in
prosthetics, children's devices usually emphasize simplicity and reliability. General guidelines
based on experience with many children over time can be given for when to provide a
particular level of complexity. The optimum time to utilize a component for a specific child,
however, must be individually determined by the clinic team. You can help expand the
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
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 (½ 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 toe-
out 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 solid-
ankle, 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
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
increasing concern for both boys and girls. This is also a time of transition for the
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.
CONSIDERATIONS BY LEVEL OF AMPUTATION

As has been discussed, the primary factor in selection of prosthetic componentry is
developmental readiness. Beyond that, durability and function become significant
considerations. During the "sandbox years," simplicity and repairability may be prime
requirements; as adulthood approaches, much more sophisticated prostheses are increasingly
common.
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 partial-
foot 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
orthosis (AFO) is one solution. Another approach is to provide a flexible laminated rubber
"boot" for both function and better cosmetic appearance.
Syme Ankle Disarticulation

The Syme and similar levels play an important role in pediatric amputations since the growth
plates are preserved (when compared with a transtibial level) and the risk of bony overgrowth
is avoided. Furthermore, most children with Syme or Boyd amputations can ambulate short
distances without any prosthesis. For the very young child there is often insufficient
discrepancy to provide a commercial foot mechanism; the discrepancy usually increases as
the child matures due to more rapid growth on the uninvolved side. Epiphysiodesis just prior
to the cessation of growth is always an option. The SACH foot has been the only option until
recently. Dynamic-response feet have been well received by adults, and some types are
beginning to appear in pediatric sizes.
Transtibial (Below Knee)

Foot components are selected according to the function desired, as in adults. SACH remains
most common, but dynamic-response designs, particularly for the older child, have also
been well received. Many methods of suspension are suitable for this population. Cuff
suspension alone may stress the ligaments if not reattached regularly as the child grows.
Although a loose cuff or fork strap attached to a waist belt is more forgiving, such belts are
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.
Transfemoral (Above Knee)

The same controversies that exist regarding adult sockets apply to pediatric designs.
Ischial containment and quadrilateral contours have both worked well with this age group.
Many prosthetists elect to use an individualized shape for growing children that is based on
the cast impression of their residual limb. The presence of significant body fat or the use of
bulky diapers dictates a unique shape for the small child's socket. Knee criteria have been
previously discussed; a free knee is unnecessary for the very young child.
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.
Proximal Focal Femoral Deficiency

This limb deficiency warrants individual discussion because of the complex clinical picture it
presents. Not only is there a significant limb length discrepancy, but hip joint involvement is
also common. Hip abduction and flexion contractures are common. The knee is often
unstable and may be difficult to palpate within the short, fleshy thigh tissues. All those
factors complicate prosthetic management.
Prosthetic restoration is geared to minimize the excessive trunk bending and internal rotation
of the hip that typify proximal femoral focal deficiency (PFFD) gait. This is accomplished by
meticulous casting of the affected leg and pelvis while maintaining the proper rotation and
hanging angle. Careful molding is necessary to achieve good ischial weight bearing rather
than posterior-thigh weight bearing. In cases where the foot remains, it must be molded in a
plantar-flexed position that allows good cosmesis yet permits some weight bearing on the
sole of the foot. For those with telescoping hip joints, maximum elongation during casting
improves ischial weight bearing during stance.
Transparent test sockets are invaluable in evaluating the above factors. Remodification of the
positive model and fitting with a revised test socket is often required. Dynamic alignment is
individualized but must take into account the child's age, physical findings, and any additional
abnormalities. For those with concomitant upper-limb involvement, the socket brim may be
utilized as a control cable anchor point.
In some cases, the clinic may elect to initially fit the young child with shoe buildups and/or an
AFO. Once the child has grown somewhat, fitting with an extension prosthesis or ablation of
the foot and fitting with a modified knee disarticulation prosthesis may be undertaken.
Rarely, Van Nes rotation-plasty may be performed and the child is fitted with a modified
transtibial prosthesis. Bilateral PFFD is a special circumstance, and surgical intervention is
generally avoided. Definitive treatment with orthotic devices or with extension prostheses may
be offered. As the child with bilateral PFFD grows and the extension devices become longer,
endurance and balance are reduced. Many abandon external devices as they approach
adulthood and choose to ambulate unencumbered.
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
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.
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.
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; 29:11-
18.
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.
36A: The Multiple-Limb-Deficient Child | O&P Virtual Library
Search
GO
Special Considerations: The Multiple-Limb-Deficient Reproduced with

Child permission from
Bowker HK,
Michael JW (eds):
Ernst Marquardt, M.D. Atlas of Limb
Prosthetics:
Prior to the 1950s adult prosthetics in Germany ranged from good to excellent in both the Surgical, Prosthetic, and
quality of the prosthesis and medical care. However, for children, each prosthetist had to build Rehabilitation Principles.
on his own personal experiences. There was no systematic treatment of the limb-deficient
child, nor were there organized limb deficiency clinics or child amputee clinics. There was no 1992, reprinted 2002.
special education or organized interchange of ideas, practices, and experiences among
workers with child amputees. No center was able to claim the presence of a complete clinic Much of the material in this text
team, such as that started in Grand Rapids, Michigan, or other similar teams in the United has been updated and published
States. There were no special devices or equipment for children's prosthetics. Patients with in Atlas of Amputations and Limb
congenital limb deficiencies were treated on an individual basis in the regular orthopaedic
hospitals. In some of these hospitals, such as in Berlin, Hannover, Heidelberg, Miinster, and (retitled third edition of Atlas of
Volmarstein, experience in certain limb deficiencies existed in the orthopaedic and prosthetic Limb Deficiencies), ©American
services. However, they did not work together as a full team, and each center developed its Academy or Orthopedic Surgeons.
own ideas without exchange of ideas with others in the same field. Click for more information about
this text.
The philosophy of upper-limb devices centered on the development of technical aids for limb-
deficient persons. Soft leather sockets for transradial amputees had adaptors so that spoons,
forks, pencils, or other items could be attached directly to the prosthesis. In 1917, Biesalski
demonstrated a 9-year-old boy with new bilateral terminal devices. On one side, the boy Prosthetics was
had the "Finger-Klaue" and, on the other side, the "Spann-Klaue," both developed by Fischer provided by the
in Berlin. This boy was able to demonstrate that both of these were as practical as the Northern Plains Chapter of the
hook; however, these terminal devices were not widely used and were soon forgotten. American Academy of Orthotists &
Prosthetists
It was widely assumed that children with transverse deficiencies of the upper limbs or children
with traumatic amputations should be fitted with prostheses only after they had completed
their growth. Because of this philosophy, it is understandable that the Krukenberg procedure
had greater acceptance in Germany than in the United States. With this procedure, the
bilateral amputee was able to achieve independence in many of the activities of daily living.
For the very high upper-limb amputee, the Heidelberg pneumatic prosthesis gave additional You can help expand the
independence for some individuals but did not have a wide sphere of influence. O&P Virtual Library with a
Lower-limb prostheses for children were even more provincial and personalized. They were
generally fitted with the most simple walking devices that could be constructed. Many of these
were stirrups fixed by splints or leather sockets that functioned as extensions.
THE BEGINNING OF MODERN PROSTHETICS

The 1950s proved to be an exciting and revolutionary time for children's prosthetics in
Germany. Three factors were central to the changes that occurred in the field. The first of
these was the visit of the German Study Group to the United States in 1952 and the
outpouring of new ideas resulting from this stimulation. The second was the international
cooperation that developed with Kessler of New Jersey, who provided advice and stimulation
to his German colleagues in the development of comprehensive clinic programs. The third
event was the thalidomide catastrophe.
In 1952, the German orthopaedic surgeon Hepp and a group of experts in prosthetics came to
the United States to review the progress and problems encountered in the prosthetic centers
in that country. In the following years, Hepp and his coworker Kuhn developed special
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
develops activities of daily living. Following these experiences, we developed the Pat-A-
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 multiple-
limb-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 treatment of a limb-deficient child is centered in the family, not in the hospital. The
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.
The provision of an actively powered prosthesis starts about the beginning of the second year
of life. Shoulder movements or, if present, small digits emanating directly from the
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 pho-
comelic 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 body-
powered 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
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.
SPECIAL SURGICAL PROCEDURE FOR THE MULTIPLE-

LIMB-DEFICIENT CHILD
A number of surgical procedures have been used to advantage in children with multimembral
deficiencies and might have application only occasionally in selected cases of single-limb
deficiency. Because of the degree of functional disability in patients with multiple deficiencies,
procedures that are designed to provide even limited improvement in function are more
frequently indicated. Several procedures that have been used to treat bony overgrowth,
enhance function of transhum-eral prosthetic use, and provide surgically assisted prehension
in a forearm stump as well as considerations in the positioning of residual prehensile
members are reviewed in some detail.
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
osseous overgrowth that uses autogenous cartilage-bone transplants. The goal is
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 quadrimembral-
deficient 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.
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 skin-
manual stretching by the mother. New sockets were prescribed. In October 1975, there was
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 stump-
capping 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 90-
degree 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.
Angulation Osteotomy of the Humerus

An amputee with a long transhumeral deficiency can use a body-powered prosthesis quite
effectively. With the conventional fitting, however, the important and useful function of active
pronation and supination of the forearm is absent. This may be provided by passive rotation
of the terminal device at the wrist, but must be preset by the patient. This is particularly
difficult for the bilateral transhumeral amputee to accomplish. In addition, mediolateral
positioning of the forearm segment and terminal device through humeral rotation is usually
deficient in strength and range. Passive rotation through a turntable elbow unit or the use of
an externally powered rotation unit has never been completely satisfactory.
Although most amputees with long or middle-length stumps have essentially normal shoulder
function and strength, full abduction and, particularly, full shoulder rotation cannot be
transmitted through the stump-socket interface to the terminal device with the conventional
transhumeral fitting.
In an effort to provide the transhumeral amputee with a simpler and more effective prosthetic
device that might help to provide these additional functions, I have developed a technique of
angulation osteotomy of the humeral stump. Following this osteotomy of the distal portion of
the humerus, an open-socket prosthesis suspended only by two straps may be used. In
the long transhumeral amputee the dorsal end of the stump may be left exposed for tactile
sensation. With this fitting, the artificial elbow joint is set somewhat proximal to the distal end.
External locking hinges are used. In the middle-length stump the distal angulated humeral
segment is maintained by one or two straps. This strap suspension is easy for the bilateral
amputee to apply himself. More important, however, is that it frees the shoulder for full
abduction and elevation, as well as allows full internal and external rotation to be transmitted
to the prosthesis. The flanges necessary for stability in the conventional prosthesis are
eliminated, and rotational stability and motion are provided by the angulated distal end of the
stump in the socket. When the forearm is in a moderately extended position, the humeral
rotation can also transmit a useful amount of pronation and supination at the terminal device.
The angulation osteotomy should be used primarily for the bilateral long transhumeral
amputee as well as for the elbow disarticulation stump with hypoplastic humeral condyles. In
the case of middle-length stumps, however, the shortening of the humerus conditioned by the
length of the angulated humeral segment should be measured before surgery by help of a
radiographic sketch. The angulation osteotomy is contraindicated if the stumps would be
unable to touch each other in front of the chest after surgery or additional stump lengthening
would be indicated.
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.
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."
The Krukenberg Procedure

In 1917, Hermann Krukenberg developed an operative procedure to convert a long transradial
amputation stump into a pincer-like grasping organ with tactile sensation. This operation
has not received wide acceptance in the United States, probably due to cosmetic objections,
but in Germany and elsewhere it is quite widely used.
It has been generally accepted that the prime indication for the Krukenberg procedure is the
bilateral transradial amputee who is blind and absolutely requires tactile sensation for
independence. Children with mul-timembral deficiencies, however, who have bilateral long or
medium-length transradial stumps should also be considered for this procedure. Swanson
reports on excellent results in children and extends the indication "for patients living in areas
where prosthetic services are unavailable. . . .The advantages of readily available prehension
with sensation are significant, especially in dressing, bathing, eating and toilet activities."
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
distal part of the forearm were excised. Bauer, in 1949, described a similar incision but
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
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 L-
shaped 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
dissected and preserved. The supinator will become the major adductor. The pronator
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.
If healing is satisfactory, physical and occupational therapy may be started. The voluntary
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
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 open-
end 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.
Surgical Considerations in the Radial Clubhand

The implication of radial clubhand as a component of multiple deficiencies is quite different
from when it occurs as an isolated anomaly. In the child with multi-membral anomalies in
which longitudinal deficiency of the radius (radial clubhand) is present, consideration of the
contraindications to surgery deserve more emphasis than do the indications. The position of
uncorrected deformity in the bilateral case may have very significant functional advantages,
which should not be sacrificed in attempts at cosmesis.
It has already been emphasized that in the infant and small child the shortened arm must be
left exposed and not covered or concealed by clothing, as parents often are wont to do, so
that the child will develop maximum function of the fingers, elbow, and shoulder. During the
day, the hands and fingers should be free for play. In addition, corrections with traction,
shown and controlled by the physical therapist, should be done by the mother or father every
day several times to minimize the contracture. Splints to maintain the corrected position are
used, if at all, only at night. Most important is the physical therapy program to emphasize
maximum mobility of all joints.
In watching and assessing the developing function in these children the careful observer will
note important compensatory functions that depend on the radial positioning of the hand.
Many of these patients have limited elbow flexion, and radial abduction of the wrist is an
important substitution to bring the hand to the mouth or face. Radial abduction combined with
volar flexion is often used for grasping. Hypermobility of the wrist and metacarpals substitutes
for lost pronation and supination (Fig 36A-19.). and greatly enhances dexterity. In the radial
clubhand the fifth finger is much more often used for fine pinch than is the index finger, when
there is a hypoplastic or absent thumb, and may be more suitable for pollicization than the
index in terms of useful function.
The range of motion of finger joints, particularly the metacarpophalangeal joints, is important
in assessing function. In many of these children the power of the hook created by radial
deviation of the hand is the only power grasping action. They will develop fine grasp between
the fingers, especially on the ulnar side.
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
hand (Fig 36A-20.). The contraindications should be recognized. The most important is
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 quadrimembral-
deficient child, however, I still prefer, as do Witt et al., to do these surgical procedures only
after the completion of growth provided that, in spite of conscientious examination and
observation, there are no major contraindications (Fig 36A-21.).
Surgical Procedure (Centralization of the Hand)

Where indicated, surgical correction of the radially deviated hand for centralization is carried
out in two stages. The first, only for cases without the possibility of passive correction, is
primarily a procedure in the form of a Z-plasty of the skin on the radial side of the wrist with
soft-tissue release. After developing the skin flaps, the fascial contractures are released
and tendons lengthened as necessary. This may be adequate to allow correction of the radial
deviation, but in severe deformity it may be necessary to open the radial side of the wrist joint
capsule. In this process care must be taken in the volar dissection to identify and protect the
radially displaced median nerve. As the hand is deviated in an ulnar direction, care must be
exercised to avoid stretching the nerve, which may, in fact, limit the extent of correction at
this first stage. With the desired correction attained, the flaps of the Z-plasty are reversed and
the wound closed.
The hand is positioned to avoid tension on skin sutures, and the correction is maintained in a
plaster of paris dressing. Postoperative therapy emphasizes function and motion of the
fingers. In some instances, especially in patients with acutely angulated radial abduction who
require the function of the clubhand position, this procedure is adequate to obtain enough
correction to increase the range of movement without losing this functional need. In other
instances, this procedure is a preliminary release of the shortened radial structures to permit
bony centralization of the hand on the ulna with a minimum of shortening of the bony
elements.
The second stage is accomplished after the conclusion of growth and after thorough healing
of the first stage through an S-shaped dorsal incision beginning on the ulnar side of the distal
forearm, curving around the styloid of the ulna, transversely crossing the proximal wrist, and
then turning distally to the base of the second metacarpal. The transverse portion of the
incision is superficial, and the large dorsal veins and cutaneous nerves, as well as the
extensor tendons, remain intact and protected. These structures are then elevated from the
underlying ulna and dorsal carpal ligaments as an intact soft-tissue bridge beneath which the
procedure is completed.
The dorsal capsule is then elevated from the ulna and dissected distally to expose the carpus.
The carpal bones are seldom normal. For the most part the carpal bones on the radial side of
the wrist are extremely hypoplastic or absent. Frequently there are various degrees of
synostosis of the carpal bones. The region of the lunate bone in the synostosis is excavated
to form a bed for reception of the shortened ulna. The ulna is shortened sufficiently to obtain
full correction of the clubhand. If the lunate and triquetral bones are separate, I propose
excavating both of them while carefully protecting their distal joints to prevent displacing them.
These two bones together have a larger base and with it a better resistance against recurrent
deformity than does the lunate bone alone. The excellent mobility of the joints distal to these
bones with regard to dorsi-flexion and volar flexion will be preserved, and we should save
mobility and function for the multimem-bral-deficient person as much as possible without
increasing the risk of recurrent deformity. If there is insufficient shortening to permit
centralization without excessive soft-tissue tension or if the lunate bone is too dysplastic, the
lunate may be excised completely and the bed for the reception of the ulna excavated in the
capitate bone or in the distal portion of the synostotic carpal block. Other hand surgical
techniques for correction of the radial clubhand have been described by Blauth and
Schneider-Sickert and by Buck-Gramcko, as well as by Lamb et al. in "Suggested
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.
Procedure With a Hypoplastic Radius (After the Growth Period)

For those patients in whom the radius is hypoplastic rather than absent and radial deviation
of the hand is present, no attempt should be made to perform arthrodesis to the wrist. The
procedure should be a release of the contracted structures on the radial side of the wrist,
followed by elevation of a capsular flap and shortening by removal of a segment of the ulna
while preserving approximately 2 cm of its distal end. The ulna should be shortened to a level
of about 1 mm proximal to the distal end of the radius. A wedge of bone with its base
ulnarward and dorsalward is removed from the distal carpal row. When the wedge defect is
closed, centralization and correction of the deformity is obtained (Fig 36A-22.). As with the
other procedures, care must be taken to not place the neurovascular structures under
tension. Circulation must be checked prior to internal fixation with crossed
Kirschner wires. In this procedure an additional technical detail should be noted. In reducing
the shortened ulna, the distal fragment should be externally rotated slightly so that the line of
pull of the extensor carpi ulnaris within its groove is partly changed to that of ulnar abductor.
This tendon should be shortened proximal to the ulnar styloid process under sufficient tension
so that it prevents passive radial deviation of the wrist. Immobilization and aftercare are
similar to the procedure previously described. Nowadays the lengthening of the radius,
instead of the described shortening of the ulna plus wedge resection, would be possible. The
correction with shortening of the bones, however, is less risky with regard to function of the
fingers. Too much tension on the tendons may have fateful consequences for the future
function of the hand, even if blood supply and sensation are intact. This is true during the
whole period of lengthening and underlines the need for careful observation and daily medical
examinations.
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-year-
old 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
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 lower-
limb 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 end-
bearing 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.
Reconstruction and Prosthetic Fittings for Multiple-Limb Deficiency

The child in Fig 36A-24 (a-d). and Fig 36A-24 (e-h). was born Sept 17, 1968, to healthy
parents with a 3-year-old normal sibling. There was, however, a significant family history in
that he was born with a twin who had limb deficiencies as well (Fig 36A-25 (a-d). and Fig
36A-25 (e-i).). There was an additional history of the father's sister having given birth to twins
who died at birth with unknown limb deficiencies. There was no history of unusual medication
during the pregnancy.
At the time of birth, the infant was noted to have bilateral upper-limb deficiencies consisting of
total longitudinal deficiency of the ulna, partial carpal deficiency, and a total
metacarpophalangeal deficiency of digits 2 through 5. There was additionally hypoplasia of
both the radius and humerus, as well as a flexion deformity at the radiohumeral joint. The
child had bilateral longitudinal deficiencies of the lower limbs consisting of a total tibia, a
partial tarsal, and total metatarsophalangeal deficiencies of digits 1 through 3. The
combination of total ulna and tibia longitudinal deficiencies is extraordinary. There was also a
left coxa vara with bowing and hypoplasia of the femur. The child's twin was born with
bilateral lower-limb deficiencies (Fig 36A-25 (a-d). and Fig 36A-25 (e-i).).
The patient was first seen in April 1972, at which time training in the activities of daily living
was immediately instituted. Bilateral pneumatic upper limbs were prescribed for the child and
reconstruction of the knees and feet undertaken. In August 1972, he was fitted with his first
lower-limb prostheses. The initial fitting was temporary plaster of paris sockets with solid-
ankle, cushion-heel (SACH) feet. These were replaced by orthoprostheses with stiff knees
and SACH feet (Fig 36A-24 (a-d).,D). In December 1972, the child was ambulatory.
Meanwhile, his training with the upper-limb prostheses was quite satisfactory, and he was
able to feed himself as well as play by using the artificial limbs. Further efforts at
reconstruction concluded in June 1977, with arthrodesis of both knees, partial-foot
amputation, and stabilization of the astragalus to the fibula bilaterally (Fig 36A-24 (e-h).,E
and F). Knee disarticulation was contraindicated because of the hypoplasia of both femora
and also to preserve his independence. Use of transfemoral prostheses would have required
the help of others to don them. Following this surgery, the child was fitted with new
orthoprostheses. The prescription included plastic transfemoral sockets with windows and
Velcro suspension, knee joints with Swiss locks, and articulated feet. Again, he became
ambulatory and independent in donning and doffing his four prostheses. New limbs were
prescribed in February 1979. The patient is fully ambulatory, wears his lower limbs full-time,
and is able to play soccer while wearing them, but at home he likes to walk on his stumps.
He used his upper limbs approximately 8 hours a day for years, attended regular school and
high school, and is independent in eating and drinking, writing, and other activities of daily
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.
Reconstructive Surgery in Upper and Lower Limbs Prior to Prosthetic

Fitting
The child in Fig 36A-27 (a-d). and Fig 36A-27 (e-h). was born of healthy parents on May 15,
1961. The history, however, reveals that at approximately 6 weeks after her last menstrual
period, the mother of the patient ingested thalidomide for a period of 3 days for surgery. The
pregnancy was uneventful with a normal birth. The child had the following limb deficiencies:
upper limbs showed bilateral hypoplasia of the radius with partial carpal absence and, on the
right, partial absence of metacarpophalangeal 1, whereas on the left, metacarpophalangeal 1
was totally absent. In the lower limbs there was bilateral total longitudinal deficiency of the
tibia, with coxa vara of the femur on the right and a longitudinal deficiency of the proximal
portion of the femur on the left (Aitken class A) and subtrochanteric pseudarthrosis.
The patient was first seen in 1964, prior to which he had been fitted with stubby prostheses
at the University of Tubingen. Shortly thereafter, centralization of the fibula under the femur
and of astralgus under the fibula was carried out at Tubingen for stiffness on the right. In
1967, orthoprostheses as well as a night splint were provided, and he began a physical
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 full-
time 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).
Hip Disarticulation Prostheses for Bilateral Lower-Limb Deficiency

This child was born Nov 4, 1962 (Fig 36A-28 (a-c). and Fig 36A-28 (d-h).). There was no
family history of limb deficiencies, and his two siblings were normal. There was no history of
ingestion of any medication during the pregnancy.
The child was born with bilateral transverse lower-limb deficiencies, deficiency of the upper
third of the thigh, and a transverse deficiency of the forearm, proximal third (with a very short
ulna segment remaining). He had other congenital anomalies.
The child was first evaluated in November 1972, at which time he was using primarily a
wheelchair but was able to get around on the floor by using his hands. He was also noted to
have a scoliosis. Bilateral lower-limb prostheses were prescribed with automatic knee locks in
the stance phase and automatic combined hip and knee flexion for sitting. A left transhumeral
prosthesis was constructed with a crutch attached to the functional hand for ambulation.
These prostheses were first applied July 1973, and after 4 weeks of training he was able to
ambulate on a level surface and, with considerable effort, even manage stairs. He was also
able to sit and stand independently. Stairs were particularly important because without this
ability, he would not be permitted to attend high school at home but would have to attend a
special school. In 1974, his upper-limb prosthesis was changed to a cable-controlled Hosmer
outside-locking elbow with a Dorrance 10X hook interchangeable with an Otto Bock hand. He
was additionally supplied with a cosmetic forearm prosthesis for swimming. His lower-limb
socket had to be changed in 1976, again in 1978, and most recently in 1979 to extend the
socket somewhat proximally to act as a support for his progressive scoliosis. It was believed
that because of his problems in ambulation with bilateral hip disarticulation-type prostheses,
Harrington instrumentation should not be considered.
CONCLUSION
An effort has been made to document a philosophy for management of the multimembral-
deficient 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.
SUGGESTED READINGS
Boos O: Die Versorgung von Ohnhandern. Stuttgart, West Germany, FK Schattauer Verlag,
1960.
Gocht H: Atiologie, Pathogenese und Therapie der Deformi-tiiten im allgemeinen, in Hoffa A

(ed): Orthopddische Chirurgie. Stuttgart, Germany Ferdinand Enke Verlag, 1925.
Hepp O: Information on Measures for Habilitation for Children With Dysmelia. Heidelberg,
Deutsche Vereiningung fur die Rehabilitation Behinderter, 1963.
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; 60:30-39.
Kallio KE: Recent advances in Krukenberg's operation. Acta Chir Scand 1948; 97:165.
Kelikian H: Congenital Deformities of the Hand and Forearm. Philadelphia, WB Saunders Co,
1974, pp 780-824.
Kessler HH: Cineplasty. Springfield, 111, Charles C Thomas Publishers, 1947.
Kuhn GG: Neue technische Hilfen fur schwer Korperbe-hinderte kinder, in Baumgartner R
(ed): Amputation und Prothesenversorgung beim Kind. Stuttgart, West Germany, Ferdinand
Enke Verlag, 1977.
Lamb DW: Radial club hand. J Bone Joint Surg [Am] 1977; 59:1-13.
Manske PR, et al: Centralization of the radial clubhand: An ulnar surgical approach. J Hand
Surg 1981; 6:423-433.
Marquardt E, Neff G: The angulation osteotomy of above-elbow stumps. Clin Orthop 1974;
104:232-238.
Martini AK: Klumphandkorrektiir nach Wachstumsabschliits. Handchirurgie 1980; 12:229-233.
Nathan PA, Nguyen BT: The Krukenberg operation; a modified technique avoiding skin grafts.
J Hand Surg 1977; 2:127-130.
Sauerbruch F: Die willkiirlich bewegbare kiinstliche Hand, Eine Anleitung fur Chirurgen and
Techniker mit anato-mischen Beitnigen von G. Ruge and W. Felix unter Mitwirkung von A.
Stadler, Berlin, 1916, Julius Springer Verlag, 1916.
Thomsen W: Diskussionsbeitrag zum Thema Krukenberg-Plastik. Verh Dtsch Orthop Ges

1949; 36:60-61.
Willert HG, Henkel HL: Klinik und Pathologie der Dysme-lie. Die Fehlbildungen an den
oberen Extremitaten bei der Thalidomidembryopathie, in Experimentelle Medizin, Pathologie
und Klinik, vol 26. Berlin, Springer-Verlag, 1969.
References:
1. Bauer KH: Zum Problem der Ohnhanderversorgung und zur Frage der operativen
Behandlung, insbesondere des Krukenberg-Armes. Verh Dtsch Orthop Ges 1949;
36:51-53.
2. Biesalski K: Die Kunstglieder der Versuchsund Lehr-werk-statte des Oskar-Helene-
Heims. Z Orthop 1917; 37:174-278.
3. Blauth W, Schneider-Sickert F: Handfehlbildungen-Atlas ihrer operativen Behandlung.
Berlin, Springer-Verlag, 1976.
4. Buck-Gramcko D: Angeborene Fehlbildiingen der Hand, in Handchirurgie, Vol. 1.
Stuttgart, West Germany, Georg Thieme Verlag, 1981, pp 1-115.
5. Fischer: Z Orthop 1917; 37:228-247.
6. Hafher O: Die pneumatisch bewegte Prothese. Pat-entschrift des Patents der
Bundesrepublik Deutschland, No. 828291, July 28, 1949.
7. Hepp O: Dies Haufung der angeborenen Defektmidbil-dungen der oberen,
Extremitaten in der Bundesrepublik Deutschland. Med Klin 1962; 57:419-426.
8. Hepp O: Prothesen der oberen Extremitat, in Hohmann G, Hackenbrock K, Lindemann
L (eds): Handbuch der Orthopadie, vol 1. Stuttgart, West Germany, Georg Thieme
Verlag, 1957.
9. Heyne S: Ergotherapie bei blinden Ohnhandern mit Krukenberg-Plastik,
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,
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
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.
[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 (Dysmelie-
Syndrom). 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.
36B: Van Nes Rotation-Plasty in Tumor Surgery | O&P Virtual Library
Search
GO
Van Nes Rotation-Plasty in Tumor Surgery Reproduced with

permission from
Ivan Krajbich, M.D. F.R.C.S.(C) Bowker HK,
Michael JW (eds):
J. Dietrich Bochmann, C.P.O.(C.), F.C.B.C.
Atlas of Limb
Prosthetics:
The standard treatment for malignant tumors of the limbs has for decades, if not centuries,
been an amputation. In the lower limb with the tumor usually situated around the knee, this Rehabilitation Principles.
usually meant transfemoral (above-knee) amputation or a hip disarticulation and, in more Rosemont, IL, American Academy
proximal lesions, a transpelvic amputation (hemipelvectomy). With the advent of modern of Orthopedic Surgeons, edition 2,
chemotherapy, new imaging techniques, and consequent improved survival rates came a 1992, reprinted 2002.
renewed interest in improved surgical techniques to avoid ablative surgery. Thus in the last 15
years or so the surgical science of limb salvage surgery came into being. From the pioneering has been updated and published
work of Campanacci, Enneking, and others a number of surgical techniques have been in Atlas of Amputations and Limb
developed that are aimed at preserving limbs. The biggest challenge to the surgeons engaged Deficiencies: Surgical, Prosthetic,
in this practice has been the problem of the loss of the knee joint in a young patient. The and Rehabilitation Principles
early efforts tried to avoid this problem by creating a knee arthrodesis, i.e., replacing the (retitled third edition of Atlas of
excised knee segment with autograft or allograft bone. Although this technique is still quite Limb Deficiencies), ©American
useful in many patients, it has very significant drawbacks, particularly for a person of relatively
tall stature or a person inclined toward physical and athletic activity. In addition, the technique this text.
is impractical in young children due to the necessary resection of growth plates around the
knee and the resultant leg length discrepancy.
The newer technique of limb salvage using a tumor replacement endoprosthesis is currently of the Atlas of Limb
quite popular; however, it also has significant limitations. A sufficient soft-tissue-muscle Prosthetics was
envelope must be preservable to stabilize and motorize the new endoprosthetic knee. It must provided by the
be understood that this metallic-plastic implant has a finite life span due to material fatigue.
The metal-bone interface also has the potential for long-term problems due to the shear Prosthetists
stresses secondary to different Youngs moduli of elasticity of the two dissimilar, yet intimately
apposed materials, such as bone and a metal or plastic. Again, in young children, the loss of
the growth centers, with resultant leg length discrepancy, is a significant problem in using an
endoprosthesis in this age group. This is in spite of efforts to produce a satisfactory version of
a "growing endoprosthesis."
The technique that appears to address at least some of the problems associated with the
above-described procedures is a modified Van Nes rotation-plasty. This technique replaces tax-deductible contribution.
the excised knee with a biological joint, the patient's own ipsilateral ankle, which is rotated
180 degrees and fixed at the level of the opposite knee. The consequent absence of the
lower portion of the leg and foot is then replaced by an external prosthesis. It is hoped that
the patients function will approximate the function of a transtibial (below-knee) amputee with
a fully functional "knee joint."
The technique was first adapted to treat osteosarcoma of the distal third of the femur by
Saltzer and Kotz in Vienna in late 1970s. The rotation-plasty itself was first described by
Borggreve in Germany in 1930 for a patient whose knee was destroyed by tuberculosis. The
technique was later made popular in the English literature by Van Nes in 1950. He used the
technique in children and young adults affected by congenital limb deficiency. This use of the
rotation-plasty in children with proximal femoral focal deficiency (PFFD) gained popularity in a
number of centers. This familiarity with the operation and availability of both surgical and
prosthetic expertise allowed relatively smooth adoption of this procedure as a limb salvage
technique in North America.
PRINCIPLES AND INDICATIONS
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.
Principles Specific to Rotation-plasty

Rotation-plasty is a technique where the ankle and foot replace the knee joint; thus, it can
potentially be used in any of the lesions of the lower limb provided that the ankle and foot are
disease free, their blood and nerve supply can be maintained, and adequate muscle can be
found to power it. Not surprisingly then, the technique, which was originally described for
lesions of the distal end of the femur, has been modified for use in lesions of the proximal
parts of the femur and the tibia. The technique for all those modifications follow the same
principles:
1. The ankle and foot must be disease free.

2. Adequate nerve supply to the foot and ankle must be preservable.
3. Adequate blood supply to the foot and ankle must be either preservable or restorable
after resection of a segment of a disease-involved vessel.
4. It must be possible to restore muscle power to the ankle joint.
5. Large amounts of tissue can be resected, thus making this procedure possible even in
cases where there are quite extensive and large lesions (Fig 36B-1.).
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:
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.
Distal Femoral Lesions

Rotation-plasty in tumor surgery was originally described for lesions of the distal part of the
femur and is still most widely used in this situation (Fig 36B-4.). For the procedure the whole
lower limb is prepared and draped free (Fig 36B-5.). Incisions are marked on the skin. We
usually employ a circular circumferential incision proximally and an oval circumferential
incision dis-tally to compensate for the difference in the diameter of the leg distally and
proximally. The two circumferential incisions are connected by longitudinal incisions medially
and laterally to facilitate the dissection of the neurovascular bundles. The sciatic nerve needs
to be isolated along the entire length of the surgical wound. The femoral vessels are either
dissected free along the entire length or isolated proximally and distally when the vessels are
involved by tumor. Quadriceps, hamstrings, and adductors are then transected at the level of
the planned bone transection. Distally, gastrocnemius heads are divided 2.5 cm. distal to their
origin on the back of the femoral condyles. Pes anserinus tendons are divided near their
insertion on the proximal end of the tibia. Osteotomies of the tibia and femur are completed,
and in the case of vessel resection, these are now cross-clamped and divided. The resected
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.).
Proximal Tibial Lesions

The technique for the procedure in cases of proximal tibial lesions uses similar skin incisions
to the ones described above, except that they are based over the distal ends of the femur
and tibia, respectively (Fig 36B-9.,A and B).
The sartorius, gracilis, and hamstring muscles are divided approximately 5 cm proximal to
their insertions and labeled. The medial and lateral heads of the gastrocnemius are detached
from their origins on the distal part of the femur. This facilitates exposure of the neurovascular
bundle in the proximal part of the popliteal fossa. Vessels and nerves are then sacrificed as
necessary or dissected free and preserved as planned preop-eratively. The anterior tibial
artery almost always has to be divided at its origin, as does the deep branch of the peroneal
nerve. The structures to be sacrificed are then divided distally.
The tendons that control the ankle and foot are identified, labeled, and divided. Bones are
osteotomized and the specimen removed. Osteosynthesis is carried out (Fig 36B-10.), and
the vessels are reanastomosed where required. Finally, the thigh muscles are attached to the
tendons of the ankle and foot: the biceps femoris and semimembranosus to the tibialis
anterior tendon, the semitendinosus to the extensor hallucis longus and extensor digitorum
longus tendons, and the gracilis and sartorius to the peronei. The quadriceps tendon is
attached to the Achilles tendon and the vastus lateralis to the tendon of the tibialis posterior.
The tension on these tendons should balance the foot in a neutral position (Fig 36B-11.,A
and B). Skin edges are trimmed as needed and the wound closed, care being taken not to
place the skin under undue tension. The limb is then immobilized in a neutral position in a
well-padded plaster cast.
Proximal Femoral Lesions

In lesions of the proximal end of the femur and around the hip joint, the extent of the
proximal dissection will vary depending on the extent of the tumor involvement (Fig 36B-12.).
It can be as little as an internal hip disarticulation or as extensive as almost complete internal
transpelvic amputation. The sciatic nerve must be preserved, but the femoral nerve can be
sacrificed if needed, and a segment of the femoral vessels can also be resected and later
reanastomosed. An attempt is made to preserve as much of the iliopsoas and gluteus
maximus as possible and to later reattach them to the distal stump of the hamstrings and
quadriceps, respectively. The rest of the thigh musculature is removed together with the
tumor. Distally the femur is transected above the knee, with the exact length being
determined by the necessary extent of the proximal excision. It should be such that after the
femur-to-pelvis osteosynthesis, the level of the rotated knee joint is at the same level as the
opposite hip. Osteosynthesis of the distal part of the femur is either to the side of the pelvis
just cranial to the acetabulum in the case of a disarticulation or to the stump of the ilium in
the case of a partial transpelvic amputation. The osteosynthesis is carried out with the distal
fragment rotated 180 degrees, thus converting knee flexion into a new "hip" flexion and knee
extension into "hip" extension. Because the knee joint is essentially a one-plane hinge joint
rather than a multiplane ball and socket, joint abduction and adduction and any rotation are
lost (Fig 36B-13.). The rotated ankle again functions as a knee.
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
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
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 36B-
18.). 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
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.
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
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 limb-
salvage 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
36C: Juvenile Amputees: Sports and Recreation Program Development | O&P Virtual Library
Search
GO
Special Considerations: Juvenile Amputees: Sports and Reproduced with

Recreation Program Development permission from
Bowker HK,
Michael JW (eds):
Carol J. Page, P.T. Atlas of Limb
Duane G. Messner, M.D. Prosthetics:
Recreation can be Rehabilitation Principles.
a significant factor in eliminating the web of obstacles restricting the person with 1992, reprinted 2002.
a disability. Recreation, once confined to institutions and hospital settings with a
resulting emphasis on illness, can now occur anywhere that life can be fully Much of the material in this text
tasted-on a mountain, rafting a river or running the Boston Marathon. has been updated and published
PHILOSOPHY and Rehabilitation Principles
Children with limb deficiencies, whether congenital or acquired, are conscious of being Limb Deficiencies), ©American
physically different when they interact with their families and peers. This recognition has a Academy or Orthopedic Surgeons.
significant impact on a child's development of self-perception and self-esteem. Body integrity
this text.
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 Funding for digitization
the child from exposure to seemingly risky or challenging activities. Although parents are well of the Atlas of Limb
meaning, they may hinder children with limb deficiencies from physically exploring their Prosthetics was
provided by the
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 American Academy of Orthotists &
be more inclined to "trust" their child to such a program. They perceive such programs as Prosthetists
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.
Medical facilities (see Annotated Resource List, no. 1) and supportive organizations are
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 O&P Virtual Library with a
with family and friends (Fig 36C-1. and Fig 36C-2.), and far greater opportunities become tax-deductible contribution.
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.
PROGRAM PLANNING
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.
Participant Selection and Background Information

Assessing whether or not a child fits within the program guidelines is important in helping to
ensure that all participants achieve optimum benefit from program involvement. Individual
assessment should include identification of physical ability, level of social functioning, and
evaluation of the needs required for participation. Detailed medical background information on
each child is essential. These data provide valuable participant information (e.g., the need for
medical intervention, recommended adaptive aids, precautions and/or contraindications to be
considered, staff/volunteer requirements and training needs, and behavior considerations).
Awareness of the impact of the illness and/or the disability on the child and family is also of
value. This information helps to determine realistic expectations for the child's participation.
Strong parental support also has a significant, positive impact on program success.
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.
Staffing Needs and Requirements

Dedicated staff members committed to providing "a little bit extra" are extremely important.
Often medical staff involvement is over and beyond the normal work hours, and salary may
not be included.
In addition, volunteers are essential (Fig 36C-6.). Volunteer qualifications should be

determined according to the expertise required. Staff training in a specific activity may be
necessary (see Annotated Resource List, nos. 4 and 7). And although there are many
similarities in teaching techniques and equipment modifications for each disability, staff must
be trained to evaluate the participants for their own unique abilities and needs. For the safety
and success of the program, staff must be familiar with and understand the particular needs
of each child and identify contraindications, concerns, and medical needs (e.g., lower-limb
weight-bearing status, prosthetic needs, skin concerns, medical management needs, general
health and physical fitness, and behavior management).
Guidelines and/or job descriptions must be identified in writing, and a signed contract may be
advisable. Volunteer health screening, for the betterment of the participant as well as the
volunteer, should be considered.
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
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.
ANNOTATED RESOURCE LIST

1. The Children's Hospital Handicapped Sports Program, 1056 E. 19th Ave., Denver, CO,
80218. Producer of films featuring sports and recreation for children with handicapping
conditions.
2. Special Love Inc: PO Box 3243, Winchester, VA 22601, (703) 667-3774. A nonprofit
organization providing unique experiences for children with cancer and their families.
3. Sunshine Kids Foundation: 2902 Ferndale Place, Houston, TX 77019, (713) 524-1264.
A nonprofit organization sponsoring special programs for children with cancer.
4. National Sports Center (NSCD) for the Disabled: PO Box 36, Winter Park, CO 80482.
(303) 726-5514. Internationally known center for recreational and competitive winter
and summer activities for the disabled.
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.

Atlas of Limb Prosthetics O P Virtual Library PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Atlas of Limb Prosthetics O P Virtual Library PDF

Uploaded by

Copyright:

Available Formats

Atlas of Limb Prosthetics | O&P Virtual Library

O&P Library > Atlas of Limb Prosthetics

Atlas of Limb Prosthetics

Chapter 4: Prosthetic Management: Overview, Methods, and

Chapter 6: Upper-Limb Prosthetics

6C / Components for Adult Externally Powered Systems

6D / Control of Limb Prostheses

Chapter 7: Partial-Hand Amputations

7B / Prosthetic and Orthotic Management

Chapter 8: Wrist Disarticulation and Transradial Amputation

Chapter 9: Elbow Disarticulation and Transhumeral Amputation

Chapter 10: Shoulder Disarticulation and Forequarter

10B / Prosthetic Principles

Chapter 11: Adult Upper Limb Prosthetic Training

Chapter 12: Special Considerations

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 14: Analysis of Amputee Gait

Chapter 15: The Energy Expenditure of Amputee Gait

Chapter 16: Partial-Foot Amputations

16B / Prosthetic and Orthotic Management

Chapter 17: The Syme Ankle Disarticulation

17B / Prosthetic Management

Chapter 18: Transtibial Amputation

18B / Prosthetic Management

Chapter 19: Knee Disarticulation

19B / Prosthetic Management

Chapter 20: Transfemoral Amputation

20B / Prosthetic Management

Chapter 21: Hip Disarticulation and Transpelvic Amputation

21B / Prosthetic Management

Chapter 22: Translumbar Amputation (Hemicorporectomy)

22B / Prosthetic Considerations

Chapter 23: Physical Therapy Management of Adult Lower-Limb

Chapter 24: Special Considerations

24B / Adaptations for Sports and Recreation

24C / Emerging Trends in Lower-Limb Prosthetics: Research and

Part IV: Management Issues

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

Part V: The Child Amputee

Chapter 32: Acquired Amputations in Children

Chapter 33: The ISO/ISPO Classification of Congenital Limb

Chapter 34: Upper-Limb Deficiencies

34A / Surgical Management

34B / Prosthetic and Orthotic Management

34C / Externally Powered Prostheses

34D / Developmental Approach to Pediatric Upper-Limb Prosthetic

Chapter 35: Lower-Limb Deficiencies

35B / Prosthetic and Orthotic Management

Chapter 36: Special Considerations

36B / Van Nes Rotation-Plasty in Tumor Surgery

36C / Juvenile Amputees: Sports and Recreation Program Development

O&P Library > Atlas of Limb Prosthetics

O&P Library > Atlas of Limb Prosthetics > Chapter 1

Chapter 1 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

History of Amputation Surgery and Prosthetics Reproduced with

A COORDINATED PROGRAM FOR AMPUTEES