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Suction socket prosthesis for above-knee amputees
SUCTION SOCKET PROSTHESIS FOR ABOVE/KNEE AMPUTEES INTERIM
REPORT
OF VETERANS
ADMINISTRATION
AUGUSTUS
THORNDIKE,
EXPERIMENTAL
PROGRAM
M.D.
Boston, Massachusetts
A
PROSTHETIC device first patented by Dubois ParmeIee of New York in 1863 has again attracted the attention of the medica profession. OriginaIIy utilized in conjunction with a pyIon Ieg attaching the Iower extremity prosthesis to the body by suction, Parmelee’s idea had been tried in 1885 by Beacock and Sparham in Canada, in 191 I by ToIes in CaIifornia and in 1926 by Underwood in England. To improve the degree of suction the British added a heIica1 groove in the socket lining. Furthermore they re-designed the appliance for use with a meta Ieg, the inserted bucket being fabricated of wood or papiermachc. In these earlier Iimbs the vaIves varied from a simple faucet to a one-way air escape valve. (Fig. I.) FoIIowing WorId War I about thirty suction sockets were fitted at Roehampton, EngIand. Until recently case histories on these thirty patients had been lost and the suction socket prosthesis had been discarded. Then OesterIe of UIm, Germany, advocated the use of the “Springer Vacuum Ieg” in 1933.’ Furthermore, in Germany Felix beIieved the deveIopment of a satisfactory valve for the vacuum chamber was the item that popuIarized this method of prosthesis fixation in above-knee Ieg amputations.” Next Kirschner and Dittert reported a series of thirty-nine cases in 1944.~ About the same time Hepp4 described a contact type of prosthesis, a modification of the suction socket. Some mihtary medical reports on suction sockets received in the United States immediateIy folIowing V-E Day (May 8, 1945) prompted Major Genera1 Norman T. Kirk to appoint and dispatch to Europe in March, 1946, a committee of distinguished civiIian and miIitary engineers and orthopedic surgeons to investigate and report upon new orthopedic technics and appliances incIuding the suction socket prosthesis. In 1946 this report was submitted to the NationaI Research CounciI of the NationaI Academy of Sciences for con-
November, 1949
603
sideration by The Committee on Artificial Limbs. In 1947 this Committee became known as the Advisory Committee on ArtificiaI Limbs and was seIected by the Veterans Administration, Army and Navy to coordinate a11 research projects pertaining to artificia1 Iimbs. It is a pleasure to report that the results of this Committee’s activities are rea1. Many new devices have appeared such as the new arm prostheses designed by Fitch, by Hosmer and by the Northrop Aircraft Corporation. The wrist Aexion unit and supinator and pronator device for beIow-eIbow arm amputees represent recent deveIopments. The department of medicine and surgery of the Veterans Administration has been cooperating with this Committee. At this time among devices for artificia1 legs in the developmenta stage are a new ankle joint incorporating horizonta1 rotation, several knee brake and Iock mechanisms, both hydraulic and mechanical in operation and the suction socket for aboveknee amputees. RecentIy Canty reported his experience at Mare IsIand Naval Hospital with the suction socket.5 AIthough results obtained on the suction socket prosthesis to this date are most promising it is deemed advisable not to consider them as conclusive. The source material reported here is contained in two reports received in 1949, by the Advisory Committee on May, ArtificiaI Limbs. These reports were rendered by representatives of the limb manufacturing industry and by the Lower Extremity Committee, a technica subcommittee of the Advisory Committee on ArtificiaI Limbs. It is beIieved that unti1 a significant number of case histories can be compiIed on those who have successfuhy worn the suction socket daiIy for an entire caIendar year under a large variet,y of climatic conditions, it wouId be a mistake to claim compIete success. Today there are very few surgeons or limb-fitters in this country who couId cIaim to have seen or fitted more than
f-304
Thorndike--Suction
FIG. I. The first known mode1 of suction No. 37.637.) a handful of cases twelve months ago. Therefore, this report is to be considered as mereIy informational. The statistics in Table I on above-knee suction socket experience have been compiIed from responses to a questionnaire maiIed to 159 members of The Orthopedic AppIiance and Limb Manufacturers Association. The Veterans Administration Experimental Suction Socket program which has been in operation Iess than two years invoIved first a training program for limb-fitters and surgeons. A tota of twenty schools have been heId in various parts of the country in which a tota
Socket
Prosthesis
socket prosthesis.
(U.S. Patent
Ofice,
of 200 limb-fitters and over 200 surgeons have been certified as qualified to fit the suction socket. Each one of this great number of fitters has been authorized to fit three suction socket limbs to veteran amputees. As of this date 495 suction socket limbs have been authorized to be fitted to above-knee veteran amputees. The most recent report (ApriI 15, 1949) received from Professor Howard D. Eberhart, Chairman of the Lower Extremity Committee of the Advisory Committee on Artificial Limbs, records a tota of 21 I cases of which nine or 4.3 per cent are considered to be faiIures. (TabIe II.) The geographic distribution of these
American
Journal
of Surgery
Thorndike-Suction
Socket
60 5
Prosthesis
veterans is widespread involving all degrees of climatic variation. The causes of the nine failures in the 21 I cases reported are tabulated in Table III. A group of twenty-nine patients exists still alternating in the use of the suction socket and
shape of the socket from the earlier design. Furthermore for the first six months the wearer must report at regular intervals for adjustments. Inasmuch as the stump becomes an active and functioning part of the amputee, stump changes occur. The usua1 adipose and
TABLE I* Number of Sockets fitted to aboveknee amputees. 1,232 Xlen ,._ 1,023 164 Women..... .,. Children. 45 $0 (4 per cent) Number of complete failures. * From Report of PreIiminary Results, OALMA, Ma v *, ,94(,.
TABLE III* REASONS FOB FAILURES (NINE CASES) Non-cooperation, gave up during initial Iitting. 3 z Poor Iit and aIignment. MedicaI contraindications: Cyst or abscess on adductor roI1 remaining from usingoldleg................................... 2 Insecurity (teIevision actor gave up after Iive months’ trial)........................................ I L.oss of suction (mechanic lost suction when lifting I motor from chassis).
the original conventional limb for reasons listed in Table IV. It is only reasonable to adjudicate these results by the Iength of time that the suction socket has been worn. It must be emphasized that in this group of patients in the experiTABLE II * BHAVCH VETERANS ADMINISTRATlON OFFICE DISTKIBLTION OF RESULTS
Wearing
r”utinrly.
* Report
of Subcommittw,
ACAL,
April I 5, ,919.
mental program 123 or 58 per cent have been wearing the suction socket four months or less and that in this group lie 75 per cent alternating between the use of the suction socket and conventiona limb. Table v ilIustrates the time interval in those cases in which a suction socket type of prosthesis was used. Inasmuch as only three patients in this series have been wearing the prosthesis successfully for ten months, one may readiIy comprehend the fact that unqualified approval of this device must be deferred. To judge these results in the Veterans Administration Experimental Program as good is reasonable. RecaIling that most fitters have been authorized to fit only three veterans and realizing that experience in pulling a suction socket is Iimited in most areas of the country, one might conclude that this report represents a fair measure of success. Moreover it is of importance to point out that successful fitting depends upon a change in the pattern and November,
1949
*
Total...................................... Report of Subcommittee,
9
ACAL, April I 5, 1049.
flabby stump loses its fat tissue and develops more norma musculature. During this period of change the surgeon, amputee and limb-fitter must be particularly conscious of the necessityfor adequate foIIow-up. TABLE IV* KEASONS FOR ALTERKATINGWEAR (TWENTY-SINE CASES1 time on suction socket New cases, increasing graduaIIy................................... 9 : Insecurity on leg, loss of suction, bad aIignment h No time for proper adjustment, Iong working hours. 3 Replaced old socket, not yet adjusted to new one.. 2 Wears, except at work. L Excessive edema and perspiration. I Insecurity on leg, biIatrra1 amputee Total.
z)
* Report of Subcommittee,
ACAL, ApriI
I 5,
,949.
At First these sockets were usualIy fitted too tightly. The degree of suction required is only 1>4 pounds per square inch negative pressure which during the stance phase of walking will change to 1,%5pounds per square inch positive. TABLE v* LENOTH OF TIME ON SUCTION Months
“12
3
I
Wearing routinely Afternatingt. Failurest..
o 4 3 2
Sub-total
3 ar 31 3-
Cumulative
., total.
J
!/ 5
6
SOCKE?
7
_
81, _,__,_
10
Total -__
0 Is 23 3 8 5
I
3 24 55 92
*Report of Subcommittee, ACAL. t Months since initial fitting date socket.
April I 5. 1949. rather than time on suction
Thorndike-Suction
FIG. 2. Perimeter measurement
Socket Prosthesis
for determining
pattern size.6
An adequate air-escape valve has been designed so that these pressures are maintained consistentIy. It is perhaps erroneousIy termed a suction socket; the degree of suction is minimaI. Suction aIone hoIds the artificia1 Iimb when
HOLD WOOD FOR IGCHIAL SEAT
*...
PERIMETER.
INCHES
/
POSTER,OR ,.,..I
FIG. 3. Cross-section
pattern at ischiat seat leveI.6
the stump is reIaxed whiIe during actua1 waIking the hoIding force is better described as even contact of the stump with the socket waI1. The patient by contracting his remaining muscles in the stump can prevent its forcefu1 withdrawa1. The modification in the shape of the suction socket pattern from the original design can be expIained as the resuIt of experience gained. It wouId be we11 to Iist the main changes as foIIows: (I) reduction in size of the ischial seat; in about 3 per cent of the cases fitted the ischia1
FIG. 4. Deviation socket.”
from pattern
of a typica
suction
seat may be eliminated (indicated if a Iarge and powerfu1 glutea1 muscIe bundle is present) ; (2) properly shaped posterior surface of the
American
Journal
of Surgery
Thorndike-Suction
Socket
thigh making the back of the socket thinner and flatter, sometimes utiIizing a soft back; (3) “easing” the fit on the walIs of the socket all around below the level of the brim; (4) greater emphasis in proper alignment of the entire limb. The main advantages in this suction socket
Prosthesis
improved control and position sense. In addition the wearing of a stump sock is no longer necessary. There is not space to describe the details of fabrication of this type of socket. Sufl?ce it to state that a willow block is carved to form-fit
SOCKET IS STARTED BY MEASURING THE STWP PERIMETER AT THE ISCMAL SEAT LEVEL TO DETERMINE THE *PPROXIMATE PATTERN SIZE .
WE
OUT APPROXIMATE SOCKET OUTLINE FROM RTTERN. MAKE ALTERATIONS IF NECESSARY AS SHOWN IN WE FOLLOWING ILLVSTRATIONS.
LAY
LAY OUT LENGTH OF MEDIAL SIDE AS ‘h’ LESS THAN DISTANCE FROM ANTERKWI-MEDIAL APEX TO ISCHIAL TUBEROSITY-@I).
LAY OUT LENGTH OF POSTERIOR SIDE EPVAL TO MAX LATERALMEDIAL STUMP MEASUREMENI@I I
k-4
ESTIMATE REOVIRED
1 OF
(StHIA!_
WW,Y FORM
SEAT -6.
LENGTH
GLUTEAL AREA TO co*cTO STUMP CONTOUR-@ FIG.
,.,OOlFY MEDLAL SIDE TO GONFORM TO STUMP CONTOUR-@.
MODIFY ANTERIOR-MEDIAL APEX TO CONFORM TO ST”,“,’ CONTOUR WITH ADDUCTOR LONGUS TENSED-@
ADO PROTUBERANCE SIDE IF NECESSARY-
MOOIFY ANTERIOR FORM TO SWMP
1949
SlOE TO COW CONTOUR- @.
5. PreIiminary Iayout of the suction socket outIine.6
type prosthesis are: (I) providing the aboveknee amputee with a naturaIIy functioning hip joint whereby his remaining muscles in the stump and about the hip resume physiologic balance resulting in better coordination; and (2) abolishing the suspension straps or peIvic belt with hinge. Suspension by a pelvic belt and a metal hinge in the conventional Ieg prevents necessary rotation in proper waIking and has resuhed in a high degree of belt breakage. On _ _. . . . . _ the other hand the amputees claim that suction socket type prosthesis feeIs as if it were a constituent part of the stump, resuhing in
November,
ON LATERAL @,.
FIG. 6. ReIation of the bony peIvis to the suction socket at the ischial seat Ievel as viewed from below.”
the stump. An air-escape valve is inserted into the lower ‘portion and over the lower end of the
608
Thorndike-Suction
Socket
Prosthesis
___ --9 x
bIock a plywood cover with an air seal is glued. This socket is then attached bIock, knee bolt and lower interested in the details of referred to the third edition
to the usual knee assembIy. Those construction are of the brochure,
A. FOOT OFTEN ROTATED CUTWAR0 WHEN SlTTlNG ON HARO SURFAOES DUE TO SOCKET SHWE. NECESSARY TO SHAPE SOCKET SACK AFTER WALKING ALIGNMENT IS OBTAINED.
8.
with impaired circulation, capiIIary fragiIity in the stump, short or long stump or overweight individuaIs. Of course, the surgeon shouId accept only the most favorabIe cases at the start. However, by proper fitting experienced sur-
FOR PROPER SITTING ALIGNMENT, REMOVE EKCESS WOOD AS Y0IOATE0.
0. ELEVATION OF ISCHIAL SEAT W”,LE SlTTYlG CAUSES STRETCHING OF SKIN ANO MAY CAUSE LOSS OF SUCTION.
c. PRWER SlTTlNG *LIGNNENT. THCKNESS OF WALL OONSISTENT WITH STRENGTH.
E. PROPERLY SLOPED AS0 ROt”‘DEO ISCML SEAT WITH FLAT E&K IYP(IOVES SITTING CONfORT.
FIG. 7. Shape of the socket back and alignment of the Ieg in reIation to sitting comfort.~
“The Suction Socket Above-Knee Artificial Leg.“‘? (Figs. z to 6.)* Many surgeons have been fearfu1 of titting stumps to this prosthesis because of associated injuries of the opposite Ieg, a biIatera1 aboveknee amputee, deep or adherent scars beIow the top IeveI of the socket, spurs or bone masses at the rower end of the stump, arteria1 disease * Figures 2 to IO are reproduced through the courtesy of Prosthetic Devices Research Project, University of California.
geons and limb-fitters have fitted stumps of Iess than three inches (crotch measurement). (Figs. 7 to IO.) Moreover, Gritti-Stokes end-bearing stumps tolerate this prosthesis we11if the Iower end of the socket is padded with feIt. Sometimes, however, Iong weight-bearing stumps require a Iowering of the knee boIt and shortening of the shank. Specific contraindications exist. Perhaps the most important of these pertain to the psychoIogic attitude of the patient. It is much easier
American Journal of Surgery
Thorndike-Suction
Socket
to satisfy a prosthesis wearer with a suction socket if the first Ieg fitted is of this type. AI1 patients seIected for this suction socket must be screened. The emotional, negativistic type of amputee shouId never be changed from a
Prosthesis
Iished meet one morning a week under the guidance of an orthopedic consultant. In these clinics wiII be fitted not only the suction socket wearer but aIso a11 orthopedic shoe, brace and for the fieId prosthesis wearers. As outlets
TOO TIGHT POSSISLY
MEDIAL SloE FLARE0
CAUSING THE SOC((ET
WHILE MEDIAL
WOIALLY
WALKING. AREA.
PLACED
Too
TO lRR,TAT,,,G
lSCMPL
M”CH,
SHIFT THE
INTERIOL-POSTERIOR DIMENSION TOO GREAT, ALLOWING THE ISCHIAL TUSEROSITY TO FALL ,NS,DE OF WHIAL SEAT. MAKlNG SOCKET VERY WlNF”L
SEAT.
CPlUSE SITTING
TOO
OF
OLE
LARGE
609
ISCH~AL
SEAT
BURNING SENSATION TO STRETCHING
ANTERIOR REGION. CAUSING
EDEMA.
TOO LARGE OR TOO SMALL ,, PROT”SERAWE,CAUSING LOSS OF SUCTION ip1 WME ST”MP5.
TOO
LARGE
GLUTEUS
RELIEF
W”,LE THE SKIN
FIG. 8. Common errors in fit at top of socket .6 Errors indicated by dotted lines.
conventiona artificial limb. Those amputees harboring low grade osteomyeIitis of the femur should be denied the fit of a sudtion socket. Patients with chronic dermatitis or fungus infection or eczematous rash on the stump should be excluded from wearing the suction socket unti1 cured. The few patients with depressed scars at the top of the thigh shouId be denied this socket inasmuch as suction couId not be maintained. The importance of follow-up and constant vigilance of the suction socket wearer during his first four to six months cannot be overemphasized. In fact it might be stated that too many surgeons discharge their patients after the fitting of any orthopedic appliance. To alleviate most complaints and to provide better professional service to the veteran orthopedic appIiance wearer, the Veterans Administration is setting up PiIot Orthopedic Clinics throughout this continent in twenty-three of its Iarger regional offices. Five of these already estab-
November, I 949
FIG. 9. Suction socket for the same stump; A B and D, unsatisfactory.”
and
c, satisfactory;
testing of new orthopedic devices have great potentia1 vaIue.
these clinics
Thorndike-Suction
Socket 4.
SUMMARY
To recapituIate, the tentative concIusions on the current experimenta use of the suction socket above-knee prosthesis are as folIows: I. The suction socket above-knee prosthesis
Prosthesis
HEPP, OSCAR. Haft prosthesen.
Ztscbr. f. Ortbop.,
77: ==9* 1944. 5. CANTY, THOMAS J. and WARE, ROBERT J. Suction
socket for above knee prosthesis. Bull., 49: 216, 1949. 6. The Suction Socket Above-Knee
U. S. Navy M. Artificial
Leg.
6: I-
B
*.- TIGNT FIT IN THlS AREh WLL CAUSE EOEYA WHEN STUMP MUSCLES ARE CONTRACTED AS SNOWN IN 0.
c
C - NEGATIVE PRESWRE OF ONE AND WE-HALF PER SQUARE INCH WILL S”CESY”LLY SUSPEND THE LEB EOEYA MAY OCG”i) WTH r\N IHCOm?EC7 FIT AS IN A OR 8.
POUNDS
D.- A MGN NEGATWEPNESWNE WGXATES A VERY FIT, PNOOUCINGFORCES TENDING To P”S”
TIGNT
TNELEG OFF. THE
SOWET
U”ST
SE EK*RSEO
IYMEDIAIELI.
FIG. IO. Errors in fit below brim of socket.6
is described and found to have been fitted to 2 I 1 veteran amputees. 2. CompIete failures represent 4.3 per cent of the patients. 3. Inasmuch as 58 per cent of the patients have been wearing this prosthesis for four months or Iess, the favorabIe resuhs cannot be construed as conclusive evidence for general approva1 of the suction socket prosthesis. REFERENCES I. KIRSCHNER, FRIEDERICH. uber den Kunstbeinbau. Med. Welt, 7: 1,282, 1933. 2. FELIX, W. Praktische erfahrungen mit den saugprosthesen. Ztscbr. j. Ortbop., 72: 352, 1941. 3. KIRSCHNER, FRIEDERICH and DITTERT, RUDOLF. tjber erfahrungen mit dem niederdruckunstbein. Arch. f. ortbop.
u. Unfall-Cbir.,
43: IOI, 1944.
University
of CaIifornia
Press. 3rd ed. Berkeley,
‘949. DISCUSSION
OF PAPERS AND
BY
DRS.
BENNETT
THORNDIKE
DONALD GORDON (New York, N. Y.) : Dr. Thorndike has given a brief but exceIIent comprehensive resume of the suction socket program in this country. I understand that in Germany it is extensiveIy fitted and has been used since the recent war. After we have learned its advantages and shortcomings we shouId be abIe to do in this country what the Germans have accompIished so successfuIIy abroad. The Veterans Administration by deveIoping and affording the fitting and use of this exceIIent type of prothesis hopes to make it usefu1 not onIy to battIe casualties but aIso to civilian amputees. The
American Journal of Surgery
Thorndike-Suction Administration hopes to demonstrate to the Iimb industry the undoubted vaIue of this prosthesis in suitabIe cases. I hqve been afforded an unusua1 opportunity as a V. A. consuItant of observing and examining a group of twenty-eight suction socket wearers fitted in the Research Laboratory of the Prosthetic and Sensory Aids Service at the New York Regional Office of the Veterans Administration. They were a group of wearers fitted in the New York Univcrsity Experimenta Suction Socket Program. The wearers were seIected from a group of sixtyeight as suitabIe to cooperate in further experimenta1 work on shin, knee and ankIe activating devices and to permit the two Iimb-fitters more time to appIy and study the appIication of such devices to the suction socket as we11 as fitting experimentai upper Iimb prosthesis. AI1 the piIot wearers had been screened by psychoIogists and their stumps examined by surgica1 consuItants who excIuded unsuitabIe stumps for the various reasons mentioned by Dr. Thorndike. They were fitted by, or their fitting in a suction socket schoo1 supervised by, the two skiIIed and experienced Iimb-fitters. Their stump muscIes were tested for change in voIume, strength and coordination by an exceIIent physica therapist who trained them in gait, aIignment and posture. Their stumps were examined by me when the wearers came in for fitting or with compIaints. This was done in the presence of the Iimb-fitter. I wouId discuss the medica probIems presented and their reIation to the fit of the socket. The fitter wouId in turn expIain to me the possibIe reason for the fit causing the physioIogic disturbance and how it couId be corrected, made smaIIer with a Iiner or given more opening to prevent squeezes as changes in the stump occurred. This reIationship is a most necessary one in fitting a suction socket and is to be carried out in pIanned PiIot Orthopedic CIinics. The Iimb-fitter wouId make such changes as were agreed upon and the stump and fit studied after the changes. A common compIaint was skin irritation in the abductor region or crotch which is reIieved when a correct fit is obtained. Skin foIds or redundancy above the brim, due to the socket being too smaI1 just beIow the brim to permit the skin to be drawn into the socket, is reIieved by opening the socket. A very smaI1 change either way or at different points in a we11 shaped socket accompIishes much for the correction of pressure points and comfort. DiscoIoration is due to capiIIary congestion due to squeeze at the brim or deeper in the socket. SweIIing or edema at the end of the stump is due to the same cause or overuse of the Iimb. I have seen sweIIing deveIop in a few hours or onIy after thirty-six hoIes of goIf. One piIot had onIy a moderate degree of sweIIing. It may be obvious only
November, I 949
Socket
Prosthesis
611
as an increased thickening of the pinched skin. If aIIowed to persist, it may deveIop into a buIbous stump with breaking down of the skin. This shouId not be interpreted as deveIopment of muscuIature as was reported in an outside case. The treatment is remova of the socket for a period, correction of any squeeze in the socket and eIevation of the stump above the heart with the patient Iying on his back. Bandaging wiI1 aid onIy if it is done with uniform compression avoiding constriction above the end. I have seen onIy moderate sweIIing and discoIoration which were quickIy reIieved by these measures. Rubbing which irritates the skin may cause increased keratinization which by piIing up causes smaI1, hard pimpIes. If the skin gIands become obstructed, cysts occasionaIIy deveIop. Lack of carefu1 hygiene of skin and disinfection of socket (I have advised M of I per cent aqueous soIution of formaIin wiped off with a damp cIoth) are apt to produce superficia1 furuncIes if contamination occurs. The stump sock of the conventiona Iimb cannot be disinfected as easiIy as the suction socket. I have seen an amputee give up using a conventiona socket and choose to use a suction type because of furuncuIosis. A carefu1 excIusion of Iatent fungus infection shouId be done when skin irritation becomes persistent. I have seen a most discouraging case for the Iimb-fitter turned into one in which the patient was a satisfied suction socket wearer by the correction of a yeast fungus, infection. I have seen very few petechiae or smaI1 subcutaneous hemorrhages and these were found due to squeeze or pumping action in a Ioose socket, occasionaIIy to a defective vaIve. The usua1 discoIoration deveIops as an eIIiptic area embracing the end and media1 aspect of the stump which may fade to a Iighter hue as time goes on or may endure as a pigmented area. I have seen no trouble from this nor had any compIaints. There are few compIaints of pain except that due to sore muscIes from fatigue due to proIonged continuous overuse without rest. This is reIieved by rest and warm bathing. I have caIIed attention to a few of the points spoken of by Dr. Thorndike to emphasize that a bad fit causes certain IocaI physica conditions. These in turn increase the fitting probIem which in turn adds to the other two. If the vicious cycIe is not understood and corrected, menta1 antagonism deveIops and cooperation is Iost. To secure a satisfied suction socket wearer caIIs for tact and surgica1 judgment in cooperation with a skiIIfu1 Iimb-fitter to reassure the amputee during the period of changes in the stump and deveIopment of his atrophied muscIes unti1 these are abIe to contro1 the prosthesis. His reward wiIl be the avoidance of an irritating abdomina1 beIt
612
Thorndike-Suction
with hinge or shouIder harness and an inconspicuous Iimp in a comfortabIe, controIIabIe Iimb. It is quite apparent that by having beginners in its fitting see others using it successfuIIy and taIking with them makes them aware of its advantages and is most heIpfu1 in gaining their cooperation unti1 a correct fit is obtained. It has been a great priviIege to be permitted to work in cIose contact with Dr. Thorndike’s Service which affords promise of such an efficient aid in rehabiIitating the above-knee amputee. LOUIS G. HERRMANN (Cincinnati, 0.): I reaIize that Dr. Bennett did not have the oooortunitv to discuss the probIem of the care of the Iarge mixed nerves of an extremity at the time of amputation. We are agreed that any injury to these Iarge mixed nerves at the time of amputation may Iead to severe phantom Iimb pains or chronic aching pain in an amputation stump. It has been our opinion for a Iong time that centraIIy conducting axons carry abnol’ina]. inipuIses to the higher nerve centers and give rise to the syndrome which is caIIed phantom Iimb pain. The time to do most for such nain is at the time of amputation and not six or ejght months afterward. Before this Association some years ago we reported our own experiences with the management of Iarge mixed nerves at the time of amputation. We expressed the opinion that no injury to a mixed nerve shouId be permitted at the time of amputation whether that injury is by a smaI1, hoIIow needIe with novocain, aIcoho1 or any other simiIar soIution in it. We beIieve that the best way to reduce the incidence of phantom Iimb pain and pain in the amputation stump is to use a nonabsorbable Iigature and tie it tightIy around the otherwise norma nerve above the site of amputation so that a band of scar tissue wiI1 deveIop at the point of pressure necrosis. The perineurium then seaIs over the end of the nerve without the formation of a neuroma. Whether or not neuromas are actuaIIy responsibIe for phantom Iimb pain is disputabIe. I believe we can reduce the incidence of nhantom Iimb oain by more carefu1 attention to thk Iarge nerves a; the time of amputation of the extremity. With respect to Dr. Thorndike’s paper, I shouId Iike to ask him one question. He did say extensive arteria1 disease was a contraindication to suctiontype stumps? I think the suction socket is a rea1 advance. We see a great number of patients who have extensive arteria1 disease or arterioIar disease and I wouId Iike to hear him say something about the indications for the suction stump in that type of patient. JOSEPH E. J. KING (New York, N.Y.): I shouId like to ask a question of Dr. Bennett, Dr. Thorndike, Dr. MaytieId or anyone eIse present. Dr. Bennett spoke about the phantom Iimb pain but I shouId Iike to ask anyone in this audience if he ~I
I
Y
Socket
Prosthesis
actuaIIy knows what to do for it. When the patient comes to you, what do you say to him? If a person needs resection of his stomach or an appendectomy, one can readiIy state, “Yes, we know what do do” but I have never known what to do for the phantom Iimb. A number of peopIe with.whom I have taIked say that they usuaIIy try to get them to go to someone eIse. ARTHUR R. METZ (Chicago, III.): Dr. Bennett has discussed a number of points to be considered in amputations as a group caIIing specia1 attention to amputations through the foot. It is good practice to maintain whenever possibIe a weight-bearing surface in doing a foot amputation. Whenever possibIe the fIexor tendons shouId be preserved thus giving the patient a stump that he can contro1 and waIk on. In case tdo much of the foot is injured to preserve the flexor tendons of the ankIe and there is stiI1 padding over the OS caIcis, Pirogoff’s amputation shouId be performed which consists of ankyIosing the OS caIcis to the end of the tibia and gives the patient a weight-bearing heel to which a satisfactory appIiance can be fitted. Patients with this type of amputation get so they can carry on in a very active manner and do reguIar work. In amputations beIow the knee it is desirabIe to have a stump 4 to 5 inches Iong as determined by measuring the tibia on x-ray fiIms. In addition a more comfortabIy fitting stump can be made if the entire fibuIa is dissected out at the time of amputation and the perineal nerve severed high up so as to avoid pressure in the socket. A stump of onIy I to 2 inches of tibia wiI1 be enough to give the patient knee action which is the important part in an amputation beIow the knee. An effort shouId aIways be made to preserve knee joint action in any amputation beIow the knee. Dr. Bennett has pointed out many practicaI points to be observed in amputations in generaI. R. J. BENNETT (cIosing): Dr. King mentioned the phantom Iimb. I have gone over the Iiterature thoroughIy and I have attempted to do some experimenta work on this phantom Iimb. However, these are onIy subjective symptoms and it is impossibIe to do experimenta work but we go by the signs and symptoms of peopIe who have had phantom Iimbs. You wiI1 find severa cases of phantom Iimb in the Iiterature. In one particuIar case one man had his arm taken off whiIe in the air force during the Iast war; he returned and they had quite a time with him. He insisted on going back with his unit and he was not aIIowed to go. I beIieve the story goes that he had a particuIarIy painfui phantom Iimb. He was reaIIy disabIed with it. FinaIIy, a report came through to the effect that he was aIIowed to return to his unit and the phantom Iimb quieted down. He has not had any troubIe since. I think, undoubtedIy, the psychiatric side plays
American
Journal
of Surgery
Thorndike-Suction a part in phantom limb. By giving the procaine intravenousIy whereby we wiI1 get the IocaI, regiona and centra1 wiping out of these impressions, we may be abIe to find out something. I do know that procaine has been used intravenousIy in the most painfu1 cancerous conditions in which the patient has been absoIuteIy unabIe to stand the pain and it has been wiped out by this intravenous injection. AUGUSTUS THORNDIKE (cIosing): ReIative to Dr. Kennedy’s remarks from Dr. Gordon, I want to recaI1 to your minds that the twenty-eight patients whom he examined were some of the very lirst that were fitted and they had every known compIication, I think. The fit was too tight at that time but we have saIvaged twenty-eight by I’oIIow-up and carefu1 adjustment so that they arc now considered satisfactory. Remember, the patients in the series that 1 reported are a11 old amputees. They formerIy had been on a temporary or permanent Ieg of the Army or Navy. They have had to be retrained entireIy and many of them have had to come back innumerable times to be fitted and adjusted correctIy. Dr. Herrmann mentioned the phantom Iimb pain and aIso Dr. King. We have a research project under way now that shows some promise. I am not abIe to say very much about it but perhaps in another year we wiI1 have some resuIts we can taIk about. One of our research contractors is working on that probIem now. We arc not prepared to say a great dea1 about t hc problem of arteria1 disease and contraindication
November,
1949
Socket
Prosthesis
613
for suction socket at this time but we have fitted the suction socket to some definite arterioslcerotic individuaIs, veterans of WorId War I. These veterans seem to be very happy and deIighted that nothing has happened; they have worn it over a period of six months. We cannot say it is right in every respect. We do not know how far even these cases wiI1 go but it is promising. I was interested to hear Dr. Bennett mention procaine intravenousIy. I am personaIIy a IittIc skeptica but I wouId Iike to see somebody report a series of cases. We are open-minded; we do want to lick this phantom limb probiem. I want to thank the discussers for what they have said and I hope that we may be abIe to report further on other developments in this rcscarch program on prosthesis. LOUIS G. HERRMANN (Cincinnati, 0.): I wouId like to bring up another question. I toId you that we were interested in the prevention of phantom Iimb pain because we have tried aImost every known procedure to reIieve pain and have not been uniformIy successfu1. Dr. Thorndike has aIso indicated that it is one of the big probIems in the management of both severe trauma to an extremity as we11 as amputations foIIowing arteria1 disease, particuIarIy arterioscIerosis. I shouId Iike to have a morning devoted to the probIem of pain in an extremity sometime in the near future in this organization so that we ean discuss a11 the failures (psychiatric and neuroIogic) and also the technica side of the probIem of the relief or prevention of phantom limb pain.
REPORT
OF VETERANS
ADMINISTRATION
AUGUSTUS
THORNDIKE,
EXPERIMENTAL
PROGRAM
M.D.
Boston, Massachusetts
A
PROSTHETIC device first patented by Dubois ParmeIee of New York in 1863 has again attracted the attention of the medica profession. OriginaIIy utilized in conjunction with a pyIon Ieg attaching the Iower extremity prosthesis to the body by suction, Parmelee’s idea had been tried in 1885 by Beacock and Sparham in Canada, in 191 I by ToIes in CaIifornia and in 1926 by Underwood in England. To improve the degree of suction the British added a heIica1 groove in the socket lining. Furthermore they re-designed the appliance for use with a meta Ieg, the inserted bucket being fabricated of wood or papiermachc. In these earlier Iimbs the vaIves varied from a simple faucet to a one-way air escape valve. (Fig. I.) FoIIowing WorId War I about thirty suction sockets were fitted at Roehampton, EngIand. Until recently case histories on these thirty patients had been lost and the suction socket prosthesis had been discarded. Then OesterIe of UIm, Germany, advocated the use of the “Springer Vacuum Ieg” in 1933.’ Furthermore, in Germany Felix beIieved the deveIopment of a satisfactory valve for the vacuum chamber was the item that popuIarized this method of prosthesis fixation in above-knee Ieg amputations.” Next Kirschner and Dittert reported a series of thirty-nine cases in 1944.~ About the same time Hepp4 described a contact type of prosthesis, a modification of the suction socket. Some mihtary medical reports on suction sockets received in the United States immediateIy folIowing V-E Day (May 8, 1945) prompted Major Genera1 Norman T. Kirk to appoint and dispatch to Europe in March, 1946, a committee of distinguished civiIian and miIitary engineers and orthopedic surgeons to investigate and report upon new orthopedic technics and appliances incIuding the suction socket prosthesis. In 1946 this report was submitted to the NationaI Research CounciI of the NationaI Academy of Sciences for con-
November, 1949
603
sideration by The Committee on Artificial Limbs. In 1947 this Committee became known as the Advisory Committee on ArtificiaI Limbs and was seIected by the Veterans Administration, Army and Navy to coordinate a11 research projects pertaining to artificia1 Iimbs. It is a pleasure to report that the results of this Committee’s activities are rea1. Many new devices have appeared such as the new arm prostheses designed by Fitch, by Hosmer and by the Northrop Aircraft Corporation. The wrist Aexion unit and supinator and pronator device for beIow-eIbow arm amputees represent recent deveIopments. The department of medicine and surgery of the Veterans Administration has been cooperating with this Committee. At this time among devices for artificia1 legs in the developmenta stage are a new ankle joint incorporating horizonta1 rotation, several knee brake and Iock mechanisms, both hydraulic and mechanical in operation and the suction socket for aboveknee amputees. RecentIy Canty reported his experience at Mare IsIand Naval Hospital with the suction socket.5 AIthough results obtained on the suction socket prosthesis to this date are most promising it is deemed advisable not to consider them as conclusive. The source material reported here is contained in two reports received in 1949, by the Advisory Committee on May, ArtificiaI Limbs. These reports were rendered by representatives of the limb manufacturing industry and by the Lower Extremity Committee, a technica subcommittee of the Advisory Committee on ArtificiaI Limbs. It is beIieved that unti1 a significant number of case histories can be compiIed on those who have successfuhy worn the suction socket daiIy for an entire caIendar year under a large variet,y of climatic conditions, it wouId be a mistake to claim compIete success. Today there are very few surgeons or limb-fitters in this country who couId cIaim to have seen or fitted more than
f-304
Thorndike--Suction
FIG. I. The first known mode1 of suction No. 37.637.) a handful of cases twelve months ago. Therefore, this report is to be considered as mereIy informational. The statistics in Table I on above-knee suction socket experience have been compiIed from responses to a questionnaire maiIed to 159 members of The Orthopedic AppIiance and Limb Manufacturers Association. The Veterans Administration Experimental Suction Socket program which has been in operation Iess than two years invoIved first a training program for limb-fitters and surgeons. A tota of twenty schools have been heId in various parts of the country in which a tota
Socket
Prosthesis
socket prosthesis.
(U.S. Patent
Ofice,
of 200 limb-fitters and over 200 surgeons have been certified as qualified to fit the suction socket. Each one of this great number of fitters has been authorized to fit three suction socket limbs to veteran amputees. As of this date 495 suction socket limbs have been authorized to be fitted to above-knee veteran amputees. The most recent report (ApriI 15, 1949) received from Professor Howard D. Eberhart, Chairman of the Lower Extremity Committee of the Advisory Committee on Artificial Limbs, records a tota of 21 I cases of which nine or 4.3 per cent are considered to be faiIures. (TabIe II.) The geographic distribution of these
American
Journal
of Surgery
Thorndike-Suction
Socket
60 5
Prosthesis
veterans is widespread involving all degrees of climatic variation. The causes of the nine failures in the 21 I cases reported are tabulated in Table III. A group of twenty-nine patients exists still alternating in the use of the suction socket and
shape of the socket from the earlier design. Furthermore for the first six months the wearer must report at regular intervals for adjustments. Inasmuch as the stump becomes an active and functioning part of the amputee, stump changes occur. The usua1 adipose and
TABLE I* Number of Sockets fitted to aboveknee amputees. 1,232 Xlen ,._ 1,023 164 Women..... .,. Children. 45 $0 (4 per cent) Number of complete failures. * From Report of PreIiminary Results, OALMA, Ma v *, ,94(,.
TABLE III* REASONS FOB FAILURES (NINE CASES) Non-cooperation, gave up during initial Iitting. 3 z Poor Iit and aIignment. MedicaI contraindications: Cyst or abscess on adductor roI1 remaining from usingoldleg................................... 2 Insecurity (teIevision actor gave up after Iive months’ trial)........................................ I L.oss of suction (mechanic lost suction when lifting I motor from chassis).
the original conventional limb for reasons listed in Table IV. It is only reasonable to adjudicate these results by the Iength of time that the suction socket has been worn. It must be emphasized that in this group of patients in the experiTABLE II * BHAVCH VETERANS ADMINISTRATlON OFFICE DISTKIBLTION OF RESULTS
Wearing
r”utinrly.
* Report
of Subcommittw,
ACAL,
April I 5, ,919.
mental program 123 or 58 per cent have been wearing the suction socket four months or less and that in this group lie 75 per cent alternating between the use of the suction socket and conventiona limb. Table v ilIustrates the time interval in those cases in which a suction socket type of prosthesis was used. Inasmuch as only three patients in this series have been wearing the prosthesis successfully for ten months, one may readiIy comprehend the fact that unqualified approval of this device must be deferred. To judge these results in the Veterans Administration Experimental Program as good is reasonable. RecaIling that most fitters have been authorized to fit only three veterans and realizing that experience in pulling a suction socket is Iimited in most areas of the country, one might conclude that this report represents a fair measure of success. Moreover it is of importance to point out that successful fitting depends upon a change in the pattern and November,
1949
*
Total...................................... Report of Subcommittee,
9
ACAL, April I 5, 1049.
flabby stump loses its fat tissue and develops more norma musculature. During this period of change the surgeon, amputee and limb-fitter must be particularly conscious of the necessityfor adequate foIIow-up. TABLE IV* KEASONS FOR ALTERKATINGWEAR (TWENTY-SINE CASES1 time on suction socket New cases, increasing graduaIIy................................... 9 : Insecurity on leg, loss of suction, bad aIignment h No time for proper adjustment, Iong working hours. 3 Replaced old socket, not yet adjusted to new one.. 2 Wears, except at work. L Excessive edema and perspiration. I Insecurity on leg, biIatrra1 amputee Total.
z)
* Report of Subcommittee,
ACAL, ApriI
I 5,
,949.
At First these sockets were usualIy fitted too tightly. The degree of suction required is only 1>4 pounds per square inch negative pressure which during the stance phase of walking will change to 1,%5pounds per square inch positive. TABLE v* LENOTH OF TIME ON SUCTION Months
“12
3
I
Wearing routinely Afternatingt. Failurest..
o 4 3 2
Sub-total
3 ar 31 3-
Cumulative
., total.
J
!/ 5
6
SOCKE?
7
_
81, _,__,_
10
Total -__
0 Is 23 3 8 5
I
3 24 55 92
*Report of Subcommittee, ACAL. t Months since initial fitting date socket.
April I 5. 1949. rather than time on suction
Thorndike-Suction
FIG. 2. Perimeter measurement
Socket Prosthesis
for determining
pattern size.6
An adequate air-escape valve has been designed so that these pressures are maintained consistentIy. It is perhaps erroneousIy termed a suction socket; the degree of suction is minimaI. Suction aIone hoIds the artificia1 Iimb when
HOLD WOOD FOR IGCHIAL SEAT
*...
PERIMETER.
INCHES
/
POSTER,OR ,.,..I
FIG. 3. Cross-section
pattern at ischiat seat leveI.6
the stump is reIaxed whiIe during actua1 waIking the hoIding force is better described as even contact of the stump with the socket waI1. The patient by contracting his remaining muscles in the stump can prevent its forcefu1 withdrawa1. The modification in the shape of the suction socket pattern from the original design can be expIained as the resuIt of experience gained. It wouId be we11 to Iist the main changes as foIIows: (I) reduction in size of the ischial seat; in about 3 per cent of the cases fitted the ischia1
FIG. 4. Deviation socket.”
from pattern
of a typica
suction
seat may be eliminated (indicated if a Iarge and powerfu1 glutea1 muscIe bundle is present) ; (2) properly shaped posterior surface of the
American
Journal
of Surgery
Thorndike-Suction
Socket
thigh making the back of the socket thinner and flatter, sometimes utiIizing a soft back; (3) “easing” the fit on the walIs of the socket all around below the level of the brim; (4) greater emphasis in proper alignment of the entire limb. The main advantages in this suction socket
Prosthesis
improved control and position sense. In addition the wearing of a stump sock is no longer necessary. There is not space to describe the details of fabrication of this type of socket. Sufl?ce it to state that a willow block is carved to form-fit
SOCKET IS STARTED BY MEASURING THE STWP PERIMETER AT THE ISCMAL SEAT LEVEL TO DETERMINE THE *PPROXIMATE PATTERN SIZE .
WE
OUT APPROXIMATE SOCKET OUTLINE FROM RTTERN. MAKE ALTERATIONS IF NECESSARY AS SHOWN IN WE FOLLOWING ILLVSTRATIONS.
LAY
LAY OUT LENGTH OF MEDIAL SIDE AS ‘h’ LESS THAN DISTANCE FROM ANTERKWI-MEDIAL APEX TO ISCHIAL TUBEROSITY-@I).
LAY OUT LENGTH OF POSTERIOR SIDE EPVAL TO MAX LATERALMEDIAL STUMP MEASUREMENI@I I
k-4
ESTIMATE REOVIRED
1 OF
(StHIA!_
WW,Y FORM
SEAT -6.
LENGTH
GLUTEAL AREA TO co*cTO STUMP CONTOUR-@ FIG.
,.,OOlFY MEDLAL SIDE TO GONFORM TO STUMP CONTOUR-@.
MODIFY ANTERIOR-MEDIAL APEX TO CONFORM TO ST”,“,’ CONTOUR WITH ADDUCTOR LONGUS TENSED-@
ADO PROTUBERANCE SIDE IF NECESSARY-
MOOIFY ANTERIOR FORM TO SWMP
1949
SlOE TO COW CONTOUR- @.
5. PreIiminary Iayout of the suction socket outIine.6
type prosthesis are: (I) providing the aboveknee amputee with a naturaIIy functioning hip joint whereby his remaining muscles in the stump and about the hip resume physiologic balance resulting in better coordination; and (2) abolishing the suspension straps or peIvic belt with hinge. Suspension by a pelvic belt and a metal hinge in the conventional Ieg prevents necessary rotation in proper waIking and has resuhed in a high degree of belt breakage. On _ _. . . . . _ the other hand the amputees claim that suction socket type prosthesis feeIs as if it were a constituent part of the stump, resuhing in
November,
ON LATERAL @,.
FIG. 6. ReIation of the bony peIvis to the suction socket at the ischial seat Ievel as viewed from below.”
the stump. An air-escape valve is inserted into the lower ‘portion and over the lower end of the
608
Thorndike-Suction
Socket
Prosthesis
___ --9 x
bIock a plywood cover with an air seal is glued. This socket is then attached bIock, knee bolt and lower interested in the details of referred to the third edition
to the usual knee assembIy. Those construction are of the brochure,
A. FOOT OFTEN ROTATED CUTWAR0 WHEN SlTTlNG ON HARO SURFAOES DUE TO SOCKET SHWE. NECESSARY TO SHAPE SOCKET SACK AFTER WALKING ALIGNMENT IS OBTAINED.
8.
with impaired circulation, capiIIary fragiIity in the stump, short or long stump or overweight individuaIs. Of course, the surgeon shouId accept only the most favorabIe cases at the start. However, by proper fitting experienced sur-
FOR PROPER SITTING ALIGNMENT, REMOVE EKCESS WOOD AS Y0IOATE0.
0. ELEVATION OF ISCHIAL SEAT W”,LE SlTTYlG CAUSES STRETCHING OF SKIN ANO MAY CAUSE LOSS OF SUCTION.
c. PRWER SlTTlNG *LIGNNENT. THCKNESS OF WALL OONSISTENT WITH STRENGTH.
E. PROPERLY SLOPED AS0 ROt”‘DEO ISCML SEAT WITH FLAT E&K IYP(IOVES SITTING CONfORT.
FIG. 7. Shape of the socket back and alignment of the Ieg in reIation to sitting comfort.~
“The Suction Socket Above-Knee Artificial Leg.“‘? (Figs. z to 6.)* Many surgeons have been fearfu1 of titting stumps to this prosthesis because of associated injuries of the opposite Ieg, a biIatera1 aboveknee amputee, deep or adherent scars beIow the top IeveI of the socket, spurs or bone masses at the rower end of the stump, arteria1 disease * Figures 2 to IO are reproduced through the courtesy of Prosthetic Devices Research Project, University of California.
geons and limb-fitters have fitted stumps of Iess than three inches (crotch measurement). (Figs. 7 to IO.) Moreover, Gritti-Stokes end-bearing stumps tolerate this prosthesis we11if the Iower end of the socket is padded with feIt. Sometimes, however, Iong weight-bearing stumps require a Iowering of the knee boIt and shortening of the shank. Specific contraindications exist. Perhaps the most important of these pertain to the psychoIogic attitude of the patient. It is much easier
American Journal of Surgery
Thorndike-Suction
Socket
to satisfy a prosthesis wearer with a suction socket if the first Ieg fitted is of this type. AI1 patients seIected for this suction socket must be screened. The emotional, negativistic type of amputee shouId never be changed from a
Prosthesis
Iished meet one morning a week under the guidance of an orthopedic consultant. In these clinics wiII be fitted not only the suction socket wearer but aIso a11 orthopedic shoe, brace and for the fieId prosthesis wearers. As outlets
TOO TIGHT POSSISLY
MEDIAL SloE FLARE0
CAUSING THE SOC((ET
WHILE MEDIAL
WOIALLY
WALKING. AREA.
PLACED
Too
TO lRR,TAT,,,G
lSCMPL
M”CH,
SHIFT THE
INTERIOL-POSTERIOR DIMENSION TOO GREAT, ALLOWING THE ISCHIAL TUSEROSITY TO FALL ,NS,DE OF WHIAL SEAT. MAKlNG SOCKET VERY WlNF”L
SEAT.
CPlUSE SITTING
TOO
OF
OLE
LARGE
609
ISCH~AL
SEAT
BURNING SENSATION TO STRETCHING
ANTERIOR REGION. CAUSING
EDEMA.
TOO LARGE OR TOO SMALL ,, PROT”SERAWE,CAUSING LOSS OF SUCTION ip1 WME ST”MP5.
TOO
LARGE
GLUTEUS
RELIEF
W”,LE THE SKIN
FIG. 8. Common errors in fit at top of socket .6 Errors indicated by dotted lines.
conventiona artificial limb. Those amputees harboring low grade osteomyeIitis of the femur should be denied the fit of a sudtion socket. Patients with chronic dermatitis or fungus infection or eczematous rash on the stump should be excluded from wearing the suction socket unti1 cured. The few patients with depressed scars at the top of the thigh shouId be denied this socket inasmuch as suction couId not be maintained. The importance of follow-up and constant vigilance of the suction socket wearer during his first four to six months cannot be overemphasized. In fact it might be stated that too many surgeons discharge their patients after the fitting of any orthopedic appliance. To alleviate most complaints and to provide better professional service to the veteran orthopedic appIiance wearer, the Veterans Administration is setting up PiIot Orthopedic Clinics throughout this continent in twenty-three of its Iarger regional offices. Five of these already estab-
November, I 949
FIG. 9. Suction socket for the same stump; A B and D, unsatisfactory.”
and
c, satisfactory;
testing of new orthopedic devices have great potentia1 vaIue.
these clinics
Thorndike-Suction
Socket 4.
SUMMARY
To recapituIate, the tentative concIusions on the current experimenta use of the suction socket above-knee prosthesis are as folIows: I. The suction socket above-knee prosthesis
Prosthesis
HEPP, OSCAR. Haft prosthesen.
Ztscbr. f. Ortbop.,
77: ==9* 1944. 5. CANTY, THOMAS J. and WARE, ROBERT J. Suction
socket for above knee prosthesis. Bull., 49: 216, 1949. 6. The Suction Socket Above-Knee
U. S. Navy M. Artificial
Leg.
6: I-
B
*.- TIGNT FIT IN THlS AREh WLL CAUSE EOEYA WHEN STUMP MUSCLES ARE CONTRACTED AS SNOWN IN 0.
c
C - NEGATIVE PRESWRE OF ONE AND WE-HALF PER SQUARE INCH WILL S”CESY”LLY SUSPEND THE LEB EOEYA MAY OCG”i) WTH r\N IHCOm?EC7 FIT AS IN A OR 8.
POUNDS
D.- A MGN NEGATWEPNESWNE WGXATES A VERY FIT, PNOOUCINGFORCES TENDING To P”S”
TIGNT
TNELEG OFF. THE
SOWET
U”ST
SE EK*RSEO
IYMEDIAIELI.
FIG. IO. Errors in fit below brim of socket.6
is described and found to have been fitted to 2 I 1 veteran amputees. 2. CompIete failures represent 4.3 per cent of the patients. 3. Inasmuch as 58 per cent of the patients have been wearing this prosthesis for four months or Iess, the favorabIe resuhs cannot be construed as conclusive evidence for general approva1 of the suction socket prosthesis. REFERENCES I. KIRSCHNER, FRIEDERICH. uber den Kunstbeinbau. Med. Welt, 7: 1,282, 1933. 2. FELIX, W. Praktische erfahrungen mit den saugprosthesen. Ztscbr. j. Ortbop., 72: 352, 1941. 3. KIRSCHNER, FRIEDERICH and DITTERT, RUDOLF. tjber erfahrungen mit dem niederdruckunstbein. Arch. f. ortbop.
u. Unfall-Cbir.,
43: IOI, 1944.
University
of CaIifornia
Press. 3rd ed. Berkeley,
‘949. DISCUSSION
OF PAPERS AND
BY
DRS.
BENNETT
THORNDIKE
DONALD GORDON (New York, N. Y.) : Dr. Thorndike has given a brief but exceIIent comprehensive resume of the suction socket program in this country. I understand that in Germany it is extensiveIy fitted and has been used since the recent war. After we have learned its advantages and shortcomings we shouId be abIe to do in this country what the Germans have accompIished so successfuIIy abroad. The Veterans Administration by deveIoping and affording the fitting and use of this exceIIent type of prothesis hopes to make it usefu1 not onIy to battIe casualties but aIso to civilian amputees. The
American Journal of Surgery
Thorndike-Suction Administration hopes to demonstrate to the Iimb industry the undoubted vaIue of this prosthesis in suitabIe cases. I hqve been afforded an unusua1 opportunity as a V. A. consuItant of observing and examining a group of twenty-eight suction socket wearers fitted in the Research Laboratory of the Prosthetic and Sensory Aids Service at the New York Regional Office of the Veterans Administration. They were a group of wearers fitted in the New York Univcrsity Experimenta Suction Socket Program. The wearers were seIected from a group of sixtyeight as suitabIe to cooperate in further experimenta1 work on shin, knee and ankIe activating devices and to permit the two Iimb-fitters more time to appIy and study the appIication of such devices to the suction socket as we11 as fitting experimentai upper Iimb prosthesis. AI1 the piIot wearers had been screened by psychoIogists and their stumps examined by surgica1 consuItants who excIuded unsuitabIe stumps for the various reasons mentioned by Dr. Thorndike. They were fitted by, or their fitting in a suction socket schoo1 supervised by, the two skiIIed and experienced Iimb-fitters. Their stump muscIes were tested for change in voIume, strength and coordination by an exceIIent physica therapist who trained them in gait, aIignment and posture. Their stumps were examined by me when the wearers came in for fitting or with compIaints. This was done in the presence of the Iimb-fitter. I wouId discuss the medica probIems presented and their reIation to the fit of the socket. The fitter wouId in turn expIain to me the possibIe reason for the fit causing the physioIogic disturbance and how it couId be corrected, made smaIIer with a Iiner or given more opening to prevent squeezes as changes in the stump occurred. This reIationship is a most necessary one in fitting a suction socket and is to be carried out in pIanned PiIot Orthopedic CIinics. The Iimb-fitter wouId make such changes as were agreed upon and the stump and fit studied after the changes. A common compIaint was skin irritation in the abductor region or crotch which is reIieved when a correct fit is obtained. Skin foIds or redundancy above the brim, due to the socket being too smaI1 just beIow the brim to permit the skin to be drawn into the socket, is reIieved by opening the socket. A very smaI1 change either way or at different points in a we11 shaped socket accompIishes much for the correction of pressure points and comfort. DiscoIoration is due to capiIIary congestion due to squeeze at the brim or deeper in the socket. SweIIing or edema at the end of the stump is due to the same cause or overuse of the Iimb. I have seen sweIIing deveIop in a few hours or onIy after thirty-six hoIes of goIf. One piIot had onIy a moderate degree of sweIIing. It may be obvious only
November, I 949
Socket
Prosthesis
611
as an increased thickening of the pinched skin. If aIIowed to persist, it may deveIop into a buIbous stump with breaking down of the skin. This shouId not be interpreted as deveIopment of muscuIature as was reported in an outside case. The treatment is remova of the socket for a period, correction of any squeeze in the socket and eIevation of the stump above the heart with the patient Iying on his back. Bandaging wiI1 aid onIy if it is done with uniform compression avoiding constriction above the end. I have seen onIy moderate sweIIing and discoIoration which were quickIy reIieved by these measures. Rubbing which irritates the skin may cause increased keratinization which by piIing up causes smaI1, hard pimpIes. If the skin gIands become obstructed, cysts occasionaIIy deveIop. Lack of carefu1 hygiene of skin and disinfection of socket (I have advised M of I per cent aqueous soIution of formaIin wiped off with a damp cIoth) are apt to produce superficia1 furuncIes if contamination occurs. The stump sock of the conventiona Iimb cannot be disinfected as easiIy as the suction socket. I have seen an amputee give up using a conventiona socket and choose to use a suction type because of furuncuIosis. A carefu1 excIusion of Iatent fungus infection shouId be done when skin irritation becomes persistent. I have seen a most discouraging case for the Iimb-fitter turned into one in which the patient was a satisfied suction socket wearer by the correction of a yeast fungus, infection. I have seen very few petechiae or smaI1 subcutaneous hemorrhages and these were found due to squeeze or pumping action in a Ioose socket, occasionaIIy to a defective vaIve. The usua1 discoIoration deveIops as an eIIiptic area embracing the end and media1 aspect of the stump which may fade to a Iighter hue as time goes on or may endure as a pigmented area. I have seen no trouble from this nor had any compIaints. There are few compIaints of pain except that due to sore muscIes from fatigue due to proIonged continuous overuse without rest. This is reIieved by rest and warm bathing. I have caIIed attention to a few of the points spoken of by Dr. Thorndike to emphasize that a bad fit causes certain IocaI physica conditions. These in turn increase the fitting probIem which in turn adds to the other two. If the vicious cycIe is not understood and corrected, menta1 antagonism deveIops and cooperation is Iost. To secure a satisfied suction socket wearer caIIs for tact and surgica1 judgment in cooperation with a skiIIfu1 Iimb-fitter to reassure the amputee during the period of changes in the stump and deveIopment of his atrophied muscIes unti1 these are abIe to contro1 the prosthesis. His reward wiIl be the avoidance of an irritating abdomina1 beIt
612
Thorndike-Suction
with hinge or shouIder harness and an inconspicuous Iimp in a comfortabIe, controIIabIe Iimb. It is quite apparent that by having beginners in its fitting see others using it successfuIIy and taIking with them makes them aware of its advantages and is most heIpfu1 in gaining their cooperation unti1 a correct fit is obtained. It has been a great priviIege to be permitted to work in cIose contact with Dr. Thorndike’s Service which affords promise of such an efficient aid in rehabiIitating the above-knee amputee. LOUIS G. HERRMANN (Cincinnati, 0.): I reaIize that Dr. Bennett did not have the oooortunitv to discuss the probIem of the care of the Iarge mixed nerves of an extremity at the time of amputation. We are agreed that any injury to these Iarge mixed nerves at the time of amputation may Iead to severe phantom Iimb pains or chronic aching pain in an amputation stump. It has been our opinion for a Iong time that centraIIy conducting axons carry abnol’ina]. inipuIses to the higher nerve centers and give rise to the syndrome which is caIIed phantom Iimb pain. The time to do most for such nain is at the time of amputation and not six or ejght months afterward. Before this Association some years ago we reported our own experiences with the management of Iarge mixed nerves at the time of amputation. We expressed the opinion that no injury to a mixed nerve shouId be permitted at the time of amputation whether that injury is by a smaI1, hoIIow needIe with novocain, aIcoho1 or any other simiIar soIution in it. We beIieve that the best way to reduce the incidence of phantom Iimb pain and pain in the amputation stump is to use a nonabsorbable Iigature and tie it tightIy around the otherwise norma nerve above the site of amputation so that a band of scar tissue wiI1 deveIop at the point of pressure necrosis. The perineurium then seaIs over the end of the nerve without the formation of a neuroma. Whether or not neuromas are actuaIIy responsibIe for phantom Iimb pain is disputabIe. I believe we can reduce the incidence of nhantom Iimb oain by more carefu1 attention to thk Iarge nerves a; the time of amputation of the extremity. With respect to Dr. Thorndike’s paper, I shouId Iike to ask him one question. He did say extensive arteria1 disease was a contraindication to suctiontype stumps? I think the suction socket is a rea1 advance. We see a great number of patients who have extensive arteria1 disease or arterioIar disease and I wouId Iike to hear him say something about the indications for the suction stump in that type of patient. JOSEPH E. J. KING (New York, N.Y.): I shouId like to ask a question of Dr. Bennett, Dr. Thorndike, Dr. MaytieId or anyone eIse present. Dr. Bennett spoke about the phantom Iimb pain but I shouId Iike to ask anyone in this audience if he ~I
I
Y
Socket
Prosthesis
actuaIIy knows what to do for it. When the patient comes to you, what do you say to him? If a person needs resection of his stomach or an appendectomy, one can readiIy state, “Yes, we know what do do” but I have never known what to do for the phantom Iimb. A number of peopIe with.whom I have taIked say that they usuaIIy try to get them to go to someone eIse. ARTHUR R. METZ (Chicago, III.): Dr. Bennett has discussed a number of points to be considered in amputations as a group caIIing specia1 attention to amputations through the foot. It is good practice to maintain whenever possibIe a weight-bearing surface in doing a foot amputation. Whenever possibIe the fIexor tendons shouId be preserved thus giving the patient a stump that he can contro1 and waIk on. In case tdo much of the foot is injured to preserve the flexor tendons of the ankIe and there is stiI1 padding over the OS caIcis, Pirogoff’s amputation shouId be performed which consists of ankyIosing the OS caIcis to the end of the tibia and gives the patient a weight-bearing heel to which a satisfactory appIiance can be fitted. Patients with this type of amputation get so they can carry on in a very active manner and do reguIar work. In amputations beIow the knee it is desirabIe to have a stump 4 to 5 inches Iong as determined by measuring the tibia on x-ray fiIms. In addition a more comfortabIy fitting stump can be made if the entire fibuIa is dissected out at the time of amputation and the perineal nerve severed high up so as to avoid pressure in the socket. A stump of onIy I to 2 inches of tibia wiI1 be enough to give the patient knee action which is the important part in an amputation beIow the knee. An effort shouId aIways be made to preserve knee joint action in any amputation beIow the knee. Dr. Bennett has pointed out many practicaI points to be observed in amputations in generaI. R. J. BENNETT (cIosing): Dr. King mentioned the phantom Iimb. I have gone over the Iiterature thoroughIy and I have attempted to do some experimenta work on this phantom Iimb. However, these are onIy subjective symptoms and it is impossibIe to do experimenta work but we go by the signs and symptoms of peopIe who have had phantom Iimbs. You wiI1 find severa cases of phantom Iimb in the Iiterature. In one particuIar case one man had his arm taken off whiIe in the air force during the Iast war; he returned and they had quite a time with him. He insisted on going back with his unit and he was not aIIowed to go. I beIieve the story goes that he had a particuIarIy painfui phantom Iimb. He was reaIIy disabIed with it. FinaIIy, a report came through to the effect that he was aIIowed to return to his unit and the phantom Iimb quieted down. He has not had any troubIe since. I think, undoubtedIy, the psychiatric side plays
American
Journal
of Surgery
Thorndike-Suction a part in phantom limb. By giving the procaine intravenousIy whereby we wiI1 get the IocaI, regiona and centra1 wiping out of these impressions, we may be abIe to find out something. I do know that procaine has been used intravenousIy in the most painfu1 cancerous conditions in which the patient has been absoIuteIy unabIe to stand the pain and it has been wiped out by this intravenous injection. AUGUSTUS THORNDIKE (cIosing): ReIative to Dr. Kennedy’s remarks from Dr. Gordon, I want to recaI1 to your minds that the twenty-eight patients whom he examined were some of the very lirst that were fitted and they had every known compIication, I think. The fit was too tight at that time but we have saIvaged twenty-eight by I’oIIow-up and carefu1 adjustment so that they arc now considered satisfactory. Remember, the patients in the series that 1 reported are a11 old amputees. They formerIy had been on a temporary or permanent Ieg of the Army or Navy. They have had to be retrained entireIy and many of them have had to come back innumerable times to be fitted and adjusted correctIy. Dr. Herrmann mentioned the phantom Iimb pain and aIso Dr. King. We have a research project under way now that shows some promise. I am not abIe to say very much about it but perhaps in another year we wiI1 have some resuIts we can taIk about. One of our research contractors is working on that probIem now. We arc not prepared to say a great dea1 about t hc problem of arteria1 disease and contraindication
November,
1949
Socket
Prosthesis
613
for suction socket at this time but we have fitted the suction socket to some definite arterioslcerotic individuaIs, veterans of WorId War I. These veterans seem to be very happy and deIighted that nothing has happened; they have worn it over a period of six months. We cannot say it is right in every respect. We do not know how far even these cases wiI1 go but it is promising. I was interested to hear Dr. Bennett mention procaine intravenousIy. I am personaIIy a IittIc skeptica but I wouId Iike to see somebody report a series of cases. We are open-minded; we do want to lick this phantom limb probiem. I want to thank the discussers for what they have said and I hope that we may be abIe to report further on other developments in this rcscarch program on prosthesis. LOUIS G. HERRMANN (Cincinnati, 0.): I wouId like to bring up another question. I toId you that we were interested in the prevention of phantom Iimb pain because we have tried aImost every known procedure to reIieve pain and have not been uniformIy successfu1. Dr. Thorndike has aIso indicated that it is one of the big probIems in the management of both severe trauma to an extremity as we11 as amputations foIIowing arteria1 disease, particuIarIy arterioscIerosis. I shouId Iike to have a morning devoted to the probIem of pain in an extremity sometime in the near future in this organization so that we ean discuss a11 the failures (psychiatric and neuroIogic) and also the technica side of the probIem of the relief or prevention of phantom limb pain.