Cineplasty In Children
Henry H. Kessler, M.D., Ph.D.
I first became interested in cineplasty during a 1928 visit to Professor Ferdinand Sauerbruch in Berlin. Sauerbruch, out of his experience in World War I, had made a thorough study of this procedure including not only the surgical but also the mechanical and engineering features as well. The results of his studies were embodied in a book, "Die Willkuerliehe Bewegbare Hand." ("The Voluntary Movable Hand") His associates, Gorband and Nissen, and later Lebsche, continued their interest in this procedure. However, prosthetic and surgical difficulties discouraged many other surgeons from applications of this technique.
The opportunity to work with Sauer-bruch and Gorband in 1928 was enhanced by a close association with Sauerbruch's prosthe-tist, M. Biederman. Hence the problem of obtaining suitably adapted prostheses did not loom so large in my own case. Casts and measurements were taken locally and the plaster models sent to Germany. Generally, the prosthesis was very accurately built and arrived quite quickly, with the result that my first few cases worked out quite satisfactorily.
At that time bilateral canals were prepared in below-elbow as well as in above-elbow amputation stumps. The only problem encountered was that of adjusting the two reciprocal lever mechanisms to provide the proper amount of tension and leverage neces-
sary for good reciprocal motor action. After the first six cases this adjustment no longer created a problem.
Work Interrupted by World War II
With the outbreak of World War II, my supply of prostheses from Berlin was cut off and continuance of my cineplastic work was hampered.
One of my patients, a 65-year-old left above-elbow amputee on whom I had successfully performed a bilateral cineplasty with German prostheses, volunteered to duplicate the German devices. He was an Austrian lithographer whose prosthetic ability did not quite match his enthusiasm. Hampered by lack of the special prostheses required, only a few cases of cineplasty were performed during my four years of service in the Navy.
Postwar Revival of Interest
At the end of World War II, a commission sent by the National Research Council to Germany returned to the United States with great enthusiasm for the work done by Lebsche and others, and cineplasty immediately became popular again.
Two factors oriented the profession here away from forearm cineplasty and thus concentrated attention on a strong single biceps motor to activate conventional below-elbow prostheses; one was the lack of suitable prostheses of the Biederman type, and the other was the notion that in order to activate conventional terminal devices each cineplastic motor should be powerful enough to pull 40 pounds.
On my return from Naval service, the Board of Trustees of Hasbrouck Heights Hospital, Hasbrouck Heights, New Jersey, became interested in developing a prosthesis suitable for cineplasty. Mr. Maguth, the president of the Board, had performed valuable services for the Navy during World War II and had developed a large and technically competent engineering plant which he felt could be utilized to develop the prosthesis in which I was interested. Patients and equipment that had been developed by Mr. Eberle, the Austrian lithographer, were purchased and modified, and the staff of Mr. Maguth's organization were given the responsibility of bringing Mr. Eberle's item up to modern engineering standards.
Development of Maguth Arm
In the development, part of the German system was maintained in that a mechanical lock at the wrist provided stability in securing continuous and strong grasp, thus eliminating the need for a heavy cineplastic motor, especially in the forearm. Moreover, the Maguth arm appeared to function better than the Biederman arm in that a relatively small excursion of the muscle motor produced a large peripheral excursion of the terminal device both in grasp and release. The terminal devices used were the standard split utility hook comparable to the Dorrance hook, and two long metal fingers. This rapid and large excursion was particularly advantageous to one patient, a pianist, who could actually play a single note, a chord or an octave with his prostheses, following the tempo of Liszt's Hungarian Rhapsody. During this time, Maguth also developed a hand that provided quick action similar to the hook or short metal fingers.
With the advent of the Maguth prosthesis, I resumed my active interest in cineplasty for adults. About this time, May 1946, our first amputee clinic was held at Hasbrouck Heights Hospital. A substantial number of congenital amputees presented themselves at the clinic for examination. I had organized this clinic in order to see how much of the principles and experience I had gained with a large number of young adult male amputees at the Naval Hospital at Mare Island would apply to the general problems and needs of amputees of all age groups, including children.
Techniques Adapted for Children
At this first clinic, cineplasty was described and offered to the parents of some of these children. The first two years were experimental. Forearm cineplasty was not done in children because a suitable prosthesis was not available. Biceps and pectoral cineplasty operations, however, were performed.
Case No. 1
One of our first cases in 1950 was a 4-year-old child with a total absence of both upper extremities (Fig. 1 ). This case gave us an opportunity to apply our previous cineplasty experience.
We were faced with the knowledge that the pectoralis major muscle was absent, although X-rays revealed the presence of a scapula. Hence, we could presume the presence of a coracoid process which would indicate that a pectoralis minor muscle was present, however underdeveloped it might be.
In spite of the anatomical defect and the surgical problem of preparing a reverse tube pedicle flap with an extraordinary fatty component of subcutaneous tissue, the canal was successfully prepared. With occupational therapy, an amount of power sufficient to open the terminal device was achieved (Fig. 2 ). Bilateral Maguth arms with cable control for the elbow permitted reasonably good function after a year of preparation and training (Fig. 3 , Fig. 4 , Fig. 5 , Fig. 6 ). The child maintained a fair degree of functional utility with her prostheses. However, she had already developed exceedingly good foot and toe function which she used for the routine pursuits of life Fig. 7 ).
The patient returned to Hawaii where prosthetic problems due to wear and tear and growth caused many difficulties. A local prosthetist was helpful in solving some of these problems, but it became apparent that unless she were closely followed at a highly sophisticated prosthetic center, she would have to give up her cineplastic prostheses.
Accordingly, arrangements were made with Captain Thomas Canty and the Oak Knoll Naval Hospital to refit her and continue her training with a new pair of arms. At 6 years of age she was fitted with a new pair of arms which featured the Navy Fitch elbow. With these she was successfully trained by Lieutenant Charles Asbelle to carry out many of the routine pursuits of life such as brushing the teeth, feeding with fork and spoon, writing and painting. The pectoral motors controlled the terminal device while elbow locks were avoided by the use of the Navy Fitch control.
The patient was last seen in June 1964 in her home in Sunnyvale, California. At that time she was wearing only one prosthesis. Her mother, however, assured me that the patient uses both cineplastic prostheses for feeding but for fine dexterous activity such as taking notes she uses her feet (Fig. 8 , Fig. 9 , Fig. 10 , Fig. 11 , Fig. 12 ).
The patient developed a severe scoliosis which was operated on by Dr. Ashley of San Francisco. In the meantime her prosthetic problems came under the supervision of Dr. Schottstaedt of San Francisco, and Mr. Robinson of Vallejo fabricated her present arms.
Four Additional Cases
Pectoral cineplasty was carried out on four additional children in the age group of 4-12 years (Fig. 13 , Fig. 14 , Fig. 15 , Fig. 16 ). Although each child achieved a fair degree of utility with the prosthesis, it was difficult to maintain follow-up since some of these children came from far distances. One of these patients, who is now 19 years old, wears an above-elbow prosthesis in which the pectoral muscle controls the elbow lock.
Biceps Cineplasty Cases
In addition to the children with pectoral cineplasty, six children were fitted with biceps cineplastic prostheses (Fig. 17 , Fig. 18 , Fig. 19 , Fig. 20 ). The old system of bilateral motors was not used. The single biceps motor was attached to a Maguth terminal device or hand which had the distinctive feature of a central pull from the motor instead of the conventional lateral pull. One of these patients has worn her prosthesis with a Maguth hand continuously for the past 13 years (Fig. 21 , Fig. 22 , Fig. 23 , Fig. 24 ).
In my opinion, cineplasty can still play an important role in the rehabilitation of juvenile arm amputees by increasing the range of measures available to manage the great variety of amputations encountered. Further development to provide a suitable prosthesis is still needed. The excellent results obtained with the Maguth prosthesis indicate that further exploration and development might well achieve substantial progress.
Henry H. Kessler, M.D., Ph.D. is associated with the Medical Director Kessler Institute for Rehabilitation West Orange, New Jersey