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Section 1: General Topics
Figure 14
mosaic depicting a Moorish hunter with a
trans tibial peg-leg. (Courtesy of Professor René
Baumgartner, Zumikon-Zurich, Switzerland.)
Photograph of Gallo-Roman
von Berlichingen were designed to firmly lock onto a sword or shield in battle
(Figure 15).
Despite the awakening of intellectual curiosity in the Renaissance (14th to
16th centuries), development during the
first 200 years in the field of prosthetics
did not keep pace with that of amputation surgery. Individuals who were
poor continued to use crude crutches,
peg-legs, or rolling platforms as they
had for centuries. The increasing use
of cannons and muskets, meanwhile,
made battle wounds an ever-increasing
cause of amputation as survival rates
improved (Figure 16). Prosthetic innovation finally began in the 16th century
and was closely linked to the constant
warfare of that period. The first major
advance was made during the Renaissance circa 1560 by the French surgeon
Paré, who devised an inexpensive wooden knee-walker peg-leg for poor private
soldiers and a sophisticated transfemoral
prosthesis for wealthy officers, as well as
cleverly crafted prosthetic hands with
locking fingers. Although peg-legs had
been used since ancient times, Paré’s
design featured longer sides with straps
to securely attach the prosthesis to the
thigh (Fig u r e 17 ). His endoskeleton
Figure 15
mercenary knight Goetz von Berlichingen
holding a sta with his prosthetic right hand,
which featured jointed, locking ngers to hold
a weapon. (Reproduced with permission from
the American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas: Articial
Limbs: A Consideration of Aids Employed in the
Practice of Orthopaedic Surgery. Ann Arbor,
MI, JW Edwards, vol 2, 1960, p 3.)
Figure 17
A, Front view shows the exed limb between medial and lateral uprights resting on a cushion.
B, Posterior view. (Adapted w ith permission from Paré A: Ten Book s of Surgery. 1563. Athens, GA, U ni-
versity of Georgia Press, 1969.)
Illustration of the Teutonic
Illustrations of Paré’s knee-walker peg-leg for poor private soldier-amputees.
Figure 16
homemade prostheses of poor army veteran-amputees of the Renaissance. The ankle
amputee uses a knee-walker peg-leg and cane.
The knee amputee uses an end weight-bearing
peg-leg and a crutch. (Reproduced with permission from the American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas:
Articial Limbs: A Consideratio n of Aids Employed
in the Practice of Ortho paedic Surgery. Ann Arbor,
MI, JW Edwards, vol 2, 1960.)
Illustration depicts typical
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
12
Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
Figure 18
tees. A, External view. B, Internal view. Note the leather socket, metal shank, and articulated midfoot under iron plates used to simulate armor. (Adapted with permission from Paré A: Ten Books of
Surgery. 1563. Athens, GA, University of Georgia Press, 1969.)
transfemoral prosthesis for military officers featured a leather socket, a foot
with a spring-loaded midfoot hinge, and
a knee that could be unlocked for sitting (Fig ure 18). The whole device was
covered with thin iron plates shaped
to match the contours of the opposite
armored limb and was suspended from
an undervest.
The most important prosthetic design of the Renaissance, however, was
the transtibial prosthesis introduced
by the Dutch surgeon Pieter Verduyn
in 1696. With this prosthesis, the amputee was able to fully realize the benefits of Verduyn’s revolutionary posterior
myofasciocutaneous flap. The prosthesis
consisted of a copper socket lined with
leather, a solid ankle wooden foot, and a
leather thigh corset attached to the socket with jointed metal bars. The tightly
Illustrations of Paré’s transfemoral prosthesis designed for wealthy ocer-ampu-
laced thigh corset aided in both suspension and weight bearing; the jointed metal bars allowed free knee motion
(Figure 19). This became the prototype
for functional transtibial prostheses until the introduction of the patellar tendon–bearing (PTB) prosthesis in 1961
by Charles Radcliffe and James Foort
at UCB. Nonetheless, the knee-walker
peg-leg was still commonly used during
the first half of the 19th century. It was
so ubiquitous that the ideal length of
a transtibial amputation was held to
be no more than 8 to 10 cm below the
knee joint to more conveniently fit this
design.
Conceptual progress in upper limb
prosthetic design continued with Gavin
Wilson’s artificial hand circa 1790, capable of holding a knife, fork, or pen.
Peter Baliff, a Berlin dentist, developed
Figure 19
transtibial prosthesis (circa 1696) designed
specically for patients treated with his posterior myofasciocutaneous ap technique.
(Reproduced with permission from the American Academy of Orthopaedic Surgeons: Or-
thopaedic Appliances Atlas: Articial Limbs: A
Consideration of Aids Employed in the Practice
of Orthopaedic Surgery. Ann Arbor, MI, JW Ed-
wards, vol 2, 1960.)
Illustration of the Verduyn
the first body-powered prosthetic hand
with prehension circa 1816, activated by
elbow and shoulder motion (Figure 20).
The concept of harnessing the remaining muscles of a limb to operate a terminal device has remained central to the
development of upper limb prosthetics,
as exemplified by the practical introduction of myoelectrically controlled
external power in 1958.
With the increase in higher level
gunshot injuries and the prevalence of
transfemoral amputees, interest in the
design of prostheses for this level increased, resulting in ingenious devices.
The concept of an ischial weight-bearing
socket had already been introduced by
Gavin Wilson in 1790. In 1810, J.G. von
Heine, considered the founder of German orthopaedics, introduced ball-andsocket knee and ankle joints. The knee
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
13
Section 1: General Topics
Figure 20
prosthesis designed by Peter Bali circa 1816.
The ngers were activated by e lbow and shoulder motion. This basic design was unchanged
until 1944. (Reproduced with permission from
the American Academy of Orthopaedic Surgeons: Orthopaedic Appliances Atlas: Articial
Limbs: A Consideration of Aids Employed in the
Practice of Orthopaedic Surgery. Ann Arbor,
MI, JW Edwards, vol 2, 1960.)
Illustration of the transradial
joint was locked except when sitting.
In 1816, Peter Baliff also introduced a
transfemoral prosthesis with an ingenious knee joint that unlocked on toeoff to allow knee flexion during swing
phase and relocked on heel contact to
provide stability during stance phase.
In 1816, James Pott of London made
a hollow-shanked wooden transfemoral
prosthesis with partially restrained balland-socket knee and ankle joints and
a toe hinge. The joints were connected by cords so that knee flexion would
dorsiflex the ankle (Figure 21). This leg
became known as the Anglesey leg after
one was fitted to H. W. Bayly, Marquess
of Anglesey, who lost his leg in the closing moments of the Battle of Waterloo in
1815. Various modifications of this leg
remained the standard British design
until after World War I. In 1839, the
design was brought to the United States
by William Selpho, a limbmaker in Pott’s
factory, as the “American” leg and was
thereafter modified by competitors. In
1843, Martin and Charrière introduced
Figure 21
1816 Anglesey Leg. Internal elastic straps
were used to control knee and ankle movement. (Reproduced with permission from the
American Academy of Orthopaedic Surgeons:
Orthopaedic Appliances Atlas: Articial Limbs:
A Consideration of Aids Employed in the Practice of Orthopaedic Surgery. Ann Arbor, MI, JW
Edwards, vol 2, 1960.)
Illustration of James Pott’s
another concept fundamental to contemporary prosthetic and orthotic design by offsetting the center of the knee
joint posterior to the line of weight bearing; this greatly improved stance phase
stability. In 1860, A. A. Marks of New
York produced a foot using vulcanized
rubber (invented in 1839 by Charles
Goodyear). This became the precursor
of several flexible feet popularized since
World War II. Vulcanized rubber was
also quickly formed into rubber bumpers to limit and cushion the motion of
prosthetic joints by American, British,
and European prosthetists. Marks was
also the first to shrink-wrap wooden
sockets and hollow shanks in rawhide
to increase strength and durability.
The US Civil War resulted in large
numbers of amputees, and this number was further increased by individuals injured in industrial and railroad
Figure 22
of Parmelee’s 1863 endoskeletal transfemoral
prosthesis that featured a suction suspension
socket, eliminating the need for body harnessing. Note the valve (arrow) in the distal-anterior socket, a polycentric roller knee joint, and
a multiarticulated foot. (Reproduced from the
American Academy of Orthopaedic Surgeons:
Orthopaedic Appliances Atlas: Articial Limbs:
A Consideration of Aids Employed in the Practice of Orthopaedic Surgery. Ann Arbor, MI, JW
Edwards, vol 2, 1960.)
Illustration depicts lateral view
accidents. After the war, the United
States experienced much more growth
in the development of prosthetic design
and manufacture than Europe. One entrepreneur, James E. Hanger, was a Con
federate soldier who lost his leg early in
the war and made a prosthesis for himself. In 1861, he introduced a single-axis ankle joint controlled by vulcanized
rubber bumpers rather than cords. He
went on to found the prosthetics company that currently bears his name. In
1863, Dubois Parmelee of New York was
issued a patent for the first transfemoral
prosthesis using a suction suspension
socket, eliminating the need for elaborate body harnesses or corsets. The
prosthesis also featured a polycentric
roller knee joint, a multiarticulated foot,
and endoskeletal construction at a time
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
14
Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
when most prostheses had an exoskeletal design (Figure 22). However, neither
suction suspension nor endoskeletal
construction became widely accepted
in prosthetics until the latter part of the
20th century.
Despite the many profound conceptual changes in prosthetic design of 19th
century innovators, only the rich and
government-subsidized war amputees
could afford these limbs. In 1867, the
Comte de Beaufort designed two affordable transtibial prostheses made
entirely of wood and leather for French
soldier-amputees from the Crimean and
Italian campaigns. One prosthesis was
a knee-walker peg-leg for the poor and
the other had wooden side joints and
a leather thigh lacer. Each featured a
rocker foot that made walking much
easier. The latter prosthesis, improved
with steel side joints, was used until
about 1929 and known as the “French
leg” (Figure 23).
Progress in prosthetics during the
19th and early 20th centuries as a result
of the Napoleonic, Crimean, US Civil,
and First World Wars was influenced by
several critical factors that had lasting
effects. Because prosthetics has always
been a small field that serves relatively few people, it has not always been
possible, especially for individual prosthetists, to devote the necessary time
and financial resources to fully develop
their concepts on any scale. In addition, the materials initially available to
construct limbs, such as wood, leather,
and iron, were limited. Nonetheless,
both prosthetists and amputees have
always placed a premium on reliability,
strength, comfort, and low weight as
worthwhile goals, with cost of secondary
importance. By necessity, prosthetists
have had to borrow new techniques, devices, and materials from other fields as
they became affordable and adapt them.
Innovations of the Industrial Revolution
provided many opportunities to exploit
new materials, methods, and devices
such as steel, vulcanized rubber, and
machine tools.
Another material that was adapted to prosthetic use was aluminum,
which combines reasonable strength
with light weight. Although August
Gustav Hermann of Prague had substituted aluminum for steel components
as early as 1868, a fortuitous mishap
resulted in its fullest use in prosthetics.
In approximately 1912, British test pilot
Marcel Desoutter lost his leg in a flying
accident. Unhappy with heavy contemporary prostheses, he enlisted the help
of his brother Charles, an aeronautical
engineer and his partner in the aircraft
manufacturing firm Desoutter Brothers.
Charles designed an exoskeletal prosthesis weighing only 3.5 lb using the
newly available aluminum alloy (called
duralumin) and using pelvic, rather
than shoulder, suspension. As news of
this prosthesis spread, the Desoutter
Brothers became a prosthetic design and
manufacturing firm. Demand increased
rapidly, despite the initial reluctance of
the British government to purchase
prostheses for war amputees because
of the high cost. Aluminum exoskeletal
prostheses remained the British standard until well after World War II.
Building on the Parmalee concept
of suction suspension for transfemoral limbs, Ernest Underwood, a British
war amputee, designed a wooden socket
with annular spiral grooves that closely
fitted the bare skin of the residual limb.
Fashioned of duralumin and featuring a
valve to expel air from the socket during
donning of the prosthesis, this became a
successful design of the Blatchford firm.
German designers were also active between World Wars I and II. The prosthetist Oesterlee of Ulm designed his own
suction suspension socket, followed in
1932 by one with an improved valve designed by the surgeon Felix of Dusseldorf. The use of suction suspension was
widespread in Germany by the end of
World War II and captured the attention
of an American commission charged
with improving prosthetic care for US
Figure 23
transtibial prostheses designed by Beaufort
in 1867. These prostheses were made entirely
of wood and leather. A, Knee-walker peg-leg.
B, Prosthesis featuring leather thigh lacer, locking knee joints, and adjustable leather socket.
Both designs had a rocker foot to ease rollover
gait. (Reproduced with permission from the
American Academy of Orthopaedic Surgeons:
Orthopaedic Appliances Atlas: Articial Limbs:
A Consideration of Aids Employed in the Practice of Orthopaedic Surgery. Ann Arbor, MI, JW
Edwards, vol 2, 1960).
Illustrations of two aordable
veterans. Another German development
was the design of three- and four-bar
linkage knee joints by Alfred Habermann. Probably the most important
American advance during this period
was the split hook for body-powered upper limb prostheses, invented and promoted by D.W. Dorrance, a transradial
amputee (Figure 24). Terminal devices
based on his original design remain
among the most commonly prescribed
options.
During World War II, returning military amputees quickly became dissatisfied with the design and function of
available prostheses, especially those
for the upper limb, which combined
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
15
Section 1: General Topics
Figure 24
tary-opening hook-type terminal device designed by amputee-inventor D.W. Dorrance
after World War II. (Courtesy of Hosmer Dorrance, Campbell, CA.)
Photograph of a volun-
excessive weight with minimal function.
In response, Army Col. John Loutenheiser enlisted the help of Northrop
Aviation engineers in 1943 to develop
lighter, more functional upper limb
prostheses. Plastic laminate was used
to substantially reduce socket weight
and bulk. The Bowden cable, used to
activate aircraft control surfaces, was
adapted to operating upper limb prostheses, replacing stretchable, fragile
leather thongs. Northrop engineers also
invented a shoulder-operated locking
elbow for transhumeral amputees. That
same year, the first prosthetic research
laboratory was organized by the Navy
at Mare Island, California.
Before the war ended, a concerted
national campaign was launched to
address these same concerns, led by
the amputee veterans themselves and
strongly supported by US Representative Edith Nourse Rogers, Chairman of
The House Veterans Committee, and by
Secretary of War Henry L. Stimson. The
goal was to combine the efforts of academia and private industry to improve
prosthetic design. The redevelopment
of this partnership, which had been so
productive in the war effort, resulted in
a new intellectual and clinical foundation for contemporary prosthetics. The
program eventually came under the
auspices of The National Academy of
Sciences (NAS) with its Committee on
Prosthetics Research and Development
(CPRD) and Committee on Prosthetics
and Orthotics Education.
In January 1945, the NAS organized
a meeting in Chicago of leading surgeons, engineers, and prosthetists, in
cluding the orthopaedic surgeons Paul
Magnuson of Northwestern University
and Philip D. Wilson of the Hospital for
Special Surgery, to establish standards
for upper and lower limb prostheses.
It was soon determined that data were
insufficient to formulate any meaningful
standards. The organization of a government-funded program to perform fundamental studies related to prosthetic
design, fitting, and use was recommended. With this program, basic studies of
normal human gait were conducted at
the University of California (UC) under
the direction of Verne Inman, Professor of Orthopaedic Surgery at the UC
Medical School in San Francisco and
Howard Eberhart, Professor of Civil Engineering at UCB, an amputee. They attached metal pins with reflective targets
to bony prominences of the lower limbs
and pelvises of volunteers. Using interrupted light photography, these markers
allowed the accurate measurement of
the relative three-dimensional motion
of limb segments during walking. These
and other innovations formed the basis
for the field of biomechanics. Additional
studies by M.P. Murray and Jacquelin
Perry and others over the next decades
further enhanced the understanding of
normal and amputee gait.
Within a short time, a network of
biomechanics laboratories was established, each with a particular mission.
UCB continued to study the lower limb,
and the University of California Los Angeles (UCLA) initiated a parallel biome
chanical research program on the upper
limb. Two major advances occurred at
UCLA. The first was the development of
a rationale for socket and harness design
for every level of upper limb amputation.
The second was the design and testing of
commercially available components that
could be assembled to meet the individual needs of amputees. The Veterans Administration (VA) Prosthetics Research
Laboratory in New York City, under the
direction of Eugene Murphy, applied the
-
results of the UC research directly to war
veterans with amputations. The Army
Prosthetics Research Laboratory at Walter Reed Hospital and the Navy counterpart at Oakland, California, served
their respective populations; the Army
concentrated on upper limb prosthetic development and the Navy on lower
limb development. This aggregate body
of work provided a solid rationale not
only to guide the future design and use
of prostheses, but to encourage surgeons
to save as much limb length as possible,
thus preserving more function than was
previously considered feasible.
Following reports of the widespread,
successful fitting of transfemoral prostheses with suction suspension by prosthetists in postwar West Germany, the
US Surgeon General dispatched a group
of surgeons and engineers to study this
application. The Germans had been using this method since the early 1930s,
based on Parmelee’s American patent
of 1863. This technology was promptly reintroduced to American amputees.
With the reintroduction of the intimately fitting suction suspension socket, the
fixed-position hip joint and pelvic belt
were no longer required and coronal
plane alignment of the prosthesis became
more critical. To meet this requirement,
Charles Radcliffe of UCB developed
both an adjustable knee alignment
unit and an alignment-duplication jig
to ensure accurate transfer of the threedimensional configuration achieved
during standing and walking to the fin-
-
ished prosthetic limb. These were based
on the earlier work of Hans Schneider
in Germany with his “Gehmaschine”
(walking machine), which was a highly
adjustable, reusable trial prosthesis.
Substantial improvements in prosthetic knee joints soon followed. Jack
Stewart, a motorcycle racer who underwent transfemoral amputation, developed a superior seal for a hydraulic
shank unit of his design that integrated
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
16
Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
ankle dorsiflexion with knee flexion to
clear the foot during swing phase. The
seal also proved to be a great advance
for aircraft hydraulic systems. This latter
application, as well as the prosthetic one,
was supported by Vickers Corporation
of Detroit. Immediately after World War
II, Hans Mauch, an engineer in charge
of developing the German V-1 military
rocket, moved to the United States and
resumed work on another hydraulic
knee unit with Ulrich Henschke. The
final result was a knee with hydraulic
control of both swing and stance that is
still in production. The excessive weight
of early hydraulic units resulted in the
UCB Laboratory developing a lighter
pneumatic swing control knee unit,
variations of which are still used.
By 1950, the UCB Laboratory had
developed the ischial weight-bearing
quadrilateral socket using anatomic
studies to replace the historical plug-fit.
The original concept had been brought
to England by the New Zealand prosthetist Nugent 5 years earlier. Another
major advance of that decade for both
upper and lower limb prosthetics was
the introduction by Northrop Aviation
of a thermosetting resin suitable for
laminating sockets on a plaster mold of
the residual limb. This plastic laminate
construction was used by researchers
at the Sunnybrook Hospital in Toronto
in the mid 1950s for their new Syme
and hip disarticulation prostheses.
The new lightweight Syme prosthesis
with a removable window to facilitate
donning and a solid ankle cushion heel
foot (SACH foot) renewed interest in this
level. Further development of the SACH
foot continued at UCB, with its application to transtibial prostheses. The hip
disarticulation prosthesis, designed by
Colin McLaurin, featured a freely moving hip joint mounted on the anterior
surface of the socket. Alignment stability of the hip and knee joints permitted
standing and walking without a hip
lock, eventually rendering the previous
‘tilt-table” prosthesis obsolete.
In 1696, Pieter Verduyn had replaced
the bent-knee peg-leg with the first prosthesis allowing knee motion by using
a thigh corset and side joints for both
suspension and weight bearing. Two
hundred sixty-five years later, the UCB
team of Radcliffe and Foort introduced
the full-contact PTB transtibial socket
suspended by a simple supracondylar
strap that eliminated the need for Verduyn’s thigh corset and side joints.
Later suspension options for PTB
prostheses included extension of the
socket brim over the femoral condyles
(PTB-supracondylar [PTB-SC]), developed by Kuhn in Muenster, Germany
and the PTB-SC-suprapatellar (PTBSC-SP) by Fajal in Nancy, France.
Further refinements of supracondylar
suspension included various types of
medial wedges. Because of their intimate clamp-like fit just proximal to the
femoral condyles, these new suspensions improved retention of the prosthesis while increasing socket stability
about the knee, particularly for short
residual limbs. Techniques to enhance
the suspension of both transtibial and
transfemoral prostheses with elevated
vacuum have become available. Some
devices rely solely on cyclical loading
and unloading of the prosthesis to pump
air out of the socket; others use powered
pumps complete with fobs.
In 1961, Anthony Staros of NAS formulated criteria for a temporary transfemoral prosthesis for geriatric amputees
using a plastic socket attached to thigh
and shank segments made of metal tubing and joined by a knee hinge, complete
with a foot. This became the prototype
for various endoskeletal prostheses initially produced by firms in Germany,
the United States, and the United Kingdom over the next decade. Prosthetic
applications for plastics developed by
the aerospace and other industries accelerated, with sockets formed first of
thermosetting plastic, followed by thermoplastics such as polyethylene and
polypropylene.
By the 1970s, Otto Bock Orthopadische Industrie GmbH had established
a de facto worldwide standard by producing durable, reasonably priced, interchangeable endoskeletal components
that could be realigned throughout the
useful life of the prosthesis. The result
was that the use of fixed-alignment
prostheses became increasingly rare.
Otto Bock also developed the first reliable, lightweight endoskeletal knee incorporating a weight-activated friction
brake that automatically stabilized the
knee throughout stance phase. In 1983,
the old-line British firm Blatchford introduced a 1.5-kg prosthesis formed
primarily of carbon fiber–reinforced
plastic component parts. Titanium,
used extensively in the aerospace and
arms industries, became a lightweight
substitute for steel components. Another
major advancement, during the 1980s,
was the introduction of the ischial containment socket, which combined an
increased weight transfer area during
stance phase at the limb-socket interface
with a narrow medial-lateral socket dimension that more closely matches the
thigh anatomy than the earlier quadrilateral design. Knee disarticulation began to gain more favor after Eric Lyquist
introduced a reliable four-bar linkage
knee with hydraulic swing phase control in 1973, named the Orthopaedic
Hospital of Copenhagen knee. This
design allows the shank to fold behind
the thigh segment in full flexion and
reduces the protrusion of the prosthetic
thigh during sitting; variations remain
in use today.
Several other substantial technical advances in lower limb prostheses
occurred in the 1980s and 1990s, including the development of prosthetic
feet with internal leaf springs made of
carbon fiber that enabled amputees to
walk, run, and jump with greater ease
(Figure 25). Some foot-ankle units now
incorporate hydraulic ankles to provide
greater adaptability to slopes and uneven terrain. Other foot-ankle units use
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
17
Section 1: General Topics
Figure 25
who is an elite sprinter tted with a carbonber Cheetah running foot. (Copyright Össur,
Aliso Viejo, CA.)
Photograph of an amputee
a microprocessor to control a motor and
spring combination to provide not only
terrain adaptability, but also at least a
measure of powered push-off in late
stance phase. Some of these feet include
pocket fobs for the user to control the
component’s function. Two other major
socket innovations where developed in
Iceland by amputee-prosthetist Össur
Kristinsson. These flexible-walled sock
ets were supported by an abbreviated,
rigid weight-bearing frame and flexible
roll-on suspension liners. At this time,
Blatchford introduced the first prosthetic knee with microprocessor-controlled
swing phase control, demonstrating the
clinical value of self-adjusting components that can be programmed to the
individual needs of the amputee.
In the 1990s, the German firm Otto
Bock Orthopaedische Industrie GmbH
introduced its C-Leg, which used microprocessors, force sensors, potentiometers, and lithium-ion batteries to control
a hydraulic unit, providing enhanced
stance phase stability and swing phase
control, resulting in improved comfort
and security for the wearer. Since their
introduction, these components and
their successors and competitors have
incorporated features such as wireless
communication and gyroscopes, which
are ubiquitous in consumer electronics
and most closely identified with smartphones. Wireless communication with
these knee units allows the prosthetist
to adjust the on-board settings of the
knee unit without a cumbersome wired
connection. The pocket fob enables the
user to select from available control
modes and to adjust some of the control settings.
The advent of Computer Aided Design-Computer Aided Manufacturing
(CAD-CAM) systems for the production of prosthetic sockets became possible with the introduction of desktop
computers in the 1980s. The primary
advantages have been increased manufacturing efficiency and incremental
time savings when compared with manual production of custom sockets. Companies marketing prosthetic/orthotic
CAD-CAM systems have continually
improved their products with software
upgrades and newer, more convenient
ways to scan the involved body segments. Such systems remain expensive,
often involve steep learning curves, and
are not universally available. Although
-
concrete data are lacking, market penetration has likely been limited by such
factors. This could change if the cost of
scanners is reduced by the availability
of newer scanning technologies for tablets and smart phones and lower prices.
Interest in scanning techniques has occurred in close association with interest
in three-dimensional printing (stereolithography) and additive machining.
Industry has used such techniques to
rapidly produce prototypes and explore
design ideas. Efforts are being made to
use this concept to produce sockets,
but the equipment available is expensive and slow. The technique may have
potential for future development, particularly if it can be exploited to produce
new socket designs that improve comfort and function.
The initial work on external power
for the operation of upper limb prostheses is attributed to Borchardt in Germany in 1919. In the 1950s, Russian
investigators harnessed myoelectric
signals from the forearm extensor and
flexor muscle masses of transradial
amputees to control the flow of electric current from a battery contained in
the prosthesis. Further refinements by
German, Austrian, American, and British companies have resulted in various
myoelectric hands, grippers, and elbows
to fit both adults and children. This expansion became possible with the availability, from industrial applications, of
solid-state circuits, efficient small motors, energy-dense batteries, and more
recently, microprocessors. Since 1976,
technologic growth and development
have continued unabated, and indeed,
accelerated, due largely to the incorporation of spinoff technology from the consumer electronics field, including the
rapidly advancing mobile phone, pager,
and handheld video game industries.
The need to control an ever-increasing
number of degrees of freedom hinders
the development of such devices, even
as the number of available control sites
decreases with each successively higher
level of amputation. To address this
conundrum, Todd Kuiken conducted
pioneering work in targeted muscle reinnervation to surgically increase the
number of available control sites. This
harkens back to the use of cineplasty
in the 20th century. Practical control of
such complex prostheses will likely have
to wait for the successful implementation of a brain-computer interface. The
most important clinical development in
upper limb prosthetics has been the introduction of externally powered hands
with powered digits and multiple grasp
patterns. At least one of these hands has
a smart phone app, thus linking prosthetics and consumer electronics.
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Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
For many decades, prosthetic restoration of a missing limb addressed three
main concerns of the individual with an
amputation: function, comfort, and cosmesis. Cosmesis for a lower limb prosthesis generally meant for the individual
with an amputation to be indistinguishable from anyone else by the casual observer. At times, however, a cosmetic
foam cover actually interfered with the
function of a knee or ankle unit. This
older concept of cosmesis has begun to
change with the introduction of more
functional but much less cosmetic pros
thetic components, and it has resulted in
great success by some elite athletes with
amputations. Today, many younger individuals with trauma amputation proudly wear brightly decorated lower limb
prostheses with exposed components,
which seldom elicits a second glance.
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Socioeconomic Forces Affecting
the Provision of Prostheses
From ancient times until the mid 1800s,
a prosthesis was a luxury available only
to the wealthy. The relatively few poor
individuals who survived a major amputation managed with homemade
crutches or peg-legs. Recognizing the
huge socioeconomic disparity between
wounded officers and common peasant
soldiers, Paré devised an inexpensive
wooden knee-walker peg-leg for the
peasant soldiers in France. The organization of special funds for the medical
care of disabled workers started in the
early 1600s, with the European guilds.
With the decline of the guilds a century later, various health funds were established by manufacturers and trade
unions, but none paid for prostheses.
The situation began to change, at
least for military amputees, during the
US Civil War, when both the federal
and Confederate governments began to
provide prostheses at public expense.
This was known as the Great Civil War
Benefaction. The original federal legislation of 1862 was amended in 1870 to allow a new prosthesis every 5 years, and
later to every 3 years. The Prussians and
British quickly followed this protocol,
providing both an articulated prosthesis and a peg-leg to wear during repairs
on the primary limb. These measures
substantially increased the number of
prostheses fitted, thus encouraging development of the field.
During World War I, British philanthropists established Queen Mary’s
Hospital for The Limbless at Roehampton. Beset with wartime shortages and
short-staffed facilities, British firms
alone were unable to cope with the
surge in demand for prostheses created by scything machine gun fire and
shrapnel (the two most common injury
mechanisms). To supply the necessary
expertise and to provide prostheses in
sufficient quantity, the British, as the
French had before them, turned to
American prosthetic firms to fill the
void. The firms, along with their British counterparts, were invited to locate
facilities on the hospital grounds. For
the first time, prosthetists and surgeons
met at the patients’ bedsides to discuss
their prosthetic restoration. The cumulative experience gained and knowledge
shared made Roehampton renowned
worldwide for excellence. At the same
time, the field of prosthetics began its
transformation from a cottage industry
to a multinational business. The American firms introduced new designs, materials, and production techniques to the
British and French. The characteristic
feature of the “American Leg” included
shoulder suspenders for control of the
knee in swing phase, construction of
the shank from a single piece of wood,
a single-axis foot controlled by rubber
bumpers, and external reinforcement of
the wooden shank and thigh segments
with shrink-wrapped rawhide.
The 100,000 battle amputations incurred by the Central Powers (Germany and Austria-Hungary) forced them
to drastically change their methods of
prosthesis manufacture and provision.
For the first time, anthropomorphic
measurements of the lower limbs, developed by the Berlin orthopaedist
Professor Gocht, were used to help design simple prosthetic components that
could be produced quickly. In this way,
wounded soldiers could be rapidly redeployed to supportive agricultural or war
factory work. The Hungarian military
surgeon Dollinger produced the “Arbeitsprothese” (work prosthesis) and the
Germans made the “Behelfsprothese”
(temporary prosthesis). Both were simple designs resembling von Hessings’
19th-century knee-ankle-foot orthosis
with jointed metal uprights, connected
by bands encompassing a leather socket.
To provide a proper fit, the socket of
the Arbeitsprothese was molded about
a plaster model of the amputee’s residual limb.
Prior to World War I, limb-fitting
firms were vertically integrated, including the fabrication of components for
their own use on a custom or semicustom basis as needed. With the experience gained by government-sponsored
prosthetic facilities attached to amputee
hospitals, it became clear that greater
production capacity and cost containment could be achieved by a horizontal
reorganization, allowing mass production of uniform components to be purchased and used by many firms. This
new efficiency also allowed component
manufacturers to devote the necessary
capital to exploit new materials and
techniques beyond the reach of individual prosthetic fitters. In 1919, the Otto
Bock Orthopaedische Industrie GmbH
was founded in Berlin, introducing the
mass production of prosthetic components with the techniques for their
alignment. The three major lower limb
modules were a socket block, a knee
joint with a shank, and an ankle-foot
assembly.
In anticipation of the need for
greatly increased numbers of prostheses for American war amputees, the
chief medical officer of the Council of
National Defense convened a meeting
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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Section 1: General Topics
of the 10 leading American prosthetic
firms in 1917. This meeting resulted
in the formation of the Association of
Limb Manufacturers of America, which
eventually became the American Orthotic and Prosthetic Association and
remains the preeminent trade organization for these fields in the United States.
Because of the late entry of the American Expeditionary Force into the war,
only 4,403 amputations were sustained,
2,635 of which were considered major
amputations, compared with 42,000 for
the British, allowing the redeployment
of American prosthetists to the United
Kingdom.
During World War II, US armed
forces sustained 17,130 amputations.
With thousands of American amputees
returning home throughout World War
II, the Army and Navy responded by
establishing specialized centers for overall amputee care, including all aspects
of prosthetic rehabilitation: 10 for the
Army and 2 for the Navy. These cen
ters incorporated the work of surgeons,
prosthetists, and therapists working as
a team. By 1945, the Army center in
Walter Reed Hospital received up to
1,500 amputees each month. In 1965,
the Medicare program began to provide
prostheses for US citizens older than 65
years and for younger persons permanently disabled by amputation. This
trend reversed in the 1990s, when managed care organizations began excluding prostheses from coverage or limiting
benefits to “one prosthesis per lifetime”
or annual maximum reimbursement of
as little as $1,000. It appears that access
may once again be widely available because of the provisions of the Affordable
Care Act.
With advances in prosthetic design,
manufacture, and provision well under
way for the war amputee population,
attention was focused on another group
whose care badly needed reorganization: children with limb deficiencies.
In 1952, the United States Children’s
Bureau assisted the Michigan Crippled
Children’s Commission in organizing
the first Child Amputee Program in the
United States. It was located in Grand
Rapids under the direction of orthopaedic surgeons C.H. Frantz and G.T. Aitken. A similar program was established
in 1955 at UCLA and both continue to
serve this population today. In 1956,
the CPRD established the Subcommittee
on Child Prosthetic Problems (SCPP),
chaired successively by Drs. Frantz and
Aitken. To further evaluate devices and
techniques resulting from these projects,
a Child Prosthetics Studies program was
funded the same year at New York University under the direction of Sidney
Fishman. To assist in the widest possible
dissemination of this new knowledge
in a timely manner, the Child Amputee
Clinic Chiefs inaugurated an annual
meeting and SCPP began publication
of the Inter-Clinic Information Bulletin. With the dissolution of CPRD in
1976 and with it SCPP, the Association
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of Child Prosthetic and Orthotic Clinics
(ACPOC) was formed to fill the void and
continue publication of the Inter-Clinic
Information Bulletin, later known as the
Journal of the Association of Child Prosthetic and Orthotic Clinics. This journal
ceased publication in 1994.
Education and Training
in Prosthetics
Prior to World War II, training in prosthetics was based largely on informal apprenticeships. The widespread and vocal
dissatisfaction of war amputees with the
available prosthetic designs resulted in
a massive government-sponsored research and development program. In
1949, UCB offered a pilot course in the
prescription, fabrication, and alignment
of the suction suspension transfemoral
socket recently readopted from Germany. This was followed by local courses
in key areas of the country, sponsored
jointly by the VA and the manufacturers’
association, the American Orthotic and
Prosthetic Association. Thereafter, the
VA organized 30 amputee clinic teams
for their hospitals, each consisting of a
surgeon, prosthetist, physical and occupational therapists, and a VA prosthetic
representative.
As a result of these actions, the prosthetists wanted to elevate their educational and professional status to more
closely match that of the other team
members. In 1949, the American Board
for Certification in Prosthetics and Orthotics (ABC) was formed to establish
standards for examination and certification of individual practitioners and
the accreditation of prosthetic and orthotic facilities. ABC now encompasses
pedorthics (design, modification, and
fitting of therapeutic footwear) as well
as prosthetics and orthotics. ABC offers
seven different certification programs
and two different facility accreditation
programs, one for the traditional clinical
care facility and one for central fabrication facilities. Fifteen states now require
licensure to practice and two states require certification.
Additional VA-sponsored courses
for clinic teams followed. UCLA presented 12 courses of 6 weeks’ duration
on upper limb prosthetics from 1953 to
1954. The response was so great that
prosthetics education programs were
established at New York University’s
Postgraduate Medical School in 1956
and at Northwestern University in 1959.
By the late 1980s, 12 universities offered
preparatory programs in prosthetics and
orthotics: 5 offered them at the baccalaureate level, and 7 offered postgraduate certificates in prosthetics, orthotics,
or both disciplines. By 2000, fledgling
masters-level programs had begun and
doctoral programs existed in Scotland,
Hong Kong, and Australia. The charitable German Society for Technical Cooperation (Gesellschaft fuer Technische
Zusammenarbeit) has been one of the
most effective prosthetic and orthotic
outreach organizations. This group has
organized prosthetic and orthotic training programs in several countries in Africa, Asia, and Latin America, eventually
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Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
turning the programs over to local instructors whom they have trained.
In 1970, the American Academy of
Orthotists and Prosthetists (AAOP) was
formed with a primary focus on education, modeled after the American Academy of Orthopaedic Surgeons. Shortly
thereafter, in 1972, ABC commissioned
the development of standards for educational programs in prosthetics and orthotics. These standards are maintained
by the National Commission on Orthotic and Prosthetic Education (NCOPE),
an independent body that approves education and residency programs in these
fields, in cooperation with The Commission on Accreditation of Allied Health
Education Programs. The entry-level
requirement for a certified prosthetist/
orthotist has now been set at the master’s level. NCOPE’s accreditation standards for such programs require focus
on evidence-based practice, including
how to be an effective, critical consumer
of research. Less rigorous education programs and entry pathways for the other
certification programs are also available.
Six schools offer training for prosthetic/
orthotic technicians.
AAOP has been a major force in advancing the level of practitioner education and clinical practice in prosthetics
and orthotics, sponsoring an ever-growing array of continuing education conferences and review courses each year.
In 2003, the AAOP inaugurated an ongoing series of consensus conferences to
develop clinical standards of practice,
patterned after the successful multidisciplinary consensus conferences hosted
by the International Society for Prosthetics and Orthotics (ISPO). Building
on the success of these consensus conferences, AAOP is increasing emphasis
on evidence-based practice and outcome
measures in its annual conferences.
In 1946, the first English-language
periodical for prosthetists, the Ortho-
paedic and Prosthetic Appliance Journal,
was published by the forerunner of
the American Orthotic and Prosthetic
Association. In 1976, the AAOP started
a journal. The two journals merged in
1988 to become the quarterly Journal
of Prosthetics and Orthotics. In 1964, the
Prosthetic and Sensory Aids Service
of the Department of Veterans Affairs
began publishing what has become the
Journal of Rehabilitation Research and Development, which appears bimonthly,
with additional supplements. In the late
1950s, the International Committee on
Prosthetics and Orthotics (ICPO, now
called Rehabilitation International), an
international committee that focused on
the exchange of information on prosthetics, orthotics, and amputation surgery,
began publication of a technical journal.
ICPO evolved into the present-day ISPO
and its journal became Prosthetics and
Orthotics International, published three
times per year. In cooperation with the
World Health Organization and the International Committee of the Red Cross,
ISPO has developed standards for prosthetic and orthotic education programs
and clinical care delivery systems for
developing nations. ISPO also sponsors
a triennial World Congress, as well as
periodic international consensus conferences and update courses throughout
the world that are cosponsored by local
prosthetic and orthotic organizations.
Emergence of Amputee
Rehabilitation
Until the 19th century, the governments that recruited men to fight in
wars typically turned away from those
too disabled to serve again, leaving
them to beg for subsistence. Even for
the few who received prosthetic limbs,
no organized care with a goal of societal reintegration existed. In 1867, the
Prussian government was the first to
legislate not only prosthetic restoration
but hospitalization for accommodation
to walking with the prosthesis. The
British also began providing prostheses for their war-wounded personnel
during this period, but it was not until
1915 that Queen Mary’s Hospital for the
Limbless (Roehampton) was established
as a place where physicians and prosthetists were brought together with the
patient. During this time, the Central
Powers (Germany and Austria-Hungary)
also began fitting early temporary prostheses to quickly return war amputees to
useful work in factories and farms. The
US government also established seven
widely dispersed stateside amputee centers at Walter Reed General Hospital in
Washington, DC; Letterman General
Hospital in San Francisco, California;
Fort Des Moines in Iowa; Fort Snelling
in Minnesota; Fort McPherson in Georgia; General Hospital 3 in New Jersey;
and General Hospital 10 in Boston, Massachusetts. Another concept that was
resurrected after World War II was the
fitting of an immediate postoperative
prosthesis, begun by the Frenchman
Depage in 1917. Berlemont and Weber
resumed this method in 1957, followed
by Marian Weiss of Poland who reported on his extensive experience in
1963, stimulating research in the United
States by Ernest M. Burgess in Seattle,
Augusto Sarmiento in Miami, and the
Navy Prosthetic Research Laboratory
in Oakland.
During their World War II occupation, the Dutch set up a rehabilitation
center for their wounded soldiers. The
program included physical therapy,
sports therapy, and job placement. A
similar program was in operation at
the time in Roehampton in England.
The Dutch program of amputee rehabilitation was expanded in the 1950s to
include injured civilian workers. The US
Surgeon General established specialized
centers for the rehabilitation of amputees before their separation from military service. By 1945, the Army had
10 amputee centers and the Navy had
2 centers.
The success of these military programs was replicated for civilians by the
formation of interdisciplinary amputee
clinics. Many advances in amputee rehabilitation in the second half of the 20th
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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