Notes From The Prosthetics Research Program
The information which follows has been abstracted from the Progress Report for July 1 to November 30, 1967, issued by the Prosthetics Research Study, Seattle. Ernest M. Burgess, M.D., is the principal investigator; Robert L. Romano, M.D., the associate investigator; and Joseph H. Zettle, the director of this Veterans Administration-sponsored research project. Additional material from the PRS report will be published in a subsequent issue of the ICIB.
Accelerated clinical research into immediate postsurgical prosthetic fittings and an expanded educational effort highlighted the five-month period. As experience with immediate fitting has grown, it is evident that successful application constitutes a new total concept of amputee management, not merely a specific technique. This concept implies a radical revision of many existing attitudes and practices. It holds forth a level of amputee rehabilitation appreciably greater than that now being generally obtained, especially with the geriatric, ischemic patient. We believe the general application and continued refinement of this improved management program will bring significant humanitarian, social, and economic benefits.
In the process of the study, emphasis was placed on evaluation, improvement, and possible development of other than conventional prosthetic replacements. The various conventional prostheses were fabricated, fitted, and delivered in a finished or rough stage on the same day that cast and measurements were taken, in order not to interrupt the patients' rehabilitation progress for prolonged periods of time. The types of prostheses fabricated were two Syme's, 14 patellar-tendon-bearing (PTB), four patellar-tendon supracondylar (PTS), two above-knee, and one knee disarticulation.
Seven prostheses were fabricated and fitted to seven patients at local prosthetic facilities. They consisted of five patellar-tendon-bearing and two above-knee prostheses.
Prosthetics Research Study modifications in fabrication techniques resulted in Syme's prostheses without the usual medial or posterior openings. Kemblo rubber inserts were used to avoid irritation of burn scar tissue in one patient and for evaluation purposes in the other conventional case. Both continue to wear their prostheses with great comfort and without any further additional adjustments to their prostheses since delivery four months ago (Fig. 1-6 ).
The 14 patellar-tendon-bearing prostheses fabricated included three bilaterals. One bilateral and one unilateral patients were fitted with the soft Kemblo insert. The remaining 11 consisted of hard plastic socket PTB prostheses. One patient required thigh lacer and side joints in the presence of severe psoriasis about the knee joint. With use of his prosthesis, the skin condition cleared, and the side joint and lacer are no longer required.
Four patients were fitted with patellar-tendon supracondylar prostheses. Hard plastic sockets were used, and all required a small, removable plastic wedge just proximal to the medial femoral condyle for ease of inserting and removing the stump (Fig. 7-9 ). Some noteworthy advantages in this limited experience were improved suspension characteristics (stump pis-toning is reduced to a very minimum), increased mediolateral knee stability (due to the higher brim line of the socket), and a fair cosmetic appearance. The patients' reactions and comments were favorable. Further investigation is necessary, and more PTS fittings are planned.
The two above-knee prostheses fabricated consisted of the conventional plastic total-contact suction sockets with Hydra-knee swing phase control units.
One bilateral patient with Syme's and knee disarticulation type prostheses was not an immediate postsurgical fitting. This 18-year-old white male had suffered 65 percent third-degree burns, including his lower extremities and waist, at the age of four, resulting in a very short (1-1/4-inch) left below-knee amputation which was in a permanently flexed position. On the right extremity, a Syme's amputation had been performed, and the badly deformed stiff knee was in approximately 40 degrees of flexion (Fig. 10-12 ). The patient had never been fitted with prostheses and was referred to the Prosthetics Research Study for possible evaluation and consultation.
A wedge osteotomy was performed on the right knee, placing it in approximately 15 degrees of flexion, with the Syme's stump in a good weight-bearing and functional position (Fig. 13 and 14 ). The patient was fitted with the aforementioned experimental Syme's prosthesis that extended the socket brim just proximal to the knee joint. Plastic revision of the scars behind the left thigh was carried out with wedge resection and sutures. Growth impairment allowed us to fit the stump with a plastic quadrilateral partial end-bearing socket with anterior opening and a Hydra-knee swing-phase control unit (Fig. 15 and 16 ).
The patient's progress has been astounding, and periodical follow-up indicates that he is doing extremely well walking without assistance or external aids. A ten-minute motion picture has been prepared demonstrating the patient's progress.
Two patients whose stumps were well healed and matured-one below-knee and one above-knee-were not fitted with prostheses because of other physical disabilities present at the time.
Two patients died of causes unrelated to the amputation surgery and before they were ready to be fitted with a definitive prosthesis.
(To be continued)