Prosthetics Research and the Amputation Surgeon
Rufus H. Alldredge, M.D. *
Eugene F. Murphy, Ph.D. *
Except in abnormal circumstances, man is
born into his world with four mobile members which extend from his trunk like
branches from a tree. These so-called "limbs" he uses in manifold complex
patterns, first to serve his immediate personal needs and second to shape his
own environment as best he can. Although in early life man reveals the history
of the race by crawling about on all fours, he shortly assigns to two of the
limbs chiefly, but not exclusively, the functions of supporting the body and of
moving it from place to place. The "legs" thus become the principal
weight-bearing members and the generally accepted means of
locomotion.* To the more versatile "arms" man assigns most of the more complex functions of daily living and of creative activity. No doubt to this "division of labor" can largely be attributed the rather remarkable development of art and science and literature and industry and most of the other
creative manifestations of human life.
Because, however, the limbs extend from
the body proper, they are particularly susceptible to damage, either from lack
of nutrition and disease or by external forces of one kind or another. Since the
limbs are not "vital" organs in the same sense as, say, the heart or the liver, it is possible under favorable conditions to remove one or more without loss of the whole living organism, especially since the advent of modern surgery, anesthesia, and the newer drugs
and blood substitutes. That is to say, a man has a chance of living on, though a
natural member be discarded. We thus have as a result of war, accident, and
disease a sizable number of individuals lacking part or all of one or more
limbs, and to these must be added those persons born with malformed or missing
limbs. All these people, now known generally as "amputees," are obviously
handicapped, to greater or lesser degree, in the performance of all those
functions ordinarily carried out by the arms and legs, and in extreme cases
there may be no residual function at all. To restore lost functions in as great
a measure as possible has long presented a challenge to certain people, mostly,
as might have been expected, to amputees themselves.
Early amputations undoubtedly were more
often than not traumatic events leading to a prompt death. Occasionally,
however, history records amputees who survived their bloody and painful
experiences. One famous example was Hegesistratus, who, captured and chained by
the Spartans, amputated his own foot in order to escape. With the
slow development, over the centuries, of surgery in general, amputations came to
be performed more frequently. Typically they were desperate efforts to save
life. Such works as those of Pare, of the sixteenth century,
described the techniques. In some cases, a tight tourniquet was applied and left
intact until the distal portion was lost by spontaneous amputation. In others,
the amputation was conducted with knife and saw, and bleeding was
controlled by cauterization.
From the beginning it seemed obvious that
the amputation should be as distal as feasible in order to conserve the maximum
bony lever. Many surgeons, however, preferred a disarticulation at a joint
whenever that was possible. For they had found that infection was relatively
unlikely to enter the bone through the normal surfaces which could be retained
with disarticulation, whereas, in the days before aseptic surgery, osteomyelitis
was all too common when the marrow cavity was opened by amputation through the
shaft of a bone.
Roughly a century ago the introduction of
anesthetics made prolonged surgery possible, and not long after that the germ
theory and antiseptic and aseptic surgery greatly increased the chances of
surviving either accidental wounds or surgery. These factors made possible the
comparatively long and complicated amputations now taken for granted, the
revision of otherwise unsuitable stumps, and the elective amputations in cases
of serious disease or deformity.
At about the same time, wars involving
European powers, and especially the American Civil War, led to large numbers of
surviving amputees. Also, and again more or less simultaneously, the rapid
development of heavy industry and of railroading resulted in many traumatic
amputations in civilian life, especially in the United States. All these factors
increased interest in amputation surgery and in limb-making for the large
numbers of surviving amputees.
Amputation Surgery and the Art of
Artificial limbs of one kind or another
date from antiquity. Particularly during the fifteenth, sixteenth, and
seventeenth centuries, crudely functional artificial arms came to be made,
chiefly by armorers, who were already experienced in a related field. Of many
known examples, the arm and hand made about 1509 for Goetz von Berlichingen
is by far the best known (Fig. 1), numerous copies having
been constructed for museums. In this and others of the period, joints were
flexed by the other hand and locked by ratchets. Springs returned the joints
when the ratchets were released by pressure on a projecting knob. In all such
armorlike arms and hands, iron was used, sometimes with holes punched to reduce
weight. Leather doublets or sockets, often with laces, commonly were used for
Near the end of the eighteenth century,
Klingert introduced an above-elbow arm with most of the natural
motions controlled by ten catgut cords fastened to a vestlike garment and moved
individually by the sound hand. Since in most cases the sound hand might better
have performed the intended action, this impractical prosthesis was a classic
pioneer in exceeding what some nowadays call the "hardware tolerance" of the
amputee. In 1818, Peter Ballif of Berlin developed the first
voluntary control by use of trunk and shoulder muscles. His hand was of the
voluntary-opening type with springs to close the fingers and
thumb. To the Dutch sculptor, Van Peeterssen, is attributed the first
above-elbow prosthesis with harness control permitting voluntary flexion of the
artificial elbow joint.
As the art of armormaking declined,
limb-making on the Continent came to be carried on usually in conjunction with
the making of braces, and consequently the artificial legs produced there
typically evidenced steel sidebars and molded leather corsets similar to those
used in braces. At the time of the Napoleonic Wars, the wooden leg, used from
earliest times, was provided, for example, by Potts of London for the Marquis of
Anglesey and others. Wood reinforced by rawhide was used
customarily in the United States, although a variety of other structural
materials has been suggested in the journal literature and in
Comte de Beaufort invented a
number of artificial arms as well as legs, some of which were approved for
French veterans of the Crimean and Italian campaigns. In 1858, he presented to
the French Academy of Medicine a hand with an alternator mechanism and a
double-spring hook. Dorrance introduced in America the
well-known voluntary-opening split hook with rubber bands to close a movable
finger against a rigid one. He and others rapidly produced a variety of hook
shapes intended for specific trades.
World War I
World War I led to a revival of interest
in amputations and in artificial limbs, notably in Germany, Belgium, and
England. All these countries had rather extensive programs involving the
cooperation of surgeons, limb-fitters, and engineers. Publications based on
World War I experience indicated considerable progress
in understanding of amputation techniques, of the need for prompt rehabilitation
of amputees, and of the importance of fit and alignment of the prosthesis. The
development of many new devices and components for artificial limbs for both
upper and lower extremity was described perhaps most impressively in
Ersatzglieder und Arbeitshilfen. Martin's second book , prepared for the International Labour Office, and Little's text were particularly useful because they offered critical analyses following
impartial descriptions of prostheses and mechanisms.
The wooden leg came to be used widely
throughout the Continent as well as in England and in the United States.
Aluminum, introduced by Desoutter in England in 1912, was used
particularly in England and to a lesser extent elsewhere. The fiber leg was used
by a substantial number of limbmakers, particularly in the United States.
Despite the large number of knee locks and ankle joints permitting lateral
motion, described in patents and in medical and technical literature, most
above-knee amputees used a simple uniaxial hinge for the knee joint and a
single-axis ankle joint. Rubber bumpers were used widely in place of the tendons
popular in the nineteenth century. It is interesting to note that in 1922 Little
remarked that most leg amputees had to use at least one
For the upper extremity, a great many
artificial arms, hands, and working tools were developed during World War I, as
can be seen from the major books on prostheses of the period
. American designers generally used the split mechanical
hook closed by rubber bands and separated from the forearm by a rubber washer
which provided stability by friction but which at the same
time permitted pronation-supination by means of the other hand. Europeans
generally preferred passively operated clamps and special tools so designed as
to be interchangeable by a disconnect at the wrist. Either a clamp, as on a
machine tool, or a locking bolt engaging any one of a series of holes in a disc
was used to fasten the tool in the selected position of pronation or supination.
For working purposes, the attachment for the tool was often placed at the end of
the socket, far above the normal hand level, so as to decrease the leverage of
the load on the stump. For dress wear, a cosmetic forearm and terminal device
could be attached in place of the tool.
Various wooden hands, usually with
spring-loaded or voluntarily controlled thumbs, were shown in the literature of
many countries. Generally, it was assumed that such hands were for dress and for
light office use only, either bare or covered with a leather or fabric glove.
Often the fingers were curved permanently to carry a briefcase. The Carnes arms
and hands, patented in 1912, 1922, and subsequently, were
widely sold in the United States for many years. During World War I they were
widely admired abroad and were described in detail by Schlesinger and to a lesser extent by Martin and by Little.
Similar devices, under the general name
"Germania," were built in Germany after entrance of the United States into
hostilities. Most authors admired the dexterity achieved by the Carnes
devices-particularly because of their ingenious construction, the passively
adjustable wrist flexion, and the possibility of coordinating supination with
elbow flexion to assist in eating-but criticism was leveled at complexity,
relatively heavy weight, lost motion, and the restriction against interchange of
a hook for the hand.
World War II
Surgical authorities during World War II
advocated typical "sites of election" Fig. 1 and Fig. 2) based upon
the extensive practical experience of the surgeons as well as on the advice of
many of the more active limb-fitters, who were notably successful in fitting
good stumps at these "sites of election" but who had encountered serious difficulty in
fitting such stumps as the wrist disarticulation, the very short below-elbow
stump, the knee disarticulation, or the Syme stump. Typical prostheses for the
so-called "sites of election" are shown in Fig. 3, Fig. 4, Fig. 5, and Fig. 6.
It will be noted, for example, that all
levels of forearm amputation, from the wrist disarticulation to the short
below-elbow, were fitted with the same type of forearm composed of a molded
leather socket, usually laced, extending into a cosmetic shell and reinforced by
volar and dorsal metal sidebars which formed a crosspiece at the wrist
supporting a screw thread or bayonet-type attachment for the hook or artificial
hand. Typically, the terminal device could be rotated passively by
the opposite hand against the friction of a
rubber washer but could not be pronated or supinated actively. The metal
sidebars were hinged in line with the humeral epicondyles to permit elbow
flexion in relation to a buckled or laced cuff about the upper arm. Usually the
terminal device was operated by a leather thong which passed over a pulley or
through a short length of helical wire housing at the elbow joint so as to be
independent of elbow flexion. Since the prosthesis did not provide for
pronation-supination, whatever of this function was originally available in a
stump amputated at the "site of election" soon disappeared owing to muscular
The elbow lock for above-elbow arms
generally was operated, in the case of a unilateral amputee, by the opposite
hand, or, in the bilateral arm amputee, by pressure against the body or against
a table. It usually consisted of a sliding bolt engaging one of three or four
holes in a metal strap surrounding the carved wooden elbow portion below the
molded leather or fiber humeral socket. Cotton webbing and rather heavy leather
shoulder saddles were commonly used in the arm harness, and leather thongs
transmitted forces to flex the elbow and to operate the terminal
During the period of World War II, the
typical unilateral leg amputee in the United States, including many
hip-disarticulation cases, walked without the aid of a cane, although the
above-knee amputee usually walked with the relatively fixed cadence for which
the fixed friction about the knee bolt was adjusted. Any attempt to walk faster
or slower led to excessive heel rise or to a tendency to drag the toe. The
below-knee artificial leg was often carved from a wooden block by
trial-and-error fitting. Alternatively, a leather socket, molded over a modified
plaster replica of the stump, was inserted into a fiber, metal, or
occasionally a wooden shank. Sometimes, in an effort
to increase conformity to the stump, a certain degree of softness or of ability
to flow plastically was imparted by a thin lining of felt, wax, or relatively
The above-knee leg was occasionally held
to the body by suspenders, but by 1945 a large percentage of above-knee amputees
used a pelvic band and metal hip joint. Usually the hip joint permitted the leg
to swing in one plane only, although in some designs an additional axis
permitted abduction and adduction. In England, and rarely in the United States,
a third axis, substantially vertical, also
permitted a limited amount of rotation, although about an axis outside the body
several inches from the ball and socket of the natural hip joint.
Era of Antobacterial
During World War II, blood, plasma, and
antibiotics came to be used widely to increase the chances of survival at the
time of injury as well as to permit more extensive surgery. The Surgeon General
of the U.S. Army ordered open amputation exclusively, to be followed by skin
traction until a revision operation could be performed. This flat order
unquestionably reduced the incidence of infection and gangrene from
combat injuries to U.S. Servicemen in World War II, as compared to experience in
previous wars or to the experience of certain other military forces. It
undoubtedly led also to the conservation of many stumps which, under other
circumstances, would have been reamputated at the "site of election" above the
next joint in order to avoid rapid spread of infection and gangrene. According
to Veterans Administration records, for example, the U.S. forces had over two
thirds of their lower-extremity amputations below the knee, whereas during the
American Civil War and among the Filipino Scouts and guerrillas and
the Yugoslavian guerrillas in World War II, it was estimated that at
least half of all lower-extremity amputations were above the knee. Little, in a sample of 1030 amputations among the English forces in World
War I, found only 219 "leg" (below-knee) and 441 "thigh" (above-knee) stumps in
a total of 723 lower-extremity amputations.
On the other hand, there is no question
that the order for open amputation, followed by traction and a second, or
revision, operation, led to prolonged hospitalization for some cases which safely could have been performed
primarily as closed amputations, particularly as antibiotics became available
late in World War II. Furthermore, many of these "military" amputations,
performed as they were far behind the lines, were really essentially civilian in
nature. It seems very questionable that there would be a need for performing as
many open amputations in civilian practice where risk of infection and gas
gangrene is relatively low. The surgeon has a responsibility to use open
amputation and traction when there is a clear risk, yet to consider prudently
the much shorter care which will be needed with a primary closed amputation when
it is feasible medically.
New Concepts in Rehabilitation
The large military amputation centers in
World War II provided an excellent opportunity to study the entire problem of
amputee rehabilitation. Although civilian surgeons generally had been
in the habit of dismissing the patient when the amputation scar had healed,
leaving him to search for limbfitting services with only the guidance of the
classified telephone directory and the perplexing visits of amputee salesmen and
demonstrators, the military Services reawakened the responsibility of the
surgeon for more complete rehabilitation through the stages of prosthetic
fitting, training, and subsequent follow-up. Similarly, the Services assumed
responsibility for the necessary vocational guidance and counseling.
Because of the dramatic concentration of
hundreds of amputees in a single hospital, however, the large military
amputation centers drew considerable public attention-both favorable and
unfavorable and generally over-dramatic. In operating their limbshops, they
encountered difficulties because of the scarcity of experienced personnel (P).
This problem was partially corrected, though never completely solved, by
diligent effort to locate limbfitters who had been drafted and to see that they
were reassigned to limbshops at amputation centers. In every case, however, the
bulk of the limb-shop staff was necessarily made up of men who perhaps had
mechanical aptitude but who were without previous training or
experience in the limb industry.
At the same lime the commercial
artificial-limb industry was kept very busy with its private cases from civilian
life and with the veterans from previous wars, while some of its younger men
were drafted into the Services. Besides this, the generally good business
conditions during and immediately following World War II, together with the
manpower shortage, led to the employment or advancement of a great many amputees
who, during the previous depression, had had great difficulty in finding and
holding jobs. Many of these people wished to procure new limbs, thus further
overloading the commercial limb industry.
To add to the difficulties, the industry
was then neither certified nor licensed, and it consisted, as it does today, of
several hundred relatively small workshops. While some of its members had had
formal education in other fields, there had never existed in this country any
means for formal training in the arts and sciences basic to limbmaking and
limbfitting. The sudden release, within a limited number of months, of some
21,000 veterans from military amputation centers imposed upon the industry an
exceptional burden. These men had been fitted in the military centers with a
serviceable, adequate, but admittedly "temporary" prosthesis, with the
understanding that soon after their release the Veterans Administration, through
civilian contractors, would provide a permanent prosthesis. Indeed, an
additional or spare permanent prosthesis also was provided as a matter of
The confused state of affairs about the
end of World War II, and during the year or so immediately thereafter, was further
complicated by a series of sensational stories in some of the newspapers
concerning difficulties with the limbs provided by the military
centers and covering a series of indictments and trials of certain members of
the commercial limb industry for alleged violation of the Antitrust Acts. The
rather emotional atmosphere then prevailing in regard to amputees led to
dramatic stories but in many cases to neglect of the basic
Casualities From Korea
Substantially all factors concerned have
since been greatly improved, so much so in fact that there were no difficulties
of this type over the treatment of amputees returning from the Korean conflict.
The relatively calm and orderly handling of these casualties, with the close
cooperation of all concerned, was a tribute to the progress which had been made
since 1945 in both technical and administrative aspects. Much of this change has
been due to the fine cooperation of the commercial limb industry, now emerging
into a prosthetics profession. It also has been influenced by the greater
interest of surgeons in amputations and amputee rehabilitation, by the
development of the team concept in this area as in so many other areas of
medicine (and indeed in science generally), by the contributions of many sound
administrators, and by the results of much hard work in the research and
Some of the major changes which have
influenced the amputation surgeon have been proven clinically by experience with
casualties from Korea. Concepts of level of amputation and certain of the
techniques of surgery have been affected. Perhaps most important, there is now a
greater interest in postoperative care and in the rehabilitation
responsibilities of the medical profession.
Level of Amputation and Modern Prosthetic
The surgeon's first decision in
amputating is the selection of the site. Perhaps the influence of the Artificial
Limb Program, sponsored by the Government and coordinated by the Committee on
Artificial Limbs of the National Research Council, can be shown
most dramatically by a review of the changes in recommended level. From a few
definite "sites of election," the development of new principles and devices has
made possible reaffirmation of the policy of "save all possible
length." Every level, with the possible exception of the below-knee amputation,
has benefited, particularly in the upper extremity, where it is now possible to
define at least nine amputee types (Fig. 7), all of which can be fitted
successfully. In many cases the new devices not only permit satisfactory fitting
of longer stumps but often replace additional functions beyond the important
increase in bony lever.
The Upper Extremity
The Below-Elbow Cases
The Wrist-Disarticulation Case.
The wrist-disarticulation prosthesis is a good example of the development of
a simpler appliance which yet permits better appearance and additional function
than did the conventional prosthesis of 1945. At the end of World War II, the
wrist disarticulation, if retained at all and not later reamputated at a higher
level, was fitted with a laced, molded leather socket supported by steel
sidebars jointed at the elbow, quite similar to that shown in Fig. 3, with
rather bulky harness and a leather thong for power transmission. Elbow flexion
and terminal-device operation were the only functions provided,
pronation-supination being prohibited by the single plane in which the elbow
hinge operated. The entire appliance was bulky, the uncoated leather soon
absorbed perspiration and became objectionable, and the almost complete encasing
of the forearm made the prosthesis uncomfortable in warm weather. Because of the
screw thread attaching it to the wrist, the terminal device, whether hook or
mechanical hand, projected appreciably beyond the opposite natural hand,
resulting both in limited function and in undesirable appearance. No cosmetic
covering faired the gap between the mechanical hand and the
In contrast, there has been developed
under the program of the Advisory Committee on Artificial Limbs a light and
sanitary plastic-laminate prosthesis (Fig. 8) which covers only the distal
portion of the stump and extends only a short distance up the radial side
to support tipping loads while still permitting pronation and supination. Extending farther up the ulnar aspect, the socket provides adequate
leverage and bearing area to permit comfortable resistance to large loads on the
terminal device which tend to tip the socket about the stump when the forearm is
in the horizontal position. The snug, "screw-driver" fit of the bony prominences
at the wrist into the terminal portion ensures rotation of the socket and
terminal device as the radius glides around the ulna. Since this rotation
decreases progressively up the forearm until, at the elbow, there is no relative
displacement, it is necessary to cut away as much as possible of the radial
aspect from the socket. But removal of socket material decreases both the weight
of the prosthesis and discomfort in warm weather. The plastic-laminate socket and
nylon coating of any leather used in this or any other prosthetic or
orthopedic appliance will prevent absorption of perspiration and the consequent
development of odors.
Very simple harness is adequate. For the
rare amputee requiring only an extremely light-duty prosthesis, the socket can
be held on the bulbous stump by a strap like that for a wrist watch to close a
keyhole slot so as to clamp the socket firmly just above the bulging styloids.
In this case, the only harness necessary is the cable and loop about the
opposite shoulder. Practically all amputees, however, require a somewhat more
secure, yet still minimum harness, as shown in Fig. 9, with a light triceps
pad held by an inverted Y-strap whose fork is higher than the fully tensed
biceps. A very simple figure-eight harness is used, and the steel Bowden cable
transmits energy quite efficiently without stretching and without catching the
To shorten the prosthesis markedly in
order to match the length of the opposite arm, the proximal wall of the APRL No.
4C hand may be fastened to a plate built into the distal wall
of the plastic-laminate socket, as shown in Fig. 8. Thus the plastic cosmetic
glove can readily bridge the gap between the hand and the prosthesis and extend
up under the shirt or coat sleeve of the wearer. A similar plan can be followed
with the APRL hook by removal of the stainless-steel stud and
plate by which the hook case is normally fastened to the wrist disconnect. On
other types of hooks, the stainless-steel stud can be removed or shortened and a
suitable fastening plate added by welding or brazing. For wrist friction, thin
rubber 0-rings may sometimes be used instead of thicker rubber washers, thus
further decreasing length.
In many cases, it has been found entirely
feasible, both technically and economically, to supply two sockets, one laminated to a
hand and the other to a hook, to be worn interchangeably. The added length due
to a conventional wrist disconnect and stud is thus avoided. Snap fasteners
between the flexible leather elbow hinges and the forearm socket, plus the
disconnect feature of the control-cable attachment post, permit interchange of
prosthesis without changing the harness. Thus the amputee can make the
interchange from hand to hook simply by rolling up his sleeve, it being
unnecessary for him to remove his shirt.
The Long Below-Elbow Case.
shorter below-elbow stumps, a similar type of prosthesis, but without the bulges
for the styloids, can be applied to permit the amputee to use his remaining
pronation and supination. The key factors are flexible elbow hinges and the
"screw-driver" fit of the end portion of the stump in the socket with
increasingly loose fit proximally. The fact that pronation and supination may be
retained encourages the surgeon to make every effort to avoid fusion of the
radius and ulna owing to bone spurs or similar causes and to instruct the
amputee to participate in physical therapy designed to redevelop muscular
The Medium Below-Elbow Case.
the medium below-elbow stump, the limited amount of pronation and supination is
worth retaining, yet it is inadequate to permit direct control of the
prosthesis. Accordingly, the step-up type of rotation device (Fig. 10) has been
developed. Early attempts at an automatic lock were frequently disappointing,
particularly if the amputee tended to snap the prosthesis when used with a
wrist-flexion unit, because the high inertia forces jammed the locking surfaces
and caused permanent dents which thereafter caused chattering or even
failure to lock. Instead, a simple lock has been
supplied on an experimental basis, some mechanical problems remaining to be
solved. A simple bolt in the stabilized outer socket engages one of a series of
holes in the rotating portion of the wrist whenever the elbow is flexed more
than a few degrees but is withdrawn at maximum elbow extension (Fig. 10,
detail). This device is particularly desirable even with a short, almost conical
below-elbow stump which, with elbow extended, participates in humeral rotation
from the shoulder. The entire extremity rotates within the triceps pad and outer
socket, which are stabilized by the harness. With the socket and terminal device
rotated to the desired position, the amputee returns his stump to its normal
position with the elbow axis parallel to the mechanical elbow hinges, flexes the
stump, and thus locks the wrist in the desired position.
In such applications, step-up gears are
normally provided to increase the rotation of the terminal device in relation to
that of the socket. A lock is desirable partially to transmit torsional loads on
the terminal device through the elbow hinges to the open humeral cuff,
but it is particularly desirable with outside
Bowden-cable control of the terminal device to permit the torsional component of
tension in the cable, when it spirals about the forearm, to be transmitted to
the upper arm without stress upon the stump. The mechanical advantage of torque
at the terminal device or control cable over the stump is due, of course, to the
step-up gearing used to increase rotation of the terminal device.
The Short Below-Elbow Case.
rather short below-elbow amputations, a geared poly-centric hinge (Fig. 11) has
been developed. In some cases, it permits easier fitting of
the socket and may hold the socket more firmly on the stump. For still shorter
stumps, the socket may be attached to the link connecting the two axes of
rotation, while the forearm is attached to the lower geared segment (Fig. 12),
thus providing a fixed ratio of 2:1 between degree of flexion of the
artificial forearm and degree of flexion of the below-elbow stump and socket. It
has been found, however, that this fixed ratio has only limited
The short below-elbow stump is another
example of the new principle of saving all possible length. Formerly, most
surgeons and limbmakers would have agreed that such short below-elbow stumps
could not be fitted satisfactorily. Such a stump tends to slip out of the
conventional socket and also may exhibit no useful control of the elbow joint.
Frequently, it was advised that such cases be reamputated at the "site of
election" in the humerus. Late in World War II, however, both in Canada and in
at least one U.S. Army amputation center, hinges were developed, similar to
those shown in Fig. 13, which permitted a step-up of forearm movement as
compared to stump movement, a variable ratio compensating roughly for the
resistance encountered and the strength of the stump at various
As seen in Fig. 14, the short below elbow, biceps are feasible.* Since there is no appreciable pronation-supination at this level, the biceps tendon
remains in a fixed position rather than tending to migrate from medial toward
lateral as it does when a longer stump moves from pronation to supination. The
posterior rim of the socket is carried as high as possible, substantially to the
olecranon. In some cases it is possible to hook the socket brim over the
olecranon to help pull the stump into the socket during flexion.
The middle pivot of the step-up hinges is
substantially opposite the humeral epicondyles, which define the anatomical
elbow axis. The lower hinge moves in its slot during elbow flexion, as indicated
in Fig. 13. The lower proximal end of the forearm shell must be cut out in
order to clear the short stump at extreme elbow flexion. But since this type is
used on short below-elbow stumps, there is no serious protrusion of the stump
beyond the general line of the forearm socket and, therefore, no appreciable
bulge in the coat sleeve.
Customarily, an auxiliary lift for the
forearm is provided by an above-elbow type of harness, with two separate pieces
of cable housing attached to the forearm and to the triceps cuff but bare cable
running from a space between the two separated pieces of housing, as shown in
Fig. 14. By voluntarily controlling the position of the stump, the amputee can
effectively "lock" the forearm as if by a mechanical elbow lock and can thus
operate the terminal device by increased tension on the control cable without
causing further flexion of the forearm. By means of stump action, he also can
press downward firmly enough on the forearm to perform functions such as
holding papers on a table or holding a fork to
stabilize a piece of meat while it is cut by a knife held in the opposite
The elbow disarticulation was for many
years frowned upon because of the difficulties of fitting it with a conventional
prosthesis with laced molded-leather socket and elbow lock and joint requiring a
bolt extending the full width of the elbow. In such a design, of course, the
mechanical lock was necessarily fitted below the end of the stump, thus making
an overly long humeral section and a correspondingly short forearm section,
usually preventing the amputee from reaching his mouth with the terminal device,
as well as creating an awkward appearance and difficulty in using the amputated
elbow as a support on the desk top, and the like. Capable of end-weight-bearing,
the elbow-disarticulation stump, however, is useful as a support without the
prosthesis, as in rolling over in bed. Its bulbous and irregular shape serves as
a key to stabilize the prosthesis against rotation about the long axis of the
To conserve these functions, therefore,
the external lock shown in Fig. 15 and Fig. 16 was developed to fit on the
outside of the socket in line with the humeral epicondyles and the
anatomical axis. The artificial forearm can thus be of a conventional length,
and the terminal device can be brought to the mouth readily. The locking circle
is, however, necessarily of a smaller diameter than would be available in a
conventional above-elbow type of prosthesis, so that in the present model the
number of locking positions is reduced to five (Fig. 16). Although numbering
more than in the earlier conventional above-elbow or brace locks, the five
positions are less than the 11 or even infinite number of positions provided by
above-elbow locks which have been developed in the ACAL research
The APRL-Sierra outside-locking elbow
hinge has another special application in the very short below-elbow stump where
range of motion is insufficient to operate a forearm through a step-up elbow
hinge but where a small residual motion is adequate to operate the locking
mechanism diagrammed in Fig. 16. In the arrangement shown in Fig. 17, elbow locking is effected by stump motion rather than by motion of the
shoulder, thus giving a more natural appearance and more freedom than could be
obtained with an elbow disarticulation or an above-elbow stump.
The external elbow lock has already been
used occasionally for applying artificial-arm principles to arm braces. The
situation in that entire field should improve rapidly in the near future.
Occasionally, patients have requested, or surgeons have recommended, amputation
of an arm when disease or injury have left a flail elbow. It has seemed that
improved artificial arms would actually provide the patient with more function.
It must be remembered, however, that the damaged arm provides at least some
support and perhaps sensation, and consequently every effort should be made to
replace the lost functions of stability, control, and voluntary movement by
suitable bracing. Polio cases, retaining sensation and an erratic distribution of
muscle activity, offer a special challenge.
The outside-locking hinge of Fig. 16 is
normally fitted as shown in Fig. 15 and Fig. 17 for control from the proximal
joint. Presumably, though, it could be inverted and controlled from the distal
end of the arm if some portion capable of even a little voluntarily controlled
movement with very nominal forces were available in the hand or wrist. A ring on
a finger or extreme hyperextension of the wrist could, for example, be used to
trigger the elbow lock, thus simplifying the harnessing, particularly if the
shoulder were also weakened.
It may be noted parenthetically that some
work has been done both by rehabilitation centers and by
prosthetists and orthotists to drive paralyzed fingers with mechanisms adapted
from the artificial-hand field or to hyperextend a paralyzed hand on a "cock-up"
wrist splint and substitute a hook on a rotary or even on a ball-and-socket
mounting on the volar aspect of the wrist. Even with a
quadriplegic there has been enough control of shoulder movement to provide the
necessary voluntary control for the hook, supplementing at least a weak biceps
action for forearm flexion and supination. The relatively heavy hook extending
from the volar aspect of the wrist will provide by gravity forearm
extension and a tendency toward pronation. Since the degree of paralysis and of
loss of sensation may be so variable, in the entire field of arm bracing the
role of the doctor is even more important than it is in rehabilitation after
amputation. Correspondingly, there is an even greater challenge to the ingenuity of the
prosthetist, the engineer specializing in prosthetics, and the manufacturer in
adapting or developing special appliances for the individual case and to the
patience of the therapist in redeveloping even faint voluntary movements which
might control triggers for locking mechanisms.
The Above-Elbow Cases
In the above-elbow stump, as much as
possible should be saved consistent with the nature of the injury or disease.
Even a very short above-elbow stump may be useful as an anchor point, and in
experimental work on electric arms such a stump has been used to
control the necessary switches and clutches (Fig. 18). A stump of nothing more
than the head of the humerus helps to round out
the shoulder and to provide a much more secure stabilization of the
Nevertheless there remains a challenge to
the engineer and prosthetist in providing improved shoulder-disarticulation and
very high-above-elbow arms with passive or voluntarily controlled humeral
flexion and abduction. A number of designs were shown in the literature
after World War I, but none appears to have been practical. The sectional
plates used in the ACAL research program have facilitated
independent construction of the socket and remainder of the prosthesis and their
subsequent alignment. Sometimes they have been provided with rotation to
facilitate donning of clothing with the humeral section flexed, followed by
return of the humerus to a vertical position. Such joints of the humeral section
to the shoulder cap have not permitted abduction, however, and have not normally
permitted voluntary or passive forward flexion of the humeral section about the
shoulder joint to bring the elbow forward and permit the terminal device to
reach the mouth.
The conventional sectional plates have
been solid and thus have been suited only for a true shoulder disarticulation,
but it should be feasible to leave an opening through which a very short stump,
such as the head of the humerus and its surrounding socket, could protrude into
the hollow humeral section. Provision of a sector of a complete circular track,
rather than the elongated D-shape which has been used, would also result in
better cosmetic appearance when the artificial humeral section is flexed
forward. Possibly a simple lock to stabilize such humeral flexion could be
controlled by a very short above-elbow stump, even if passive adjustment with
the other hand, or by gravity in connection with torso movement, were necessary
because of the weakness of the stump.
Attempts to provide voluntary control of
humeral abduction and rotation have been reported in the literature. Alderson
developed an experimental arm of the
shoulder-disarticulation type in which shoulder lift against the anchorage of a
groin strap generated either elbow flexion followed by humeral abduction or
humeral abduction alone, depending on whether the elbow were free or locked. At
least one commercial limb manufacturer recently has experimented with a
"universal shoulder joint" permitting a combination of actively and passively
controlled motions including upper-arm rotation by means of a turntable located
in the humeral section.
The Lower Extremity
In the lower extremity, although there
have been definite changes in techniques and devices, the influence of the
Artificial Limb Program has not as yet markedly changed the levels of
amputation. Work is, however, going forward rapidly, particularly at the
Lower-Extremity Clinical Study operated at the University of California using
facilities of the U.S. Naval Hospital at Oakland. It is to be expected that in
the next few years more definite changes can be recommended.
Meanwhile, the principal effects of wartime experience and of the ACAL
research program have been increased emphasis on the Syme and knee
disarticulation and a better understanding of muscle functions,
particularly in relation to the suction socket for above-knee
The Below-Knee Cases
The Syme Amputation.
Syme amputation is more than a century old, it has until recently been
considered controversial, with firm advocates and bitter opponents. In some
cases, criticism has rightly been directed toward very long below-knee stumps
which, however, were not true Syme amputations with the normal heel flap and
capable of full end-weight-bearing. Experience at military amputation centers
during World War II seems to have confirmed the successful results which have
been reported by the Canadians ever since World War I. A recent Canadian
report on the Syme amputation describes surgical precautions,
conventional and experimental Syme prostheses, and clinical
Although the Syme amputation requires
meticulous surgery, in the absence of sepsis, and careful attention to all
details, a successful result provides much greater freedom of action for the
amputee and enables him to remain on his feet for long periods. The broad
surface of tissues anatomically adapted to weight-bearing offers the Syme
amputee a great advantage over the below-knee amputee with limited areas
offering a wedgelike support for the stump and pressing upon tissue which has
not been accustomed to weight-bearing.
The prosthesis for the Syme has been
improved, on an experimental basis, by the Canadians (Fig. 19) and, more
recently, by the Prosthetic Testing and Development Laboratory of the Veterans
Administration (Fig. 20). Both types use a plastic laminate in place of molded
leather for greater sanitation as well as for greater strength with decreased
weight and bulk. Both use Fiberglas extensively for high strength.
Considerable success has attended efforts
to reduce the bulk at the ankle by eliminating the steel sidebars which, in
earlier prostheses, projected beyond the malleoli on the medial and lateral
aspects, thus adding thickness to a zone already the broadest portion of the
ankle. The steel sidebars had, in any case, been mechanically rather ineffective in
sustaining bending loads, as when the weight of the amputee is supported on the
ball of the foot, because the material was close to the neutral axis or central
portion of the bars. In the newer designs, this portion over the
malleoli is relatively thin, but bending moment is resisted more effectively by
the most anterior portion, ahead of the tibial crest, and by the posterior
portion at a greater lever arm than was available in the older, narrow, metal
bars. To avoid fatigue failures, special care must be taken to achieve a smooth
posterior cut in the shell-like prosthesis. The bulbous malleoli are introduced
into the prosthesis by opening a posterior portion, which may then be closed
either in trap-door fashion by a hinged portion of the shell or by a fabric- or
nylon-coated leather portion held by a slide fastener, laces, or adjustable
The shell-like combination socket and
shank section, with the end-bearing pad, is molded over a plaster model of the
stump to attain uniform fit. A slightly soft lining may be used throughout the
socket. Relief is provided along the sharpest portion of the tibial crest so as
to maintain comfort when weight is carried on the ball of the artificial foot
and there is a tendency for the socket to press sharply on the upper portion of
the tibia. Under such conditions, firm counterpressure, distributed comfortably,
is also required just above the malleoli on the posterior portion of the tibia
and fibula. Ankle action may be provided by a laminated sponge-rubber heel which
is compressed at heel contact, giving the equivalent of plantar flexion, or by a
rubber-block ankle joint with a shallow V-shaped section removed to accommodate
the long stump.
The Short Below-Knee Case.
badly scarred, below-knee stumps have heretofore sometimes been reamputated
above the knee or have been used in a permanently flexed position in the
so-called "bent-knee" or "kneeling-knee" prosthesis reminiscent of pirate tales.
In either case, the advantages of voluntary control of knee-joint movement are
The U.S. Navy below-knee "soft" socket, an outcome of recent research, consists of a plastic lining backed by a thin layer
of sponge rubber and a rigid or, recently, a rather flexible shell (Fig. 21). An
improvement on earlier commercial sockets with felt or wax lining, it may be
fitted to any below-knee stump, but particularly it has permitted conservation
of short, sensitive, badly scarred stumps. The weight-bearing impression of the
stump dipped in plaster yields a much more accurate replica than do most wrapped
plaster-bandage impressions. In general, it seems reasonable to believe that any
technique for making a socket from a cast is likely to produce a more accurate
fit more rapidly and with less discomfort than is a trial-and-error carving
process. The thin sponge-rubber lining giving the "soft" socket its
name seems to be only one of several factors contributing to its
Careful location of the mechanical knee
joints is always important. The work of the University of Denver
indicated the possibilities, for below-knee amputees in general, of improved
fitting of conventional legs with single-axis knee joints by more careful
location of the knee joints. Particularly recommended were fixtures and tools to
ensure that the mechanical joints on opposite sides of the prosthesis are on a
common axis. Poly-centric joints did not seem necessary. The report considered,
however, the possibility of a mechanical joint of the single-axis type at the
knee, but mounted high up on the thigh corset by a pivoting joint of limited
angular range, in place of rigidly riveting the upper joint bar to virtually the
full length of the corset. This idea has been proposed in the German literature. In such a case, probably a reinforcing band should be mounted in
the thigh corset to ensure that the upper joints are kept on a common
The very short below-knee stump, with the
tibia amputated in the broad condylar area and with trabecular bone structure,
is often suited to take a high fraction of weight-bearing on the distal end, in
contrast to the usual below-knee stump of much smaller diameter, limited bearing
area, and with thick, hard cortex surrounding a medullary canal. If the
thickness of pads at the end of the stump is gradually increased, particularly
if the pad in contact with the stump end is carefully molded to the
irregularities of the stump, an increasing fraction of end-weight-bearing may
often be tolerated.
These circumstances deserve careful
investigation before any thought is given to re-amputation above the knee, which
in the past has often been suggested for such stumps. End-weight-bearing is both
more nearly normal with respect to mechanical characteristics, promoting
calcification, and is desirable in avoiding any tendency toward lordosis. The
very short below-knee stump often can be fitted successfully by very careful
forming of the socket. Special care is needed in shaping the posterior brim to
accommodate the hamstring tendons, yet to rise into the popliteal space as much
as possible without cutting off circulation. The "slip" socket, elastically
supported to stay in contact with the stump during the swing phase, is an old
idea often indicated for short stumps.
Even if a very short below-knee stump
cannot take appreciable weight-bearing on its end and on the flaring tibial
condyles, it may be fitted with a long, ischial-supporting thigh corset and the
sturdy external mechanical joints which would be used in a knee-disarticulation
prosthesis. In this case the below-knee amputee, like the above-knee amputee,
must rely upon mechanical stability of the prosthesis during the stance phase
with the knee in full extension, but at a
minimum he has proprioceptive sense of knee position and usually some limited
ability to control slight knee flexion to return the knee to full extension,
thus saving himself from some falls. Partial control of heel rise at the
beginning of the swing phase and of knee extension at the end of the swing phase
permit a more graceful gait and a better range of cadence than generally can be
attained with above-knee prostheses.
The Knee-Disarliculation Case
The knee disarticulation, an old type of
amputation, typically has been fitted with a molded leather socket provided with
a lacer to permit the entry of the bulbous end of the stump. This type of
prosthesis has mechanical joints and sturdy metal sidebars similar to those in
the below-knee prosthesis. Normally, no mechanical friction has been used, and
consequently gait tends to be limited to a single cadence. Any attempt to walk
more rapidly leads to excessive heel rise and to "slamming" of the artificial
shank into full extension just before heel contact. Normally,
extension is limited by thongs similar to the back-check in a below-knee
artificial leg. Since the knee cannot be extended or stabilized voluntarily, the
joints are arranged to give mechanical stability at full extension, as in an
Many prosthetists have objected to the
knee disarticulation as a level of amputation because of discomfort of the long,
molded, leather socket, tendency toward breakage of the sidebars, and the lack
of mechanical friction. Amputation at a higher level has frequently been
advocated. The knee disarticulation, however, provides definite advantages over
the above-knee amputation. If the end of the stump is properly fitted, a broad
weight-bearing area is available. Normal transmission of weight through the
shaft of the femur minimizes the tendency toward the lordosis often developed in
above-knee amputees as the result of weight-bearing on an ischial support
located back of the normal hip joint. Clearly, disarticulation
offers the maximum bony lever of any amputation at or above the knee.
A recent informal survey of some of the
knee-disarticulation cases performed under supervision of one of the authors
(R.H.A.) at Thomas England General Hospital during World War II has indicated
satisfaction of the patient with this type of amputation and prosthesis. In
spite of the gait deficiencies noted, these knee-disarticulation amputees feel
that they walk well, continue to prefer this level of amputation, and refuse any
consideration of reamputation above the condyles to become more conventional
above-knee amputees. Although some knee-disarticulation prostheses providing
knee friction are reported in the literature, much more needs to be
done in this respect.
The Above-Knee Cases
In the above-knee amputation, at all
locations as much length as possible should be conserved. Gritti-Stokes and
similar end-bearing stumps have in many cases been fitted successfully with the
suction socket, although attachment of the muscles is then
particularly important to avoid development of excessive negative pressure owing
to displacement of muscle bulk in the necessarily limited clearance volumes
available with long stumps and end-bearing pads. Some have found difficulties in
fitting such cases with the suction socket and have preferred to rely on a
conventional pelvic-band suspension, perhaps with a second hinge permitting
abduction. In either case, the longer the above-knee stump the
As regards the above-knee case, the
principal development thus far of the Artificial Limb Program has been the
reintroduction of the suction socket, with many far-reaching effects on stump
shape, muscle conservation, socket fit, and alignment, accompanied by increased
need for the cooperation of many disciplines and the launching of a program of
education and certification. As for the first of these, the suction-socket
program shifted emphasis from the excessively flabby, conical stump (Fig. 22)
desired for the so-called "plug" fit to a more nearly cylindrical stump with
firm muscles stoutly attached to the bone. In the suction socket, the muscles
are needed both to control the newly found freedom about the hip
join and to provide a gripping action by
bulging against the walls of the socket, thereby decreasing the negative
pressure required to carry the weight of the prosthesis. Similarly, introduction
of the suction socket led to replacement of the typical conical socket of
triangular or circular cross section (Fig. 23) by a more nearly rectangular
socket (Fig. 24). The latter, developed in Germany within the last generation,
has a better basis in physiological and anatomical fact, appears to be a
necessity with the suction socket, and has, of course, also been used
successfully with an increasing number of pelvic-band conventional limbs without
use of suction.
As for alignment, introduction of the
suction socket has forced the prosthetist to pay more attention to details,
since, unlike the case of the conventional above-knee leg, errors in alignment
cannot here be concealed by trial-and-error bending of the pelvic band and
metal, single-axis hip joint which forced conventional legs to swing in a single
plane regardless of their inertia and the gait of the amputee. With the suction
socket in correct alignment, the amputee balances his weight completely on the
leg, since he has no pelvic band and hip joint to lean against for support.
Conversely, however, attention to better alignment has led to decreased stress
in the hip joints and pelvic bands of those legs which, for one reason or
another, are still fitted with pelvic bands. If one thinks of the suction socket
as being fitted with an imaginary hip joint carrying zero stress, it is apparent
that a comparable alignment will result in minimum stress in a real hip joint
and pelvic band of a conventional leg and, therefore, to greatly reduced risk of
In a very short above-knee leg, the
suction socket plus auxiliary suspension, either the Silesian bandage
(Fig. 25) or the conventional hip joint and pelvic band (Fig. 6), has permitted
conservation of greater effective stump length than would be possible
with the same stump in a conventional leg with hip joint and pelvic band but
with a "plug" fit. In donning the suction socket, the flesh is pulled into
the socket with stockinet, in contrast to the
tendency of the conventional stump sock and "plug" fit to push the soft tissues
upward and out of the socket. The auxiliary suspension provides greater control
and stability than would be available in a pure suction socket. The more logical
anatomical fit of the quadrilateral shape, including some ischial support,
avoids the roll of flesh in the adductor region and the skin irritations and
furuncles so commonly seen with the "plug" fit. Thus, some very short above-knee
stumps fitted with this combination of suction socket and auxiliary suspension
can function as if with a conventional above-knee leg without the necessity of
flexing the stump permanently in a tilting-table type of socket such as would be
used for a hip disarticulation.
Extremely short above-knee stumps, with
little more than the neck of the femur, can be fitted in some cases with the
"saucer" type of socket in place of the tilting-table
type generally used throughout the world with
a true hip disarticulation. Often the knee joint
is locked during standing and walking, so that the amputee walks stiff-legged.
In this case the prosthesis is often built shorter than the sound leg.
Sometimes, however, adequate alignment stability can be obtained to permit a
free knee joint. The thigh section is sometimes locked to the tilting-table
socket so that the back muscle can function to stabilize a free knee as
do the hip extensors in the above-knee amputee.
Hiyeda, in 1942, and
independently the Canadian Department of Veterans Affairs have used
free joints at both hip and knee, with the hip joint farther forward and the
knee farther to the rear than usual (Fig. 26). A posterior elastic strap helps
to extend the hip joint. Either the saucer socket or the tilting-table type may
be built of plastic laminate instead of from the older, molded leather, but if
for some reason leather is used, the nylon coating developed at the Army
Prosthetics Research Laboratory will make it much more
Wherever possible, of course, partial
hand or foot amputations should be performed in preference to major
amputations.* Much work was done during and immediately following
World War II on the surgery of the hand, and interest has been
lively since the formation of the American Society for Surgery of the Hand. In
the recent Korean conflict, a great many partial hand and partial foot
amputations were performed safely, whereas in previous times many of these cases
would have required major amputations, probably as below-elbow or below-knee
amputations at the former "sites of election."
In recent years, satisfactory cosmetic
gloves have been developed by the commercial prosthetics industry,
at the Army Prosthetics Research Laboratory, in the Navy, and in the Veterans Administration's Plastic Artificial Eye and
Restorations Clinics. These have made possible adequate cosmetic fitting of many
partial hand amputations while retaining some function. Moreover, various
operable terminal devices for partial hand amputations have been developed both
commercially and on an experimental basis in the ACAL program. Sometimes a small
hook is mounted on a molded socket and controlled by a conventional cable or by
wrist movement. On an experimental basis, the mechanism and wrist plate of an APRL hand have been
removed, the transmetacarpal stump allowed to fit within the hand shell, and the
side frames of the mechanical hand hinged opposite the anatomical wrist joint to
a light forearm cuff. Thus wrist flexion and forearm rotation are preserved.
Such cases clearly present individual challenges to the prosthetics clinic team
and to the designer and manufacturer.
Decision as to the level of amputation,
then, can be recapitulated in terms of saving
all length possible.* This policy is justified not only by new
devices, developed predominantly in the Artificial Limb Program, but also by the
spectacular advances in recent years in many fields of medicine and related
sciences. Blood, plasma, and antibiotics have helped to control shock and
infection and have made possible prolonged and precise operations. Medical
schools and residency training programs are only beginning to give more
attention to education in the broad field of prosthetics to make the new
findings available to the practitioner. The various medical societies are now
devoting to this broad field more and more time on their programs and more space
in their exhibits. Special courses, such as those on the suction socket held at
various locations throughout the country, and the Institutes on Upper-Extremity
Prosthetics at UCLA, are bringing specialized knowledge to
the doctor, the prosthetist, and the therapist. More attention is given to
individual prescription rather than to "sites of election," with increasing
cooperation and expert consultation from the prosthetist as to devices available
but without dictation of sites merely because they might be more convenient.
Best of all, there is now greater interest in over-all rehabilitation and
continued follow-up on the part of the medical profession to see that every
amputee, regardless of level of amputation, achieves the greatest possible
restoration to normal life.
New Techniques in Amputation
There is no need here to describe in
detail the techniques of amputation surgery, since they are all so well
presented in numerous other sources, for example, by Slocum. Certain
points reflecting the experience of the Artificial Limb Program may,
however, be worthwhile. These may first be illustrated in terms of a typical
amputation with primary closure, chiefly that producing an above-knee stump for
which suction socket is intended, followed by notes on some of the special
conditions at other levels of amputation.
The General Case
Skin Flaps and Subcutaneous
In general, the skin flaps are
approximately equal on the anterior and posterior sides and are so curved as to
meet neatly without undue skin tension but without leaving "dog ears." The usual
amputation has a central scar, although in some of the special cases of
weight-bearing stumps there is usually a longer flap on one aspect so as to move
the scar out of the end-weight-bearing zone. Even for the belowknee amputation without
end-weight-bearing, a longer posterior flap has sometimes been advocated to take
advantage of the presumably richer blood supply and more liberal muscle and
fascia, but the advisability of this technique has not yet been sufficiently
evaluated for it to be recommended here. Since when divided the skin and other
soft tissues retract, the skin flaps are initially outlined distal to the
intended level for sawing the bone, thus compensating for the successive
retraction of the various layers and permitting the bone eventually to be sawed
through at the edge of spontaneously but temporarily retracted
The subcutaneous tissue may be regarded
as a gliding mechanism, enabling the skin to move freely over the deeper fascia
and achieving the goal of freely movable skin without an adherent scar. The
subcutaneous tissue is cut perpendicularly to the skin, without beveling, and
both are allowed to retract as they are cut, without undermining.
A complete fascial envelope is very
desirable, primarily to secure the severed muscles to each other and to the bony
lever. Besides this, as Lawrence has suggested, piston action of the
bone within the soft tissues of the stump may help to pump fluid from the stump.
Presumably this action is more effective if the fascial envelope is completely
closed in order to force fluid displacement upward through the veins and
lymphatic channels. In contrast, an opening in the fascial envelope may permit a
compensating pulsation of the soft tissues through the defect, thus failing to
generate effective pumping action. Although as yet there is little direct
evidence to support such views, the reasoning seems logical.
A further advantage of the fascial
envelope is to avoid bulging of muscle through a defect in the deep fascia.
Accordingly, it is also desirable, when feasible, to repair traumatic defects in
the fascia and to refrain from removal of fascia during any plastic operations
intended to remove bad scars.
The tough fascia lata plays a special
role while the above-knee amputee is on the artificial leg during the stance
phase. Acting as a guy wire at the most favorable
leverage to balance body weight falling medial to the ischial support, it helps
to support the pelvis in a substantially horizontal position with minimal
expenditure of muscular energy. Hence every reasonable effort should be made to
secure firm attachment of the severed end of the fascia lata to the bony lever
and to the fascia on the medial side of the stump in order to replace its former
anchorage below the knee, as in the intact leg.
The incision through the fascia is
parallel to the initial skin incision but at the level of the retracted
superficial tissues. Like all aspects of amputation surgery, it should be clean
The importance of muscles has been
emphasized by the Artificial Limb Program in connection with the suction socket
as a vital part of the cineplasty studies and in analysis of the forces, motions, and hence the energy costs of both
normal and pathological gait. Only from reattachment of the
severed ends of the muscles is it possible to attain control of the stump,
particularly when greater freedom of action is made possible by improved
devices, as, for example, by the suction socket. Moreover, the muscles must be
held at substantially their original "rest length" in order to attain the
greatest force during contraction. Appreciation of this fact was
brought out especially in connection with the cineplasty program, but of course
the principle applies to all other muscles. A brief review of muscle physiology,
mostly of features known for over 50 years but re-emphasized by recent research,
is in order.
The Nature of Muscle Forces.
muscle studies at the University of California in connection with cineplasty
have re-emphasized the importance of the early studies by Blix
of force-length characteristics. Briefly, as shown in Fig. 27, the
force developed by a muscle is related to the length of the muscle at the time
the force is exerted. Any attempt to stretch a relaxed muscle beyond its rest
length results in an increasing resisting force, as shown by the "passive-tension" curve. If the muscle is
restrained at its rest length and then stimulated as vigorously as possible, a
certain maximum force can be generated. Full excitation of all the fibers, as by
electrical stimulation, yields this maximum force for isometric contraction,
although in practical voluntary use only part of the muscle fibers are activated
at a given instant, so that a much lower value is attained when the subject
"tries as hard as possible."
If now the muscle is allowed to shorten,
that is, to move toward the left of the rest length in Fig. 27, stimulation
results in some maximum isometric muscle force less than the value attained at
rest length. Continued shortening results in decreasing forces measured
isometrically until, at some value of contraction varying somewhat in different
muscles but roughly 60 percent of the original length of the muscle, no force
can be exerted.
Beyond rest length, an increased total
tension may be developed upon isometric contraction. The exact shape of the
curve varies with the nature of the muscle, its past history of stretching or
contraction over prolonged periods (especially noticeable in muscles in
which the cineplastic operation has been performed), and with the individual
case. When the passive-stretch force is subtracted from the total tension
attained by isometric contraction, the resulting net force available voluntarily tends in general to decrease again as the muscle
is elongated beyond the rest length. Thus the curve of the net force is
roughly an inverted parabola with its maximum at or slightly beyond rest length.
Since this curve varies with individuals and with training and exercise (which
affect both the cross-sectional area of a muscle and the shape of the
passive-stretch curve), examples can be found which depart markedly from this
schematic pattern. Nevertheless, the general principle leads to a number of
interesting conclusions relating to the surgery of both upper and lower
Applications of Muscle Mechanics.
It is immediately apparent from Fig. 27 that, if a muscle is allowed to
retract, temporarily or permanently, it cannot attain a voluntary force as great
as would be possible at or near the original rest length. Prosthetic devices
should be utilized, as far as practicable, with the appropriate muscles near,
perhaps slightly beyond, the rest length. A cineplastic tunnel, for example,
should be so harnessed that most objects will be picked up with the tunnel near
the rest length. As is well known, the hamstrings, if reattached to
the end of the femur in an above-knee amputee, can serve as hip extensors. On
the basis of known muscle mechanics, they will be most effective when the hip is
somewhat flexed but will be considerably less effective when the hip is fully
extended or when it is hyperextended just at the end of push-off. The amputee
may then attempt to supplement hip extension by using his back muscles, thus
producing lumbar lordosis. Alignment of the socket bore and condition of the
back-check controlling extension of the thigh socket relative to the shank will
both affect the length of the hamstrings and hence the ability of the amputee to
stand securely and to push off forcefully. Permanent contracture of
a muscle will result in a movement of the passive-tension curve toward the left
in Fig. 27 and, in general, in a steeper shape of the curve, thus resulting in
greater passive tension with only little stretching of the muscle. Thus the
maximum force which can be attained voluntarily will be reduced substantially,
and the effect may be more serious than the simple reduction in
range of motion. Avoidance of contractures is thus mandatory.
Workers at the University of California
have studied the moment (or force X leverage) available about the hip joint in
relation to the angle of adduction or abduction of the stump. Since the gluteus
medius and tensor fasciae latae are at their rest length when the stump is in
its normal position, under slight passive stretch with an adducted stump, but
allowed to contract when the stump is abducted, it is not surprising to find
that the available moment about the hip joint decreases markedly from the
adducted into the abducted region. Forcible abduction of the stump against the
socket wall is essential to keep the pelvis level during the stance phase
, and consequently maximum available abduction moment about the
hip is desirable to avoid an apparent gluteus medius limp. Therefore, workers at
the University of California have reasoned, it is highly desirable to maintain
as much adduction as feasible of the socket bore in space and in relation to the
remainder of the prosthesis. Experiments with controlled fitting and alignment
on the University of California adjustable leg have indeed shown
this reasoning to be valid. In contrast, fitting of the socket to an abducted
stump and "straight" alignment of the shank to the socket result in an
Stump Muscles in Prosthetic Control.
Muscles may have within a socket several actions particularly favorable in
the above-knee suction-socket leg. General bulging of the muscle belly during
contraction increases the diameter of the stump in the zone of the maximum
muscle belly, thus helping to grip the walls of the socket and producing
frictional forces which help to support the prosthesis. Muscle bulging and even
the contour of the relaxed muscles help to key the correspondingly irregular
socket against rotation about its longitudinal axis and thus aid in voluntary
control of rotation of the prosthesis.
Conversely, the muscles of the thigh
sometimes become detached from the cut end of the bone and the overlying fascia
but by some mischance become attached to the superficial tissues, as through the
scar. Contraction of such muscles causes a pistonlike
retraction of the end of the stump, a condition that may cause discomfort in any
case, especially if simultaneous contraction of opposing muscles tends to
stretch the scar, and one that is particularly undesirable in a suction socket.
Pistonlike retraction of the stump end, analogous to withdrawal of the plunger
from a hypodermic syringe, develops additional negative pressure in the space
between the end of the stump and the floor of the socket. Such excessive
negative pressure, far beyond that necessarily created by the weight of the
prosthesis, may tend to cause edema.
If stump retraction seems apt to occur,
the physician should consider all factors carefully before prescribing a suction
socket and, if he decides to proceed with one, should caution the limbmaker to
leave adequate clearance volume between the end of the stump and the sealing
floor. In that case, the change of volume owing to movement of the soft tissue
will be only a small percentage of the original volume, so that the resulting
negative pressure will be only a correspondingly small fraction of the
barometric pressure. But with long above-knee stumps, because of the problem of
locating the mechanical knee joint, it may not be feasible to allow adequate
clearance volume, in which case the suction socket may be
Movements of muscle bellies also may
create a wedging action within a relatively conical socket, thus tending to
force the socket off the stump and to increase negative pressure in a suction
socket, but this effect is not likely to prove serious in the relatively
cylindrical, well-muscled stump recommended. Wedging action may,
however, be desirable in the thigh muscles of a below-knee amputee so as to
provide additional support on the somewhat conical thigh corset, thus relieving
the below-knee stump of some of the pressure to which it would otherwise be
Muscles or tendons passing over the brim
of the socket may also tend to force the prosthesis from the stump when the
muscles are tensed, again tending to increase negative pressure in a suction
socket. This effect can be minimized by careful fitting of the
Muscle tissue acts as a pump to promote
return circulation of blood and lymph, as is well known. Obviously, this effect is
particularly important in the suction socket to reduce tendency toward edema,
and hence vigorous muscle activity is doubly desirable.
Securing Muscles at Rest Length.
For all these reasons, it is highly desirable that the muscles be secured to
the end of the stump at their rest lengths. Accordingly, the muscles are cut at
the levels of the spontaneously retracted superficial tissue and fascia. If
necessary, the cut muscles may be sutured to their overlying fascia. Later, when
the fascia is closed and sutured over the end of the stump, the muscles will be
carried back from their spontaneously retracted position substantially to their
rest lengths. It is desirable to have not a mass of loose muscle tissue over the
end of the stump but rather a neatly tailored muscle and fascial closure with
the muscles restored to their rest length, that is, simply pulled back against
the natural tone.
To suture muscles to each other at the
end of the stump, as has sometimes been recommended in the past, is unnecessary.
In fact, the sutures would probably pull out of muscle alone. Suturing of the
tough fascia is much more effective, so that it is unnecessary, as well as
undesirable, to suture muscles to holes drilled in the bone.
In a few special cases, the tendons of
the muscles may be sutured together. For example, in the case of knee
disarticulation, the tendons of the hamstrings and quadriceps may be sutured in
the patellar notch. Generally, the intention is to secure, by healing and
scarring processes, the cut ends of the opposing muscles to each other, to their
overlying fascia, and to the bone.
With the possible exception of the
below-knee amputation (see footnote, page 30), the surgeon will plan to save the
maximum practicable length of bony lever. The saw line is made at the level of
the naturally retracted soft tissues. Before the bone is sawed, the periosteum
is cut cleanly around with a sharp scalpel, taking special care to avoid loose
flaps of periosteum, which may later form bone spurs. The bone is then sawed off
squarely. There is no need to remove a periosteal cuff, and there should be no
attempt to elevate the periosteum.
In general, it is not necessary to bevel
the bone cortex.* Preliminary anatomical studies of bone ends at the
U.S. Naval Hospital at Oakland, California, and at the University of California
Prosthetic Devices Project have shown that the bone end, when treated as already
described, may round over spontaneously within a few months so that the
medullary cavity tends to become sealed . This simply confirms clinical
observations already made from amputation of long duration.
The aim of the surgeon is to sever the
nerves in such a manner that the inevitable neuroma will be embedded in soft
tissue at a point where it will not be stimulated. Thus, it should not be
permitted to reattach to scar or bone in such a manner that the fibrils of the
neuroma become stretched at every step owing to piston action of the bone within
the tissues or to movement of the scar as a result of muscular action. The
neuroma should also be far enough up the stump so that it is not subjected to
unusual pressure from use of the prosthesis.
The most desirable technique, it has been
realized for some years, is to dissect the nerve carefully from the
neurovascular bundle, pull it gently from its sheath, and cut it cleanly with a
sharp instrument. The severed nerve is then allowed to retract up its nerve
sheath into soft tissue. The major cutaneous sensory nerves, which are less
obvious, deserve the same careful attention given to the major nerve
Contrary to the advice in some earlier
texts, experience of the past decade has shown clearly that no injections of
alcohol or other chemicals should be given. Rather, the nerve should be left
entirely alone after it has retracted into the tissue. Much clinical
experience, and recently the studies of the
Pain Project at the University of California have indicated
that formation of a neuroma must be expected at every cut nerve. Resection of a
neuroma once formed will therefore merely lead to development of another neuroma
at a higher level. Difficulties are encountered from a neuroma only if it is
stretched or compressed. Although phantom pain is sometimes triggered by the
stimulation of a neuroma, there are so many other possible causes that repeated
surgery to remove a neuroma each time one forms generally is not
The Special Cases
The Upper Extremity
The Wrist-Disarticulation Case.
the wrist disarticulation, the distal joint between the radius and ulna must
carefully be preserved to permit free motion of the radius over the ulna during
pronation and supination. Occasionally it may be wise to round off any
exceptionally sharp surfaces on the styloids, but in general the styloids can be
accommodated by careful fitting of the molded plastic-laminate socket (Fig. 8
and Fig. 9).
The Long Below-Elbow Case
Similarly, in the long below-elbow stump, every effort should be made to
preserve free motion of the radius over the ulna to retain pronation and
supination. Cutting of the bones permits the radius to approach the ulna,
resulting in shortening, and hence weakening, of the pronator teres. Although
with training the weakness can be overcome, the proximity of the radius to the
ulna makes bone spurs or actual bony bridging between the two bones much more of
a hazard to adequate pronation-supination. Thus careful, clean cutting of the
periosteum is of particular importance.
The Short Below-Elbow Case
there is the possibility of a very short below-elbow amputation, the short stump
always should be preserved if at all medically feasible, in preference to
amputation at or above the elbow. In some cases, for example where rolling and
notching of the socket brim (Fig. 14) might be inadequate to prevent an intact
biceps from pushing the socket from the stump during elbow flexion, the surgeon
may consider cutting the biceps tendon to
permit fitting the socket brim higher than usual. If biceps cineplasty is
performed for such cases, the biceps tendon will, of course, be resected and the
cut end carefully covered over or imbricated to prevent reattachment. In this
case severing the biceps tendon may in some instances permit higher fitting of
the socket while simultaneously preserving a useful function for the biceps
The Elbow-Disarticulation Case
The elbow-disarticulation prosthesis with the new external lock (Fig. 15)
has encouraged the preservation of the elbow-disarticulation stump whenever
feasible medically. As with any end-bearing stump, it is probably desirable to
place the scar line away from the weight-bearing area. The irregular shape of
the humeral condyles may be retained to assist in anchoring the socket against
rotation. Careful attention to the nerves is desirable to prevent formation of
sensitive neuromata in the areas which will be subject to load during
end-weight-bearing or as a result of bending loads upon the prosthesis when the
elbow is locked.
The Short Above-Elbow Case
very short above-elbow stump should be preserved so far as medically feasible in
preference to a true shoulder disarticulation or, worse, forequarter amputation.
Even the short stump will serve to key the socket and provide greater stability.
In some cases the short stump can be used for control of a lock. In experimental
work on an electric arm, a very short above-elbow stump has been used to operate
a keyboard of switches and clutches (Fig. 18) for control of the electrically
driven motions as well as to control an electric elbow lock while a turntable
lock above the elbow joint was controlled by a button pressed by the pectoral
upper-extremity candidates for later cineplasty operations can
undergo the original amputation in the same manner as do those amputees who will
use conventional prostheses. Thus far ACAL has accepted cineplasty in the intact
biceps of a below-elbow amputee only (Fig. 28; see also Fig. 12, page 61), and
in the case of a veteran prior approval from the VA Central Office is required.
For many years cineplasty has been performed in a variety of locations and by many different
techniques. In the Artificial Limb Program, it has been performed experimentally
in a number of locations in various individuals, including the biceps in
above-elbow amputees and the pectoralis major for short above-elbow and
shoulder-disarticulation cases. But before such procedures can be
recommended, problems remain to be solved.
The general principle is to preserve
muscle length and attachment at the time of the original amputation so as to
prevent permanent contraction. The distal end of the muscle is released only at
the time of the cineplasty operation so as to permit prompt exercise and
stretching of the muscle soon after the tunnel has healed. Special attention
should, of course, be given to repair of any injuries proximal to the intended
saw line in order to assure full innervation and blood supply and to avoid
serious scarring of the remaining stump.
The Lower Extremity
The Syme Amputation.
In the Syme
amputation, in contrast to amputation at many other levels, preservation of the
normal heel flap permits weight-bearing on tissue normally accustomed to full
body weight and impact. The incision has a special shape across the instep so as
to permit the shelling out of the calcaneus from the heel flap and the later
formation of a suture line across the anterior aspect of the stump. To provide good bearing, the bones are sawed just above the articular
cartilage and in such a plane that the cut surfaces will be parallel to the
floor when the amputee stands (not necessarily perpendicular to the long axes,
as, for example, in the case of a bowlegged or knock-kneed patient).
To ensure preservation of circulation in
the heel flap, little if any tailoring is performed. Dog ears left at each side
of the heel flap will disappear with proper postoperative wrapping. Contrary to
the usual rule, the tendons are simply cut and permitted to retract without
attempting to suture the tendons in place or to attain fascial closure. If a
good Syme stump cannot be obtained, the surgeon should perform a conventional
below-knee amputation, since a very long below-knee stump extending to the lower third of the shank
frequently breaks down from poor circulation.
The Knee-Disarticulation Case
In the knee disarticulation, an exceptionally long anterior flap is
necessary for closure of the stump and so that the suture line may be posterior
and out of the end-weight-bearing zone. In general, the cartilage is simply left
in place. The patella, although routinely left in place, may be removed to give
extra length to the anterior flap when needed for adequate closure. The patellar
tendon is sutured to the hamstring tendons in the patellar notch between the
femoral condyles, but no attempt is made to prevent the tendons from
Techniques advocated, partly as a result
of World War II and subsequent experience and partly as a result of the ACAL
program, may be summarized as follows:
- With the possible exception of the
below-knec amputation, save all length of stump considered surgically
- Preserve the muscles at
their rest length.
- Attempt to secure attachment of
opposing muscles to each other and to the bony lever during the healing process
through suturing of the opposing fasciae, without attempting to suture the
muscles to each other or to the bone.
- Avoid attachment of the muscles
to the scar.
- Secure a complete fascial
- Secure a smooth and freely
movable scar, usually central but displaced in the case of end-weight-bearing
stumps (or possibly where skin on one side of the stump has a much better blood
supply and gliding fascia than that on the other).
- Sever a nerve cleanly and allow
it to retract into soft tissue, without injection and with as gentle treatment
The doctor should in every case maintain
continuing supervision and responsibility for the postoperative care of the
amputee. Just what are the relative responsibilities of the surgeon and of the
doctor of physical medicine, where the latter is available, is subject to
discussion and, in the present state of knowledge, will necessarily vary from
place to place depending upon their respective interests, training, and
available time for both professional and administrative duties. But it is
important for the patient's welfare that there always be available some single
physician who is familiar with the case and who can take responsibility for
seeing that the patient receives maximum cooperative service from the nurses,
therapists, prosthetist, vocational counselors, and others concerned.
Although the extremely shrunken, conical
stump of former days is no longer desired, it is obvious that some muscles (such
as the vastus group of the thigh in an above-knee amputation or the soleus in a
below-knee case) will no longer have as important functions as before and can be
expected to atrophy. It is desired that these muscles atrophy slowly without
deposition of an equivalent amount of fat. Careful application of an adequately
wide elastic bandage, in accordance with well-known techniques
will hasten the desired shrinkage.
Immediately after the amputation,
therefore, the wound is dressed and the stump wrapped with broad elastic bandage. But
the bandage will become loose in a few hours and should be replaced by a fresh
one, usually every four hours during the day. The used bandage is washed and
dried, the usual precautions being taken to restore its elasticity. After a
suitable interval, usually 10 to 14 days, sutures are removed, the wound
re-dressed, and elastic bandage again applied. Meanwhile, the patient should be
taught to cooperate in the application of the elastic bandage so that, when
dressings are no longer needed, he may himself learn to reapply fresh elastic
bandage several times a day as needed to prevent edema and to encourage
shrinkage of tissues no longer functional.
The bandage is made snug at the distal
end, with no constriction at a higher point on the stump, and it must be carried
above the next intact joint, for example up to the thigh in the case of a
below-knee amputation or above the hip and around the waist as a hip spica in
the case of the above-knee amputation. To avoid rolls of flesh, all parts of the
stump must be bandaged, notably the adductor region high into the crotch in the
case of the above-knee amputation. The patient must be cautioned against
developing above the stump a local constriction which would lead to poor
circulation. Likewise, bandaging should avoid a bulbous mass of soft tissue at
the end of the stump, which would interfere with later fitting.
Every effort should be made to restore
full range of motion of the stump as early as possible without risk of tearing
the muscles from their newly organizing attachments to the bone. The patient
should be discouraged from remaining in a fixed position, such as sitting in a
wheelchair with the hip and knee flexed, or lying in bed with the stump propped
up on a pillow. It should be carefully explained to him that some
temporary discomfort and inconvenience will be necessary to ensure subsequent
full range of motion and effective use of a prosthesis. The leg amputee should
lie in bed with his legs parallel, without abduction and external rotation of a
thigh stump or flexion of a below-knee stump.
In the event of a preliminary open
amputation, the line of skin traction should be toward the center of the bed,
and the patient should be checked frequently to be certain that he is lying with
his pelvis parallel to the bottom of the bed. In no case should he be permitted
to slant the pelvis and thus, in effect, to abduct the stump. In the more common
closed amputation in civilian life, traction is seldom necessary unless, in an
attempt to conserve greater bone length, exceptionally short skin flaps have
been used and it is desired temporarily to remove tension from the suture
Restoration of strength and of full range
of stump motion can begin when the muscles have become adequately attached to
the bone, with gentle voluntary exercises at first to prevent detachment.
Restoration of strength will depend both upon developing maximum size of the
cross section of the muscle and upon stretching of the muscle stump so that it
operates near the amputation rest length, as already discussed. The role of a
low passive-tension curve is particularly important, and of course exercises
should be prescribed with due regard to the patient's general
Home exercises, conducted by the amputee
first merely by setting the muscles and later by using simple and readily
available apparatus, are particularly important. Much can be done with a
flatiron, a pail filled with increasing amounts of water or sand, or other
convenient weights attached by a piece of sash cord over a pulley or doorknob to
a towel about the stump. Elaborate gymnasium equipment or exercise tables
obviously are not essential, convenient as they may be for the well-equipped
rehabilitation center. The amputee and his family should be convinced of the
importance of sensible home exercises, not only immediately postoperatively but
whenever indicated throughout the rest of the amputee's life to maintain good
stump condition and to avoid the flabby, weak, and contracted stump so often
seen in an amputee of long duration. The amputee should be convinced of the need
for maintaining adequate range of motion and strength in order that
he may use his prosthesis effectively,
gracefully, and with minimum effort. But of course he should be discouraged from
intermittent extremes leading only to exhaustion.
Finally, general body tone is important
both for good health and good spirits as well as for effective use of a
prosthesis. The leg amputee, for example, must have good triceps to use crutches
when necessary and good abdominal muscles to minimize the risk of lordosis. The
arm amputee will use muscles of the trunk and opposite shoulder in supporting,
positioning, and operating his prosthesis. All young, healthy amputees should be
encouraged to take part in swimming, skating, bowling, table tennis, or other
sports as appropriate.
Every amputee should be cautioned against
obesity, which in the lower extremity increases the load on the stump and in any
case increases the difficulties facing the prosthetist. Because of the
difficulties encountered from alternate tightness and looseness of the socket,
all wearers of prostheses, and especially those using the suction socket, should
be cautioned against violent fluctuations of body weight. Where indicated, all
possible conditions causing obesity should be corrected, and patients should be
supervised by a physician to stabilize body weight at normal for the
An important result of World War II
military experience, of subsequent work under the ACAL program, and of the
increasing numbers of amputation clinics both in the Veterans Administration and
in private institutions has been the increased interest by the medical
profession in its responsibilities for lifetime rehabilitation for amputees.
These include not only the obvious medical responsibilities but also
psychological aspects; pain and phantom sensations; teamwork with others
concerned in the prescription, fitting, training, and checkout of the
prosthesis; and referral for any necessary vocational counseling and
Psychological aspects of amputation are
particularly important. In many cases the doctor can provide appropriate
psychological services, but in other cases referral to a clinical psychologist
or to a psychiatrist may be desirable. Sometimes preoperative discussion and
psychological preparation may be possible, especially if the amputation is
elective or if the need for amputation can be foreseen. The prospective amputee
himself should, when possible, decide realistically that amputation is
preferable to other alternatives and that it is not "the end of the
In many cases the patient can be helped
preoperatively or postoperatively to accept amputation and to begin a realistic
estimate of the possibilities of worthwhile rehabilitation through discussion
with other amputees of the same level who have been rehabilitated successfully.
Clubs of amputees are beginning more and more to provide, on
request of doctors and hospitals, levelheaded, rehabilitated amputees for just
this purpose. Such amputees are not to be confused with the overenthusiastic
salesman type or with the psychologically disturbed exhibitionist, who so often
has demonstrated his remarkable prowess without making the patient aware of the
nature of his stump, the differences between his condition and that of the
patient, and the fact that so much depends upon the general physical condition
and the will power of the patient. Just as there are professional golfers, there
are also professional amputees. These persons can often perform remarkable feats
not ordinarily desirable in or to be expected of the average amputee and one, as
is usually the case, unwilling to make a career of stunts with a prosthetic
device. Realistic discussions of the responsibilities of the patient, yet of the
many important and fascinating things which remain possible, will be most
A matter of great importance is attention
to the attitudes of those associated with the patient. Members of the family
will wish to help in every way, yet their efforts must be guided intelligently
toward help in the real difficulties while avoiding overprotectiveness generated
by pity, which all too soon might turn into rejection. The employer can be
helped to realize that the amputee may again return to useful work, whether at
his former job or at some other and perhaps better and more skilled job after suitable
vocational guidance and retraining.
Sometimes the handicapped person, perhaps
for the first time receiving professional guidance and being forced to think
carefully about his future, will aim at more education and a much higher
economic level than before the amputation. After all, much of the heavy labor of
industrial countries is being taken over by machines. Unaffected by the
amputation, the patient's brain power and ability to make decisions and to
control the machines will command a higher value.
Friends and acquaintances too must learn
to accept the amputee for the many qualities he has left and to admire his
demonstrated fortitude and cheerfulness rather than to pity him or even to
shrink from him because of past memories of an amputee beggar. Finally, society
as a whole must learn to accept not only amputees but all handicapped and
disabled persons on the basis of their inherent dignity, ability, and worth as
human beings, not on the superficial basis of individual differences in physical
condition due to crippling disease, congenital defects, or mutilating injuries.
In the past, amputees, like members of other minority groups, have encountered
unreasoning psychological prejudices unworthy of the brotherhood of
Pain and Phantom Sensation
The amputee will need counseling, both in
the acute stage and perhaps occasionally throughout his life, about the nature
of pain in the stump, phantom sensation, and phantom pain. Postoperatively, pain
is handled as in the case of any other operation. But the amputee may be puzzled
that he still has a sensation of the missing member, perhaps in some bizarre
position. He can be assured that at least 85 percent of other amputees, and
perhaps practically all amputees other than congenital, retain such feelings.
Phantom sensations have long interested neurologists and psychologists and
recently have come in for study in considerably more detail at the University of
California. It appears that such sensations are related to the
continued activity of the cortex on which the missing limb was originally
projected but which no longer receives the normal bombardment of
constant new sensations of position, temperature, pressure, and so
Phantom pain is rare. It occurs
only in a small fraction of amputees. Sometimes it appears to be related to
specific physical difficulties in the stump or in the remainder of the body,
such as pressure on a neuroma or traction upon a neuroma which has,
unfortunately, become caught in scar tissue and is stimulated by muscular
movement or piston action of the stump in the socket. In other cases, it may be
related to some cause further up the body which might have been sought
immediately in a normal individual but which might be neglected in the amputee.
For example, a ruptured disc in the spine immediately would be sought from
certain classic patterns of pain radiating down the leg, but the same might be
overlooked in an amputee who complains that pain radiates into his missing
Studies at the University of California
involved injecting salt solution, as a stimulant, into the various vertebral
segments of both normal volunteers and amputees in order to produce radiation of
pain which could be mapped systematically. In some cases,
radiation of the pain into the phantom limb of an amputee resulted in
disappearance of the phantom sensation itself after a short period, concurrently
with disappearance of pain in the rest of the body (Fig. 29). In other cases,
distribution of phantom pain was altered, and in a few cases the phantom pain
became worse. In general, however, workers at the University of California
believed that phantom pain could be alleviated by one or more of a series of
systematic attacks. No single remedy was found that applied to all
Prosthetics Clinic Teamwork
The duties of the physician on the
prosthetics clinic team have been well outlined by Bechtol. The
increasing success of prosthetics clinic teams in overcoming the problems of the
amputee, as well as those of the wearers of braces and orthopedic shoes, has
brought a rapid expansion of amputee clinics in both government and private
circles. Indeed, the teamwork concept has been utilized
increasingly at many levels of rehabilitation for many kinds of disabilities and
throughout scientific research generally. Each member of the team needs humble
realization of his own limitations,* appreciation of the
contributions to be made by each of the other members, and, of course, an
understanding of the participation of the patient himself as a member of the
team created in his behalf. Thus only can there be created a realistic basis for
self-confidence in the total effectiveness of the team as an integrated unit. In
the Veterans Administration's Orthopedic and Prosthetic Appliance Clinic Teams,
the Chief of the Prosthetic and Sensory Aids Unit is the administrative "key" to
the success of the individual clinic.
The surgical responsibilities immediately
after operation have, of course, long been obvious. But no more can the doctor
dismiss the patient when the scar is healed-with advice to "look in the
classified telephone book for a limbmaker." Rather, the doctor should serve as
captain of the prescription team in its efforts to see that the amputee is
provided with the best current prosthesis suited to the individual and with
adequate training in its use, and he should assume continuing responsibility
throughout the lifetime of the amputee.
The doctor should, for example, have the
clinic administrator arrange for periodic checkup examinations at proper
intervals, perhaps once a year. Thus the amputee can be checked for adequate
fitting and can be informed of new improvements as they become available, both
from the commercial industry's own developments and from the Artificial Limb
Program as it makes tested devices available to the industry. The gait of
lower-extremity amputees can be observed, facility in the use of upper-extremity
prostheses can be noted, and, if necessary, further periods of training may be
prescribed. Other problems, such as obesity, spinal curvatures, skin
difficulties, and so on can be detected and corrected before they become
serious. Frequently, all the amputee needs is a reminder for encouragement to
brush up on his old skills. Reassurance and renewed encouragement are of
important psychological value to the amputee patient.
Finally, the experienced patient,
returning for his routine checkup, serves as an example to improve the morale of
the more recent patients sitting in the waiting room. The successfully placed
and well-rehabilitated patient, grateful for his own return to active life, will
be glad to assist by visiting more recent patients in the hospital. He may be
called upon whenever his unique physical condition, type of work, or hobby makes
him especially suitable to help a person of similar circumstances.
The New Knowledge and the Medicla
The challenge to the medical profession
will thus be clear. There has been a rapid increase in knowledge of prosthetic
devices themselves, in methods of performing amputations, and in the philosophy
of amputee management. Medical education must somehow fit into the medical
curricula and into the crowded training programs for interns and residents the
new knowledge and changing viewpoint in amputee rehabilitation.
Exhibits at medical meetings and papers in the medical journals offer some
of this new knowledge. The new 800-page collaboration, Human Limbs and Their
Substitutes (see Digest, this issue, page 77) presents a much more
extensive range of knowledge and broader point of view than is possible in a
single article. The busy practitioner, especially the general surgeon to whom
amputation is only a rather incidental part of practice, must somehow find time
to keep abreast of new knowledge and philosophy while conserving the best
principles he has learned in the past.
Finally, there is a growing need for
geographically spaced centers for performing amputations and to serve as bases
for orthopedic and prosthetics clinic teams serving civilians as well as
veterans. Perhaps only thus can those with specialized knowledge best serve the patients, especially those
with unusual problems. Indeed, such centers could serve as agencies of the
Artificial Limb Program, pointing out needs and priorities based on clinical
experience and providing facilities for field tests and educational
Thus, it can be seen that marked changes
have taken place from the days of the few sharply delimited "sites of election"
and the few types of prosthetic appliances available for them. The changes thus
far have perhaps been most marked in the upper extremity, where a whole new
armamentarium of appliances has been developed and rigorously tested both in the
laboratory and in clinical studies. The findings have been made available to
physicians, therapists, and prosthetists through a series of Institutes on
Upper-Extremity Prosthetics at the University of California at Los Angeles. Even
so, the present Manual shows interim devices which should be greatly
improved in years to come. Improved function and appearance are certain, and
perhaps there will be some limited sensibility of position, contact, and
In the meantime, however, a great deal of
work also has been done on the lower extremity. Although relatively few new
devices, such as the U.S. Navy above-knee artificial leg and the
suction socket have been accepted, a great many new devices and many changes in
practice are being tested at the laboratory and clinical levels. It is to be
expected that, in the next few years, an equivalent to the
upper-extremity armamentarium will be released in an array of new devices for
the lower extremity, such as stable knees, means for preventing stumbling, and
perhaps forcible ankle push-off. Current inventors' designs and test models
eventually will be tested through a systematic transition procedure and released
for routine use.
To those close to the heart of the ACAL
program for nearly a decade, the changes noted herein have occurred so slowly
and so imperceptibly in the pressure of daily emergencies that they have not
been realized fully. Until brought out by a systematic review
or by a chance conversation with someone untouched by the genuine progress which
has been made, the alterations lie buried in the seeming monotony of obvious
"good practice." Yet all these little modified details in technique, new or
revived appliances, and perhaps more profound changes in points of view and
philosophy add up strikingly to benefit the individual amputee.
It is a pleasure to acknowledge the
contributions received through past discussions with a host of associates in
military amputation centers, Veterans Administration Orthopedic and Prosthetic
Appliance Clinic Teams, the Artificial Limb Program, and private life. Some of
the concepts described may be attributed particularly to Jerome Lawrence, of the
Veterans Administration Clinic Team in New York; to Verne T. Inman, of the
University of California; and to Herman Gladstone, Surgical Consultant to the
Prosthetic and Sensory Aids Service of the Veterans Administration. Thanks are
due George Rybczynski, who provided most of the line drawings. Photographs were
supplied through the courtesy of the VA's Prosthetic Testing and Development
Laboratory, the Army Prosthetics Research Laboratory, and the Canadian
Department of Veterans Affairs.
- Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.
- Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5
- Alldredge, Rufus H., The management of war amputations in a general hospital, N. Y. State J. Med., 44:1763 (1944).
- Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone & Joint Surg., 28A:415 (1946).
- Alldredge, Rufus H., Major amputations, Surg.Gyn. & Obstet., 84:759 (1947).
- Alldredge, Rufus H., The cineplastic method in upper-extremity amputations, J. Bone & Joint Surg., 30A:359 (1948).
- Alldredge, Rufus H., Amputations and prostheses,Chapter XII in Christopher's Textbook of surgery, 5th ed., Saunders, Philadelphia, 1949.
- Alldredge, Rufus H., Recent developments and future trends in the field of orthopedic appliances, Southern Med. J., 46:7 (1953).
- Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Alldredge, Rufus H., and Eugene F. Murphy,The influence of new developments on amputation surgery, Chapter 2 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Anderson, Miles H., UCLA prosthetic course to open January 12, Orthop. & Pros. Appl. J., September 1952. p. 14.
- Anderson, Miles H, A report on the prosthetics training center at the University of California, Los Angeles, Orthop. & Pros. Appl. J., December 1953. p. 27.
- Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.
- Bechtol, C. O., and E. F. Murphy, The clinical applications of engineering principles to the problems of fractures and fracture fixation, American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.
- Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).
- Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.
- Borchardt, op. cit. pp. 397, 425, 509.
- Borchardt, op. cit. pp. 404-405.
- Borchardt, op. cit. pp. 523-528.
- Brunnstrom, Signe, Physical therapy in aftercare of amputations of lower extremity, U.S. Nav. Med. Bull., 43:634 (1944).
- Brunnstrom, Signe, The lower-extremity amputee,Chapter XIX in Bierman and Licht's Physical medicine in general practice,3rd ed., Hoeber, New York, 1952.
- Bunnell, Sterling, Surgery of the hand, 2nd ed.,Lippincott, Philadelphia, 1949.
- Canty, Thomas J., Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.
- Carnes, W. T., U.S. Patent 1,046,966, December, 1912.
- Carnes, W. T , U S. Patent 1,046,967, December, 1912.
- Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.
- Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.
- Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.
- Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, 24 August 1953.
- Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.
- Desoutter, E. R., Back to activity, DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.
- Dorrance, D. W., U.S. Patent
- 1,042,413, October, 1912.
- Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone & Joint Surg., A, in press 1954.
- Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954. p. 15.
- Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.
- Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7.
- Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.
- Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.
- Langdale-Kelham, R. D , and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.
- Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954.
- Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).
- Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).
- Little, E. Muirhead, Artificial limbs and amputation stumps, H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.
- Little, op. cit. pp. 6-7.
- Little, op. cit. pp. 7-8.
- Little, op. cit. p. 8.
- Little, op. cit. p. 10
- Little, op. cit. p. 24.
- Little, op. cit. pp. 110-113.
- Little, op. cit. p. 249.
- Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.
- Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.
- Martin, op. cit. pp. 260-279.
- McLaurin, C. A., Hip disarticulation prosthesis,Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.
- Mommsen, F., and K Buchert, Kunstliche Glieder, Heft 1, Enke, Stuttgart, 1932. pp 4-5.
- Mommsen and Biichert, op. cit pp. 86-97.
- Murphy, Eugene F., The role of an amputee club,summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.
- Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, Description of a prosthetic hand appliance, March 1, 1948.
- New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown test of the Navy above-knee prosthesis, May 1951.
- Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947. pp. 1.33-1.36.
- Pare, Ambroise, Ouevres completes, J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.
- Personal communication from Verne T. Inman,University of California.
- Personal communication from representatives ofUNRRA, 1946.
- Possibilities Unlimited, Inc., Cleveland, Ohio, Possibilities unlimited, Vol. II, Issue 2, 1950.
- Putti, Vittorio, Historic artificial limbs, Hoeber, New York, 1930. p. 7.
- Putti, op. cit. pp. 1-3.
- Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.
- Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).
- Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.
- Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone & Joint Surg., 35A(3) :543 (1953).
- Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.
- Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.
- Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone & Joint surg., 33A:601 (1951).
- Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.
- Taylor, Craig L., The objectives of the upper-extremity prosthetics program, Artificial Limbs, January 1954. pp. 4-8, especially p. 7.
- Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.
- Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.
- Thompson, T. Campbell, and Rufus H. Alldredge,Amputations: surgery and plastic repair, J. Bone & Joint Surg., 26A:639 (1944).
- United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, Philippine amputation and prosthetic unit, n.d.
- University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.
- University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.
- University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.
- Upper-Extremity Technical Committee, ACAL,minutes of meeting at University of California, Los Angeles, February 5, 1953.
- Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, The development of artificial arms for amputees who have had the cineplaslic operation, 1947.
- Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.
- Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.
- Wagner, Edmond M., and John G. Catranis,New developments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.
- War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.
- Wilson, A. Bennett, Jr., The APRL terminaldevices, Orthop. & Pros. Appl. J , March 1952.
- Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist-disarticulation case, Orthop. & Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., Die biologische Absetzung der menschlichenGliedmassen, Muench. Med. Wschr., 82:525 (1935).