Journal of Rehabilitation Research and Development Rehabilitation R & D Progress Reports 1983 Prosthetics / Amputation A. Comprehensive Amputation Management B. Lower Limb Prosthetics C. Upper Limb Prosthetics D. Orthotics E. Hip and Knee Joint Replacements F. Lower Limb Prosthetics 1. Gait Analysis 2. Miscellaneous G. Upper Limb General H. Maxillofacial Prosthetics 3 m m ~~~~~~~~~~N~~~~~~~~ ~~~~~~~~ ~ 0 ~~Y~~N Q N~~~N N~-m~~~~~~~ N ~&~~~0~~i0~~~y@ ~ R&D In this section, under the broad heading of Prosthetics/ Xennn`" . Ourpro!inn\nary !aoerdopplextooto airni\ady Amputation R&D, reports in the following general area will suggest that there is not a fine discriminative point be found: Comprehensive Amputation Management ; Lower for the !aaerdopp!or . During the upcoming year, we Limb Prosthetics ; Upper Limb Prosthetics ; Orthotics; Hip plan to expand our laser doppler analysis and also and Knee Joint Replacements ; Lower Limb — General, compare Xenon clearance techniques with tissue including Gait Analysis and Miscellaneous; Upper Limb - oxygen skin tension. General; Maxillofacial Prosthetics. Development of Temporary Prostheses — During the last 2 years we have developed and finalized tech- - - / ~/-~K\ /!\/!~~~~~-~Fl[-1F -! ![-~ !~~!\ /F niques which utilize lightweight casting materials \~^ .~~,F~ ^_ . .^_~-!^J~l!\/F-. , .~ . __ for the design and development of lightweight, cool, durable lower-limb temporary prostheses. AMPUTATION Immediate Fit After Upper-Limb Amputation -- Pre- liminary data on immediate fit after upper-limb am- MANAGEMENT putation has been verified by our subsequent patient population . More innportmnUy, data from the Tucson VA Medical Center and from the Atlanta VA Medical VAMC TUCSON Center (Emory University) was analyzed by both principal investigators (James Malone & Lamar COMPREHENSIVE MANAGEMENT Fleming) and similar data were found. OF UPPER AND LOWER EXTREMITY AMPUTATION James N . Malone, M .D. Definition of Application of Upper Limb Prosthetic Tucson Veterans Administration Medical Center Components — Our preliminary data would suggest Tucson, Arizona 85723 that there is not a cost benefit to external powered prosthetic components and, in fact (as noted above) The six main objectives of our Amputation Reha- our general approach is to fit oonvonhonal compo- nents first and only after a patient has proved to be bilitation Program are (i) amputation \ov gl determin- ation, (ii) development of temporary prostheses, (iii) successfully rehabilitated will vvethen commit our- immediate postsurgical fitting after upper extremity selves topovvereUoonnpnnents . This is not to imply amputation, (iv) definition of application of upper that there is not a role for externally powered upper- extremity prosthetic components, (v)elective ampu- limb components for the high or multilevel amputee. tation for neurologic dysfunction ; and (vi) Regional However, for the unilateral amputee, externally Amputation and Training Center. powered components have, perhaps, only a marginal value as compared to conventional components. Amputation Level Determination -- Xenono: skin clearance techniques still continue to be the most Elective Amputation for Neurologic Dysfunction -- reliable test for amputation !evel determination . The Duringth-e past year we have done tvvomore ampu- validity of this technique has recenly been docu- tations on patients with brachial plexus injuries . Our mented by the Surgery/Radiology Group at the Uni- surgical approach involves shoulder fusion, elective versity of Cincinnati who have not only confirmed annputation, and rapid fitting of upper-limb compo- the value of Xenon` u» for amputation !evel selection, nents. These patients have gone back to work, and but also reaffirmed our previously published level of we are continuing to be extremely impressed with 2 .6 ml/100 g tissue/min blood flow as the baseline the rehabilitation putential for upper-limb amputa- which is adequate to ensure amputation healing. tion in patients with non-recoverable neurologic During the past year, we have analyzed Xenon' 33 impairment of the upper limb. clearance techniques as compared to the laser dupp!erand skin fluorescence . Although skin fluor- Regional Amputation and Training Center — We escence does have some predictive value, there is have added an Occupational Therapist/Program Co- not a sharp demarcation such as one sees with ordinator to our program during the last year. We 4 PROSTHETICS I AMPUTATION are beginning to advertise indirectly for residents, and were often associated with compensatory gait students, and faculty who are interested in spending deviations. time in a dedicated Amputation Program in order to Excessive stiffness in the heel cushions of SACH improve their diagnostic, surgical, and rehabilitative feet was a frequent finding and this is being further skills. Clearly, the rehabilitation results from Cen- evaluated in our on-going studies. ters interested in amputation surgery continue to It is suggested that, in order to reduce the inci - surpass the results from Centers wherein there is dence of residual limb complaints in the veteran not a dedicated, interested team available n amputee population, the quality of the prosthetic care that is being provided needs improvement. Greater emphasis should be placed on earlier identi- fication and correction of problems of prosthetic wear and maintenance — by both the amputee and outpatient personnel. LOWV R B Clinical Study of UCBL Knee Linkage — The second FROST of these studies was a clinical study of the UCBL TICS 4-Bar polycentric prosthetic knee linkage . The mean follow-up period was 12.3 months . Very positive subjective responses were reported by 75 percent of the amputees, and more than one third stated that the device was superior to any that they had used VAMC SAN FRANCISCO previously. DEVELOPMENT, TESTING, AND EVALUATION OF NEW PROSTHETIC DEVICES Studies in Progress -- Design of the Moveable Ankle Cushion Heel (MACH) foot has progressed to the David J . Effeney, M .B ., B .S ., FRACS ; Harry B . Skinner, M .D., Ph. D., modeling phase. A study of the properties of avail- FACS ; Mark A . Abrahamson, B .A .; Leigh A . Wilson, C .P .; and able foamed polymers, to optimize energy absorption Ruth Roberts, R .P .T. stability and wear in such an application, has been Rehabilitation Research & Development Veterans Administration Medical Center started. Also included in this study is an evaluation San Francisco, California 94121 of the static loadbearing properties of commercially available SACH feet. We have concluded that there is no static differ- Survey of Problems & Needs — The first of these ence in response between some "regular" and was a survey of 179 veteran lower-limb amputees "medium" heels, and are planning to study the from two Veterans Administration medical centers, dynamic response in future studies. in order to determine their prosthetic problems and needs . Individual prosthetic evaluations of 54 re- In response to problems encountered with air leaks spondents by the research team defined more pre- in the air cushion socket, we have developed a con- cisely the status of their prosthetic care. struction technique for the air cushion socket which The most striking finding from this study was the improves the airtight seal . This socket, when properly high incidence of residual limb discomfort . Fifty-four fabricated, is highly successful for below-knee am- percent of both traumatic and dysvascular amputees putees with problem stumps, but the success is de- complained of moderate-to-severe discomfort.About pendent on determination of the proper volume of one half of the respondents noted difficulty in ob- enclosed air space for any patient and the major taining a comfortable socket fit . Among the 54 criticism has been air leakage. amputees evaluated individually, evidence of im- The root of the problem lies with the interface proper socket fit was found in 59 percent of the between the elastic sleeve and the plastic socket. below-knee and 78 percent of the above-knee pros- Even under the best of conditions there is a minor air theses . Most of these problems were related to im- leakage, due to the fact that there is no chemical proper socket construction initially. The remainder bonding between the Dow Corning 3110 elastomer were due to amputee-related factors such as changes and the polyester resin at the proximal border of the in the size of the residual limb or deterioration of elastic sleeve . The air leakage becomes worse with the socket and liner due to wear . Mechanical skin constant use of the socket, because the elastomer/ irritation or breakdown was found in 41 percent of polyester resin interface begins to break down or the below-knee and 22 percent of the above-knee erode. residual limbs. Deficiencies in prosthetic suspen- Several changes in the fabrication technique were sion, alignment, and foot function were common, devised as a solution to this problem . The first con- 5 Rehabilitation R&D Progress Reports 1983 sists of the lamination of a thin polyester resin shell Overall, the results obtained in these implantation (Banlon and fiberglass) which encapsulates the studies of the carbon-coated titanium pylon have proximal portion of the plaster model to point 3/8 of been extremely encouraging. Stable bone implants an inch distal to the level of the tibial tubercle . The have persisted for periods up to 5 years n elastic sleeve is now laminated over the model to a level 3/8 of an inch proximal to the distal edge of the polyester shell . The lamination procedure for the NSF elastic sleeve has also been changed . A 1/16-inch- diameter nylon cord loop is placed over the outer MICROCOMPUTER-CONTROLLED, layer of the Banlon at the level of the tibial tubercle, INDIVIDUALIZED MULTIMODE PROSTHESES FOR LOWER-EXTREMITY AMPUTEES prior to pulling on the outer PVA bag . The nylon cord has a dual purpose ; it serves as a collection point for Woodie C . Flowers, Ph . D. the R.T.V . rubber (thus forming a slight bulge) and Massachusetts Institute of Technology helps prevent the R .T.V. from bleeding into the fabric Department of Mechanical Engineering Cambridge, Massachusetts 02139 beyond the desired point of lamination .