Recent Articles Of Interest
Cineplasty - Ten Years Later
(The following is an abstract of an article "Follow-Up Notes on Articles Previously Published in the Journal. Cineplasty --Ten Years Later" by Colonel Ernest A. Brav, Lieutenant Colonel William F. Macdonald, and Lieutenant Colonel George H. Woodard, Medical Corps, United States Army, and Fred Leonard, Ph.D., Washington, D,C. This article appeared in the July 1964 issue of the American volume of The Journal of Bone and Joint Surgery and is a follow-up on a study made by these authors and others at the Walter Reed Army Medical Center in Washington, D,C. The earlier study was reported in the January 1957 issue of The Journal of Bone and Joint Surgery under the title "Cineplasty -- An End-Result Study.")
Original Study Described
The 1957 article reported on a study of 107 cineplasties - 78 biceps and 29 pectoral - performed between 1948 and 1953, which indicated a greater success for biceps cineplasty than for pectoral cineplasty. With a minimum follow-up of one year, 73.1% of the biceps cineplasty patients, and 31% of the pectoral cases continued to wear their prostheses regularly.
Proper selection of patients was considered of first importance. Biceps cineplasty was recommended for men with below-elbow or long above-elbow amputations who expect to engage in skilled labor and who possess the considerable intelligence and motivation required. Pectoral cineplasty was even more sparingly recommended, being deemed suitable only for the man with bilateral shoulder disarticulation who needs an additional source of prosthetic control. It was also pointed out that cineplasty should be performed only where there is an amputation center with all elements of the clinic team represented, and in localities where the necessary special maintenance facilities are available.
An analysis showed that 60% of the pectoral cases but only 38.1% of the biceps cases gave up wearing the cineplasty prostheses for reasons related to hospital management, such as tunnel breakdown, stump inadequacy, or prosthetic difficulties, thus emphasizing the difficulties inherent in the pectoral procedure.
Current Status of These Patients
After ten years, questionnaires were sent to all the original study subjects who could be located, to determine the number still wearing their cineplasty prostheses regularly. A total of 55 questionnaires was returned -- 40 by patients with biceps cineplasty, 15 by patients with pectoral cineplasty.
Of the 40 biceps cases, 29 (72.5%) were still wearing their prostheses regularly and were highly pleased with the minimum harnessing and the ease of control and function. Thirty-five patients (87.5%) stated that they would recommend the procedure to other amputees. The 11 nonwearers gave various reasons for not continuing the cineplasty prostheses, but only two of them have switched to conventional arm prostheses.
Of the 15 pectoral cases, none was still wearing his cineplasty prosthesis, but four had changed to conventional devices .
Many of the respondents reported great difficulty in obtaining proper maintenance and replacement of their cineplastic prostheses .
Further Cineplasty Cases
In the past ten years, cineplasty has been performed less frequently at Walter Reed Hospital, because of the special considerations and difficulties involved. Between 1954 and 1963, the procedure was performed on 28 patients (18.1% of arm amputees treated). During the last three years, no cineplasties have been performed, although each arm amputee was seriously considered for the procedure. In several cases, the operation was recommended but refused by the patients because they were satisfied with their conventional prostheses and did not think the advantages of cineplasty were sufficiently great to justify the inconvenience and prolonged hospitalization.
- The percentage of cineplasty wearers who use their prostheses regularly is still less than is the case with those who have been fitted with conventional limbs.
- Cineplasty should be performed only at established amputation centers where all the members of the clinic team can participate in the proper selection of patients, where there are surgeons familiar with the operative procedure, where training supervision by experienced physiatrists is available, and where the fitting can be done by prosthe-tists who understand the peculiar1 problems of the cineplasty amputee. There must also be provision for subsequent specialized prosthetic maintenance.
- . The proper selection of candidates for biceps cineplasty is the most important factor in the end result. When a cineplasty is indicated the advantages of the procedure outweigh the inconvenience and the prolonged hospitalization.
- Pectoral cineplasty, in our present state of technical knowledge, is applicable only to patients with serious problems in prosthetic fitting, such as bilateral shoulder disarticulation.
- There has been no significant change in the procedure, but meticulous surgical technique remains of primary importance .
- Dissemination of information concerning proper maintenance and replacement of cineplasty prostheses is essential if the procedure is to remain practical. There is need for further research in materials , mechanical components, and harnessing.
- Cineplasty is not advisable in patients prior to adolescence and usually is not cosmetically acceptable to women.
New Day For Leg Amputees
In the May 1965 issue of the Inter Clinic Information Bulletin (volume IV, Number 7)an article by Dr. Ernest M. Burgess and Mr. Joseph E. Traub described their early experiences with "Immediate Post Surgical Prosthetic Fitting in Children." Dr. Burgess is Clinic Chief at the Child Amputee and Congenital Deficiency Clinic, Children's Orthopedic Hospital, Seattle, Washington.
In July-August 1965 issue of the Rehabilitation Record (Volume6, Number 4),* Drs. Ernest M. Burgess** and Roberto L. Romano** present a further discussion of their experiences with the new surgical, prosthetic and ambulation techniques originated by Dr. Marion Weiss of Poland. The positive results achieved under optimal conditions are reported. The article concludes: "We are continuing to perfect the techniques of amputation surgery, immediate postsurgical prosthetic fitting, and the many technical details involved in the application of the immediate postoperative cast. Although our work is not completed, we have progressed far enough to have grounds for optimism. We feel that this combination of myoplasty and early ambulation will be an important rehabilitative measure for amputees and a major step forward in the advancement of amputation surgery."
Hector W. Kay
*Published by the U.S. Department of Health, Education, and Welfare, Vocational Rehabilitation Administration, Washington, D.C. 20201
**Prosthetic Research study, Seattle, Washington
The following abstract from the June 1964 issue of Birth Defects is reprinted with the permission of the National Foundation-March of Dimes.
Congenital Malformations In Newborn Infants Of Diabetic Women.Correlation With Maternal Diabetic Vascular Complications.
Lancet 1(7343): 1124-1126, May 23, 1964.
Pedersen, L.M., Tygstrup, I. and Pedersen, J. (Royal Matern. Dept., Royal Hosp., Copenhagen, Denmark.)
A study of 853 infants with a birth-weight of 1000 g or more born to diabetic mothers over a 37% year period disclosed a 6.4% malformation rate, or 55, in contrast to 2.1%, or 26, for a control group of 1212 offspring of nondiabetic mothers. Among infants from the diabetic group, 44 suffered major fatal or nonfatal defects, 11 had minor anomalies, 18 died perinatally, and 14 presented multiple malformations. Among the controls, 14, 12, 4, and 3 cases each were similarly classified. Excepting minor anomalies, the differences are significant.
Among 82 infants of diabetic mothers who succumbed perinatally, 16 were defective; of the latter, 10 died, and 7 had multiple abnormalities. There were 147 malformed neonates from 2238 nondiabetic mothers during the same period; of the 147, 91 died, and 67 had multiple defects. Each of these differences is also significant.
According to White's prognostic classification of pregnant diabetics the frequency of malformed outcomes were as follows: group A, 62 infants, 4.8&; group B, 295 infants, 5.1%; group C, 216 infants, 3.2%; group D, 238 infants, 9.7%, and group F, 42 infants, 16.7%. The criterion for group E was omitted. The number of infants of women in group D with mild vascular complications at time of delivery totalled 201, of whom 22 were defective. Combined with group F of severe vascular complications, the D-F sum of 30 defective offspring, or 10.7%, is more than double that for A, B, and C together, or 4.4% each without vascular difficulty. Apparently, the malformation frequency varies directly with vascular severity, while insulin therapy or age of diabetic onset are insignificant factors.
The incidence of defect in the surviving and autopsy material as well as the frequency of major and multiple malformations in the diabetic group is three-fold higher in each case than that among corresponding control populations. The evidence is scarcely unexpected since a deviant gene pattern and an abnormal intrauterine environment, especially late diabetic changes in maternal vessels, are involved. Hypoglycemia cannot be the chief cause, due to the low number of insulin reactions or insulin coma in the first trimester for most series reported. The high risk among group F mothers, the majority of whose offspring presented with major defects particularly congenital heart disease and limb deformities, indicates the. clinical desirability of abortion. Thalidomide medication was not a factor in this sample. (21 references)