Prosthetics and Orthotics International

More than 1,000 industrial amputees at the Ontario Workers' Compensation Board were reviewed. The study investigated the current employment status of amputees and the factors that influenced successful return to work post-amputation. The data obtained from a mailed questionnaire was analysed by the Statistical Analysis System. The results revealed that 89% of amputees returned to work after an amputation. The average follow-up post-amputation was 14 years with a range of one to 64 years. At the time of review the current employment status of amputees was as follows: 51% full time employed, 5% part-time employed, 25% retired and 8% unemployed. The remainder were engaged in a vocational activity, still recovering or were not seeking work. The data revealed that amputees typically changed jobs when returning to the work force. Amputees returned to jobs that were less physically demanding, but required greater intellectual skills in occupations such as clerical and service industries. Factors including prosthetic use, vocational services, and a younger age at the time of amputation were identified as being positively associated wth a return to work. Those factors that were negatively related to successful employment included stump and phantom limb pain and multiple limb amputations. The study concluded that the majority of the amputees reviewed were successful in returning to work. The authors suggest that amputees benefit from treatment programmes that include medical, prosthetic and vocational services.

A study is reported on the value of a modified KBM prosthesis compared with other types of prostheses.

Recently a new type of below-knee prosthesis (the so called modified KBM prosthesis) was introduced in the Netherlands. This prosthesis is now frequently used as a substitute for more conventional types. A study was carried out on the value of this new prosthesis, compared with the more conventional types, by means of a questionnaire sent to a group of patients who formerly used a more conventional type' of prosthesis.

The constant reminder of ever-increasing costs and problems in regard to medical care in industrialized countries highlights the need for simplified, low cost, orthopaedic appliances for use in the non-industrialized areas of the world. Those who are engaged in the field of Orthopaedic Technology should withstand the temptation to propagate unreservedly the technologies of industrialized nations. Nowadays the so-called “non-appropriate technologies” have become the target of frequent criticism.

The transfer of technology may offer visible progress in selected areas to a limited number of people but it conceals the danger of ignoring fundamental socio-economic conditions that affect the majority of people.

During the United Nations Year of the Disabled, a group of international experts unanimously came to the conclusion that the current cooperation between industrialized and Third World countries requires revision leading to a new order. The consensus demanded a new emphasis on the development of technical orthopaedic services which would take into account the unique economic, social, cultural and environmental factors of each region.

This paper examines the practices of technical orthopaedics in a “least developed country” and lays down principles and practical applications which could serve as a foundation for a more appropriate approach in this field.

A temporary prosthesis has been developed for above-knee amputees who receive long-term post-amputation chemotherapy. The temporary prosthesis has an adjustable laminated quadrilateral socket, the size of which is adjusted by metal screws.

Fifteen patients were fitted with the temporary prosthesis. Initial fittings were carried out after a period averaging 46 days from amputation. All of the patients were able to walk with one crutch after about one month from initial fitting. Although patients often had to discontinue their prosthetic training owing to chemotherapy, they could resume wearing their prostheses simply by adjusting the socket.

One patient, who was fitted with a cosmetic ultra-light prosthesis initially due to her poor general condition, was later fitted with the temporary prosthesis. She regained the ability to walk 60 days later and still wears it.

Early fitting of temporary prostheses for these patients is not only of practical convenience but also improves their mental state.

A small group of patients is reported in whom amputation or re-amputation of the upper or lower limb has been performed at increasingly higher levels in an unsuccessful attempt to relieve the patients' unrecognized chronic pain syndrome. The possibility of self mutilation should also be considered.

The etiological factors and management of this uncommon but difficult problem are discussed.

It is hoped that members of an experienced amputee team will recognize this rare problem and help to avoid multiple surgical procedures, which are harmful to the patient and costly to society.

The use of thermography in the assessment of amputation levels has demonstrated a medial to lateral thermal gradient in many cases. In order to see whether this reflected a true medial to lateral skin blood flow gradient, a prospective study was set up to measure blood flow medially and laterally below the knee. Twenty-one patients, presenting for amputation assessment with end-stage peripheral vascular disease, were studied. Skin blood flows were measured using an intradermal radioisotope clearance technique. Results showed a highly significant difference between medial and lateral skin blood flows (t = 4.79; p < 0.001). In view of the significantly higher blood flow in the medial skin of the lower leg, it is suggested that a more medially based posterior below-knee amputation skin flap may be of more value in some patients.

Maximum weight bearing observed, using a static weighing scale, in above-knee amputees wearing an airsplint, with a foot, was 10 kg and in below-knee amputees 11 kg with inflation pressures of 40 mmHg. While airsplints with a foot permitted greater weight bearing before deformation occurred, the increase is judged to be of little clinical advantage. Use of an airsplint without a foot would be more efficient for immediate post-operative dressing and for early ambulation in the parallel bars as it is less cumbersome and not subject to toe drag in the swing phase of gait. With the type of airsplints studied inflation pressures above 45 mmHg offered no advantage in terms of weight bearing in the below-knee amputee. In the above-knee amputee similarly, inflation pressures over 40 mmHg offered no advantage and had the effect of reducing the suspension of the prosthesis on the stump.

The usefulness of wisely prescribed powered components in the rehabilitation of upper extremity amputees has long been recognized (Schmidl, 1973). Their value is especially evident in the prosthetic rehabilitation of high level adult and child amputees (Heger et al, 1985). In recent years, manufacturers of prosthetic hardware have provided practitioners with a wide selection of either myo-electrically or switch controlled electromechanical components and systems. As a rule, however, most commercially available components are designed to serve the adult amputee and do not lend themselves for use in the prosthetic rehabilitation of children. One current exception is the availability of child-size electric hands.

A group of patients who are good candidates for the application of Functional Electrical Stimulation (FES) to restore reciprocal walking is described. They have incomplete lesions of the spinal cord. Because of the degree of preserved voluntary control, proprioception and sensation some of these patients can achieve crutch assisted walking by means of multichannel electrical stimulation: In a number of cases the patient has sufficient strength and voluntary control in the upper limbs and at least one leg to provide safe standing for short periods in forearm crutches. For these patients a two channel stimulator controlled by a handswitch was applied to achieve safe and practical crutch assisted walking in a relatively short period of time.

Silicone rubbers and casting tapes individually have previously been used in the manufacture of sockets (Swanson, 1972; Sweitzer, 1973; Ruder, 1977; Graves, 1980; Aqualite, 1982). The authors believe that the present combination of these materials to manufacture a directly moulded socket with a complete silicone rubber lining of variable thickness has not previously been described.

The present method of static three point bracing is unsatisfactory. The static type orthosis becomes ineffectual in reducing flexion deformities in upper and lower extremities and requires constant adjustment as the contractures are reduced.

A three point dynamic orthosis using a flexible rod construction has been designed to contain and reduce flexion deformities. This orthosis has certain advantages over the static type and has been used successfully in children with contractures due to cerebral palsy and burns.