713
SECTION II
ORTHOPEDIC SURGERY
CHAPTER VII
CARE
OF THE AMPUTATED IN THE UNITED STATES
ADMINISTRATION
The
experience of the European nations at the time of our entrance intothe
conflict was
already sufficient to indicate clearly the possible magnitude of our
amputation problem. The
general use of high-explosive shells and the prevalence of gas gangrene
had increased greatly the
frequency of amputation and had counteracted the gain due to improved
surgical methods; so
that, in the face of an estimated total at that time for all the
countries engaged of nearly 300,000
amputations, the artificial limb problem had naturally become a serious
economic question
abroad. While our own country was particularly fortunate in possessing
a thriving artificial-limb
industry, its usefulness was in great danger of being seriously
curtailed both through the loss of
its skilled workmen in the draft or by transfer to munition work and
also through difficulty in
securing supplies. It seemed wise, therefore, for our country to make
provision for meeting the
greatest possible demand under the most unfavorable conditions.
It
is evident that the highest degree of functional use with the
artificial limb can be
assured only through an organization of the work which takes into
account every phase of
treatment. Hence provision must be made for systematic attention during
each of the five stages
into which treatment naturally divides itself: (1) The amputation
itself; (2) the care of the
stump; (3) provision of the artificial limb; (4) general functional
training; (5) special vocational
training. During these successive periods the amputated pass under the
care of the surgeon, the
artificial-limb maker, and the educational officer. Furthermore,
success in training depends in no
small degree on the attitude of the general public. To secure the
effective cooperation of all these
agencies called for a definite program of education.
EDUCATIONAL
PROGRAM
On
the part of the surgeon, considerable uncertainty still existed as to
the preferable sites
of amputation, little attention had been paid to systematic stump care.
the use of temporary
appliances with plaster-of-Paris sockets asa means of securing early
functional use of the stump
was practically untried in this country, and but little was known of
the general principles of
prosthesis. Moreover. the circular method of amputation, which had been
found so necessarv
and advantageous in counteracting the dangers of infection. required an
entirely different
character of after-treatment from the customary amputation of civil
life. All these points were
covered in articles relating to amputations, fitting artificial limbs,
and the care of the stump,1 and
were distributed in reprint or other forms to Army surgeons. Further
instruction in the subject
was given to student officers by means of didactic and clinical
lectures and practical
demonstrations in the various courses of instruction in military
714
orthopedic surgery. In these courses the artificial-limb makers were
frequently called upon to
explain the design and construction of artificial limbs and the
principles of fitting. Later, as the
amputation center at Walter Reed General Hospital developed, medical
officers were sent there
for courses of instruction in the care of the stump, the principles of
stump surgery, the technique
of the construction of the temporary peg legs, and the general
principles of artificial limbs.
To
educational officers and reconstruction aides, talks, supplemented by
the use of
moving pictures, were given, covering particularly the details of the
later stages of treatment.
For
the amputated themselves this general educational work consisted of
talks to all the
men by those in charge of the service, and also practical
demonstrations in which civilian
amputated who had acquired especial skill showed what is possible with
and without an
appliance. Facts which every amputated individual should know were
formulated and issued in
pamphlet form.2 To this was added later information
concerning obtaining permanent artificial
limbs. 3
The
slight degree of incapacity for most occupations caused by the loss of
a leg, provided
a proper appliance be worn, was a matter of common knowledge on the
part of the general public
in our country, but the possibilities in loss of the upper extremity
were not so generally known.
Moreover, with rare exceptions, employers were prejudiced against the
hiring of such men for
manual occupations. It was imperative, therefore, that the public
should be taught to what extent
and in what occupations the amputated were able to carry on productive
labor. The success of
this part of the work, which was taken over by the division of physical
reconstruction, Surgeon
General's Office, as a part of its general campaign of education,4 was made possible largely
through the generous assistance rendered by the many amputated men
throughout the country
who had attained positions of competence.
AMPUTATION
CENTER
In
planning for hospital accommodations, consideration of efficiency and
economy indicated
the desirability of segregating the amputated, as far as possible, in
one center preferably reserved
exclusively for such cases. This was in accord, too, with the
experience of other countries. With
such a unification of the work, the fitting of appliances would be
greatly facilitated, training in all
its forms more readily carried out, and the study of the various
problems in the care of this type
of case carried on under the most favorable conditions. Unfortunately,
the size of our country
offered too great an objection to this arrangement, since the distances
involved in the majority of
cases were so great as to make it impracticable for the returned
soldier to be furloughed to his
home or to be visited by his friends. The situation seemed to be best
met, therefore, by arranging
for a chief amputation center, near the ports of debarkation, with a
limited number of subcenters
in other parts of the country.5
Walter
Reed General Hospital, Washington, was accordingly chosen by the
Surgeon
General as the chief amputation center, and Letterman General Hospital,
San Francisco, General
Hospital No. 26, Fort Des Moines, Iowa, and General Hospital, Fort
McPherson, Ga., were
designated as subcenters.
715
A
little later, United States Army General Hospitals No. 29, Fort
Snelling, Minn., No. 3 at
Colonia, N. J., and No. 10, at Boston, were also designated as
subcenters. Early in 1919, a change
was made in this arrangement, No. 3 at Colonia being designated as the
distributing center for all
cases of amputation arriving at the port of New York 5 and
Walter Reed General Hospital for all
those arriving at Newport News.5 Since the port at New
York was the one finally used, this
resulted in making these services practically equal, each maintaining
an average of between 600
and 700 cases during the late spring of 1919. The center at Fort Des
Moines became third in
importance. That at Letterman General Hospital proved to be the
smallest in point of numbers.
but it maintained a very high standard of work.
THE
HOSPITAL SERVICE
The
ward organization of a large amputation service proved to be an
important factor in
its success. It was found that not only could treatment be carried out
more easily but that
discipline was more readily enforced when the cases were divided
according to the stage of
treatment. A division into the following groups proved the best
arrangement: The unhealed; the
pre-operative and postoperative; the prefitting and postfitting; the
training groups. In the
unhealed group, the further separation, as far as possible, of the
recumbent and ambulatory cases
aided materially in the control of those who were recumbent.
An
appliance shop for artificial-limb fitting was provided at each center
except at Fort
Snelling; here it seemed more expedient, owing to the proximity of one
of the manufacturers of
the provisional appliances, to have the fitting done at the factory. In
arranging the shop facilities,
it was not found necessary to install an extensive equipment, since
parts whose construction
called for unusual or expensive machinery could easily be secured from
regular artificial-limb
manufacturers. This greatly simplified the problem, the equipment thus
required being no more
than that needed for the ordinary orthopedic brace work. Considerable
floor space was necessary,
however, in order to take care of a large number of cases easily and
rapidly; one of the regular
one-story pavilions met the needs very well in the smaller centers
while in the larger, one of the
regular reconstruction shops proved most satisfactory.
The
medical personnel of the amputation service consisted of its chief who
had also
professional supervision over the shop, one or, in the larger centers,
usually two assistants, one or
sometimes two officers in charge of the shop, and the usual number of
ward surgeons. The
assignment of an additional officer to both the postfitting wards and
the shop was found most
helpful in securing better supervision and fitting.
The
task of securing the required skilled personnel, for surgical and for
prosthetic work,
proved more difficult than was anticipated. Lack of training in the
care of the amputated was
largely responsible for this in the case of the surgical personnel, but
it was due also to the
qualifications demanded by the work, a considerable mechanical ability
in addition to the
surgical knowledge being necessary. Furthermore, few men were anxious
to confine themselves
to such an apparently restricted field for the duration of the war. In
the case of the personnel for
prosthetic work. the artificial limb workmen accepted
716
under the draft were few in number and on account of their age
naturally of only moderate
experience. Moreover, owing to the regulations covering overseas duty,
it was difficult or even
impossible to reserve them for domestic service. The number secured was
so small that it
became necessary to train men for the various details of limb
construction and fitting.
ARTIFICIAL LIMB LABORATORY
The Surgeon General recognized from the first the
importance of
making adequate
provision for the study of the design and construction of prostheses,
particularly from the
standpoint of standardization, and for the proper testing of the many
new appliances and devices
which were being constantly presented, as well as for the carrying out
of experimental work. He
accordingly authorized the establishment of an artificial limb
laboratory for this purpose.6 The
equipment for this laboratory, which it seemed wisest at first to
restrict to a comparatively simple
character, was installed at the Army Medical School Washington, D. C.,
in January, 1918,7 but
was moved to the Walter Reed General Hospital in March of the same
year,7 in order to secure
better coordination between the experimental and the clinical parts of
the work. A certain amount
of both experimental and routine prosthetic work was still carried on
at the Army Medical
School, however, throughout the war, in the shop of the orthopedic
section.
SUPPLY OF ARTIFICIAL LIMBS
The
artificial-limb situation in the United States was such
as to put on the question of Government manufacture an entirely
different aspect from that which
obtained in other countries. The large number of amputations in the
Civil War, with the
enormous yearly addition from industrial accidents which occurred
before the introduction of the
"Safety first" movement, had tremendously stimulated endeavor in this
field, so that our
artificial-limb industry had become the best developed in the world.
Not only was the industry a
large and thriving one but in addition it was well distributed
geographically, so that there was
hardly a city of importance that did not have one or more
artificial-limb concerns. While the
output of some of these was small and the shop facilities far from
modern, a number of our larger
firms had been engaged since early in the World War in supplying limbs
in very considerable
numbers to our Allies, thus showing their ability to handle a large
volume of business. Also it
was learned by means of a questionnaire sent out by the Surgeon General
that the industry as a
whole, with its existing equipment, could produce a thousand limbs per
month in addition to the
number required for civilian needs.8 Furthermore, in order
to be better prepared to handle the
problem and to utilize to the fullest extent the resources of our
country in this respect, the
manufacturers, at the suggestion of the Council of National Defense,
had formed The Association
of the Artificial Limb Makers of the United States.9 In view
of the ample facilities afforded by
the established industry, therefore, it seemed unnecessary to attempt
Government manufacture.
Our
relation to the question of standardization also seemed to differ from
that of other
countries. Examination of the product of a large number of concerns
showed a surprising
uniformity in all essential points. While differing
717
in minor details, they were with few exceptions similar in design,
substantial in construction, and
excellent in workmanship. Since the established policy of bonding
manufactures who desired to
supply limbs to the Government furnished a means of eliminating the
incompetent, it seemed
unwise during the stress of war to subject approved manufacturers to
the expense and
inconvenience that would be caused by the insistence on the production
of definitely standard-ized types. Moreover, while the needs of the
Army might have been met in a very satisfactory
manner by the arbitrary choice of any one of several established models
as a standard, an actual
standardization was clearly out of the question at that time. To be of
any real value
standardization can not be based on opinion but must rest on scientific
study. It is an undertaking
which is obviously not to be considered during war but which offers a
very proper subject for the
attention of the Government in times of peace.
Our
artificial-limb problem was made somewhat more difficult by the
enactment of the
War Risk Act, October 6, 1917.10 Up to this time
artificial limbs had been issued by the
Medical Department, and hence under the authority of the War
Department. In this act, however,
Congress provided for their issue to discharged soldiers and sailors
through the Bureau of War
Risk Insurance, thus transferring the authority to the Treasury
Department. The situation was
thus complicated in that the case passed from the control of one branch
of the Government to that
of another at an important stage in treatment. For, to retain the
amputated soldier in the service as
a patient in an Army hospital during the long period necessary for the
stump to attain its final
form and so be in proper condition for the fitting of the permanent
artificial limb, was obviously
inadvisable from the standpoint of the Army and of the soldier himself.
Yet it was just as
obviously essential to provide for his proper training in the use of an
appliance of the final type,
such training being regarded as one of the most important parts of
modern treatment.
To
meet all these conditions the provision of prostheses of regular
design, so as to fulfill
the requirements of training, but constructed with the intention of
meeting the demands of the
wearer only during the first six months, or if necessary the first
year, of stump life seemed most
satisfactory. An artificial leg of this sort can be constructed on the
"ready-made" plan. Fiber may
be used in place of wood and sufficient parts carried in stock to fit
individuals of different height
and size of stump. The fiber socket can be adapted very satisfactorily
to thigh amputations, while
in below-knee amputations it can be used to hold the plaster-of-Paris
socket. The artificial arm
can be constructed on this plan more easily than the artificial leg.
The advantages of such a
method are many: (a) The
minimum demand is made upon industry, since
all the work of
manufacture may be done in established plants and only such shop
facilities have to be provided
at the amputation center as are required for fitting and repairs. (b)
Production in any quantity is
possible, and hence in the event of the number of the amputated being
so great as to overtax the
established artificial-limb industry, a means is thus provided for
meeting the need until such time
as the permanent limb can be secured. (c)
The maximum number of
amputated can be cared for,
the time required for fitting the ready-made appliance being much less
than for the special one,
and no more than
718
when the temporary leg is used. (d)
The educational value of the
provisional leg is an important
feature, the wearer learning how an artificial leg should feel and act
and how to care for it; this
knowledge naturally makes easier the work of the skilled
artificial-limb maker and is at the same
time the most certain means at our command for eliminating the
unskilled one. (e) The
conditions imposed by the War Risk Act are met most satisfactorily. (f)
An equitable distribution
of the work of supplying the permanent appliance is favored, since it
is not secured until the
amputated have reached their homes; this not only makes possible the
maximum output but is in
accord with established Government policy.
TREATMENT
OF AMPUTATION STUMPS
In
order to record fully the results of experimental development and
clinical observations
of the surgical and prosthetic treatment of stumps in all centers, a
questionnaire was prepared
covering all the salient points. This was submitted to the former
chiefs of amputation centers
with a request that a detailed statement of their observations and
experiences be given, using the
outline as submitted in order to facilitate the study of comparative
methods and results. The
experiences herein related and the conclusions drawn constitute a
review of the reports received
from the former chiefs of amputation sections.12
AMPUTATION CASES RETURNED TO THE
UNITED STATES
The
following is a list of the total number of amputation cases which
werereturned to the
United States: 12
LOSS OF EXTREMITIES
Upper extremity:
One arm above elbow
...........................................550
One arm at elbow
...................................................41
Both
forearms............................................................3
One
forearm..........................................................212
One hand at
wrist....................................................26
Both
hands................................................................1
One
hand................................................................18
Part of both
hands.....................................................4
Part of one
hand.................................................1,481
One arm and one
forearm..........................................1
One arm above elbow and
part of hand.......................4
One arm below elbow
and part of
hand......................1
One forearm and one
hand.........................................2
One hand and part of
hand
........................................2
Total...................................................................2,346
Lower extremity:
Both
thighs................................................................11
One
thigh.............................................................1,137
Both legs at
knee.........................................................1
One leg at
knee.........................................................95
Both legs below
knee...................................................9
One leg below
knee.................................................327
Both legs at
ankle.........................................................3
One leg at
ankle.......................................................131
Both
feet......................................................................1
One foot
...................................................................20
719
Lower extremity- Continued.
Part of both
feet............................................................3
Part of one
foot.........................................................280
Thigh and leg at
knee.....................................................2
Thigh and leg below
knee...............................................5
Leg at knee and part
of
foot...........................................2
Leg below knee and
foot................................................2
Leg below knee and
part of
foot.....................................3
Total......................................................................2,
032
Upper and lower extremities:
Arm above elbow and
one thigh......................................3
Arm above elbow and
leg below
knee.............................1
Arm above elbow and
one
foot........................................1
Arm above elbow and
part of one
foot.............................1
Arm below elbow and
one
thigh.......................................2
Arm below elbow and
leg below
knee..............................4
One hip and part of
hand.................................................1
Leg at thigh and part
of
hand..........................................8
Leg at knee and part
of
hand..........................................1
Leg below knee and
part of
hand....................................3
Total...............................................................................25
Grand
total.....................................................................4,403
CONDITION OF STUMPS ON ARRIVAL IN THE UNITED STATES
In
1918, when the number of amputations was yet small, the majority of
stumps were
healed when they were received in base hospitals in this country,
FIG.
153.- This and
Figures 154 to 157
show the average sagittal stumps from four to eight months after trauma
FIG.
154
and many of them were fitted
with temporary appliances. Later, when thenumber of wounded rapidly
increased, most of them were only partially healed.Contractures of
adjacent joints were only occasionally seen, the
most common
720
being short thigh stumps showing a varying degree of flexion and
abduction deformity; flexion
contracture of leg stumps less frequently; Chopart stumps in equinus;
forearm stumps with
limited supination and arm stumps with limited abduction. The vast
majority of the amputations
were of the sagittal
FIG.
155
FIG. 156
(guillotine) type, or the modified sagittal with irregular skin
flaps. These stumps usually showed
a terminal circular or an irregularly shaped granulating area with
partial marginal epithelization,
often unhealthy in appearance, and
FIG.
157
FIG. 158.- Same as in Figure 157
after reamputation and healing
almost invariably giving positive cultures of staphylococcus and
streptococcus, and occasionally
diphtheria. A limited number showed visible sequestration of bone.
Edema of the soft parts
adjacent to the wound was the rule and its extent was dependent upon
the degree and nature of
the infection and upon the
721
site of the amputation, being more marked and more persistent in
amputations below the middle
third of the leg, and in the lower third of the forearm. It was evident
in most cases in which
primary aseptic amputations had been performed that the published
official instructions regarding
sites for amputation l3 had been adhered to. In spite of
the
fact that infection was the rule in stumps requiring secondary
surgery, conditions were favorable when contrasted with those
existent at the time of the primary amputation overseas. In the latter
case the primary
consideration was the eradication of a potential life-destroying
pathological process with the
minimum sacrifice of limb length, whereas under the comparatively
favorable conditions existing
at the time of the secondary stump surgery it was possible to give full
consideration to the
prosthetic and functional requirements of the stump.
FIG.
159.- Stump showing
terminal
edema and other evidences of latent infection
STUMP PATHOLOGY
REFERABLE TO BONE
In
nearly every case it was evident that the bone as well as the soft
parts had been
exposed to infection with a resulting localized osteomyelitis of
varying degree. The process of
sequestration and involucratization, with associated low-grade
infection of the adjacent soft
parts, did not differ materially from osteomyelitis under other
conditions; it was usually limited
to the terminal portion of the bone on account of the fact that
drainage was thorough. This
terminal osteomyelitis was one of the chief causes of long delay in
healing and required
roentgenographic study and special treatment before secondary final
plastic operations could be
successfully done.
The
most common type of sequestrum seen was ring-shaped, usually about1½
cm. in
thickness. It was usually loose and partially visible or palpable; less
frequently it was more or
less concealed by excessive bone production extending down from the
bone cortex. In some
instances it was seen to be practically encapsulated by new bone
formation with a small sinus
leading through the latter.
Excessive
terminal bone production in guillotined stumps was the rule. The most
common form was an irregular mushrooming, with a tendency to spurs on
the inner aspect of the
femur. Occasionally sharp exostoses were seen. These often were sharp
enough and long enough
to cause sufficient pain to warrant their removal.
722
Interosseous
bony union was seen in both the forearm and leg. In the former,
operative
interference was instituted only when the forearm stump was long enough
to preserve the
movements of pronation and supination. Treatment consisted in removing
the connecting bony
overgrowth and the interposition
FIG.
160.- Typical ring
sequestrum
of muscle. Obviously in the leg this condition is helpful
rather than detrimental, unless
associated with terminal sharp exostoses.
Displacement
of the patella in the Stokes-Gritti amputation and of the portion of
the os
calcis in the Pirogoff operation were seen. Nearly all amputations
723
of the types were unsatisfactory and required additional
surgical treatment.
Comminuted
fracture complicated by extensive osteomyelitis of the shaft was met
with
occasionally. Preliminary treatment of the osteomyelitis was of course
instituted before stump
surgery was attempted.
FIG.
161.- Complete
ring sequestrurn
surrounded by new bone formation. The stump is healed except for small
sinus
from the sequestrum
Inequality
in the lengths of the bones in amputations of the forearm and of the
leg
occasionally demanded correction. In leg amputations the prosthetic
requirement that the fibula
be approximately 2 cm. shorter than the tibia, as a rule, had been met
in primary amputation. In
certain short leg stumps it had evidently been possible at the primary
amputation to save several
inches of fibula but a much smaller amount, of tibia. Such cases
naturally form an exception to
the general rule.
724
REFERABLE TO SOFT PARTS
Stumps
with redundant soft parts were seldom found. When this condition did
occur it
was usually associated with late necrosis of bone or with
FIG.
162.- Excessive
terminal bone
production, "mushrooming." Note that muscles are above this
area
extensive comminution of bone without equal damage to the soft
parts, in which case it was, of
course, wise to save all viable soft parts available, as thereby
greatly facilitating the late plastic
surgery. The secondary removal
725
of soft parts for surgical or prosthetic reasons was not done until
the necessity for and the
possibility of utilizing them in connection with osteoplastic methods
to increase the length of the
stump had been considered.
FIG.
163.- Bony spur
in
below-knee
amputation
Tender
nerve ends occurred most frequently in amputations of the upper
extremity. They
seldom make themselves manifest until ain appliance has beef worn, so
that in the treatment of
unhealed stumps it was considered safest. to assume that every nerve
which was palpable might
give trouble, and
726
its treatment was indicated at the time of the secondary plastic
procedure. Simple high division
after crushing and ligature seemed to give results equally as good as
those obtained after more
elaborate neuroplastic methods.
FIG.
164.- Interosseous
bony union in
below-knee stump. Spurs
PREOPERATIVE AND NONOPERATIVE TREATMENT
In
a preliminary report of experiences in treating the first 500 cases,
published in 1919,14 a very conservative policy in the surgery of unhealed stumps was
advocated. It seemed then that
by the use of skin traction and other
727
nonoperative measures, healing could be obtained in a reasonable
time and that secondary
operative surgery of the stump could be dispensed with in the majority
of cases. Subsequent
experience showed that it was impossible to obtain complete healing in
guillotined stumps, but
that a very long time was required and that the resulting scar was not
sufficiently tolerant of the
usual traumas of an appliance to be practical. It was also found that
many stumps either actually
required reamputation at a higher level or that a limited amount of
bone could be removed
without damaging the stump from a functional viewpoint; so that finally
plastic methods
designed to obtain a firm closure, with freely movable skin, were
employed usually before
cicatrization was complete.
The
importance of surgical rest and in most cases actual recumbency in the
treatment of
large infected wounds of the extremities was frequently observed and
can not be too strongly
emphasized. Nothing was gained by hastening prosthetic treatment to the
point of applying
temporary prosthesis before the stump was considered surgically sound.
In the majority of cases
it was found best to treat all cases judged to require secondary
surgical procedures in recumbency
until wounds were in the required condition for operation. It was noted
repeatedly that wounds
which had remained practically stationary under ambulatory treatment
would promptly improve
in recumbency.
Skin
traction was used as a matter of routine both in recumbent and
ambulatory treatment.
In the former, direct extension was employed by means of adhesive
strapping with pulley and
weights and in the latter counter-extension with a modified Thomas
splint. It is interesting to note
that the former method is accurately described in "The Medical and
Surgical History of the
Rebellion." 15
Traction was,
of course, most effective when applied immediately after the
amputation. Its effect then was to actually reduce the extent of
uncovered area. If it had not been
applied early and the skin had been allowed to retract and to become
adherent to the edges of the
ulcer, traction did not tend to reduce the unhealed area materially,
but it relieved tension at the
edges, thus favoring healing, and was particularly helpful in
subsequent plastic operations by
rendering the skin more redundant. In a few cases in which there was
wide retraction of the skin
in short stumps, it seemed best to dissect the skin free and then apply
traction for a time before
attempting final plastic closure. The favorable influence of stump
traction in the prevention of
joint contractures was repeatedly observed.
WOUND ANTISEPSIS
The
Carrel-Dakin routine treatment was used in all infected stumps as long
as the
unhealed area was large, concave, and discharging pus freely.
Dichloramine-T was substituted
when the wound became smaller in area, the granulations healthy and
reasonably clean.
Massage
of the terminal part of the stump was found to be beneficial in several
ways. In
healed stumps with small scar areas adherent to bone, massage was
effective in loosening the
scar and improving its circulation and thus increasing its tolerance to
trauma. In unhealed stumps
massage of the skin
728
adjacent to the scar area assisted in removing edema and generally
improving the circulation, as
well as rendering the skin free and more redundant preparatory to the
final plastic procedures.
ATTENTION TO ADJACENT JOINTS
The
following prophylactic measures against joint contractures were used:
In so far as it
was possible, the recumbent position of the patient and the adjustment
of traction was such that
the usual contractures would tend to be prevented. At each dressing the
stump was moved to the
full limit in the opposite direction to that in which a contracture was
most likely to develop.
WHEN SECONDARY STUMP SURGERY SHOULD BE DONE
Attempts
to perform early secondary closure of infected guillotine stumps
resulted in a
high percentage of failures. It seemed that the most important factors
causing the failures were
(1) the poor general condition of the patients following the more or
less recent severe trauma on
the battlefield in conjunction with the subsequent operative and
postoperative treatment, and (2)
absorption of toxins from latent infection of the stump, which is not
only present in the terminal
granulating area, and in many cases in the terminal portion of the
bone, but, as has been
conclusively shown by Huggins16 and others, also exists in
the lymphatic channels for a
considerable distance proximal to the unhealed area.
It
was found that it was not justifiable to attempt plastic closures or
reamputations
adjacent to the unhealed area until at least five or six months had
elapsed from the time of the
original injury. An attempt was made to establish definite preoperative
indications by bacterial
counts from the wound surface, but it became apparent that this method
of control was not
reliable, as it gave no exact indication of the extent of latent
infection in the lymphatic channels
further up the limb. It was found better to depend upon observations
referable to the clinical
appearance of the stump and the general condition of the patient.
As
long as the stump remained swollen, boggy, and edematous it was found
that there
was latent infection present which defeated attempts at plastic
closure. The disappearance of the
edema was usually coincident with the gradual improvement in the
general condition of the
patient and in the local appearance of the unhealed area. Final closure
was deferred until (1) the
skin and subcutaneous tissue was soft, dry, and wrinkled, freely
movable and absolutely free
from edema, (2) all sinuses leading to bone or other foreign bodies had
been radically treated and
cured, (3) cultures from the unhealed area were free from streptococcus
and the field count was
reasonably low (less than five to the field) for other less virulent
pyogenic organisms.
OPERATIVE TREATMENT OF UNHEALED
CASES
From
the standpoint of treatment stumps could be conveniently and
advantageously
divided into three distinct groups, as follows: Group I.-Stumps in
which a limited amount of
bone may be removed without diminishing
729
the ultimate functional value of the stump. Group II.-Stumps
which are already too short and
which will, consequently, not permit of additional sacrifice of bone.
Group III.-Those in which
sagittal amputation has been done at a site considerably distal to the
ultimate secondary site to be
selected.
GROUP I
The
question of bone length required careful consideration in every case.
and there were
times when it was justifiable to sacrifice ideal conditions regarding
the soft parts in order to
preserve it. On the other hand, in perhaps the majority of the sagittal
amputations, little was lost
in ultimate function by removing a limited amount of bone and much
probably was gained by the
additional freedom allowed to eradicate more thoroughly tissues subject
to
FIG.
165.- Long thigh
stump requiring
secondary plastic operation. Example of Group I
possible pathological changes in the terminal portion of the
infected stump. The following are
examples in this group: Sagittal amputations 9 inches or more below the
knee-joint; infected
sagittal knee-joint amputation. Before attempting final plastic closure
of stumps in this group it
was necessary that all indications previously pointed out regarding the
proper time to operate be
present, except that the actual size of the unhealed area could be
safely disregarded.
The
following method seemed to give the best results and was quite
generally used: The
unhealed area and the scar are completely covered with a gauze sponge
which has been saturated
with tincture of iodine. The incision is now made in healthy skin
one-half cm. from the edge of
the sear. It should follow the general contour of the scar area. No
attempt should be made to form
specially designed skin flaps. The distal skin is clipped to the iodined
730
gauze as the incision is being made, thus completely isolating the
terminal infected area. The skin
and scar are then dissected distally, separating them from the muscle,
to the place where the latter
are attached to the bone. It will usually be found that this is above
the area of new bone
production and well away from the unhealed area, usually 1 to 1½
inches. The periosteum is
incised just within the area of fibrous tissue which extends somewhat
distal to the muscle fibers.
The bone is sawed at this point. If the preoperative treatment has been
properly carried out and
the scar area is not excessive, it will now be possible by careful
disposition of the skin to cover
the end completely. If it is found that the available skin is not
sufficient, additional bone or
muscle may be removed. It is better to avoid cutting through the
muscles and deep vessels. The
nerves are found usually by palpation and should be pulled down and
severed through a small
longitudinal incision in the muscles. The wound should be drained for
48 hours through a
posterior stab wound This type of drainage was found to be preferable
because it gave the best
drainage, being dependent, and, in the event infection occurred,
sufficient drainage was afforded
to prevent the incision line from separating. Primary union in the
incision line was often obtained
and maintained in the presence of purulent discharge which was
satisfactorily taken care of
through the posterior drainage incision.
GROUP II
In
this group it was found to be imperative that at least six to eight
months should have
elapsed since the initial injury and that in addition to the
preoperative requirements already
enumerated, it was preferable that the wound be completely cicatrized
or that the unhealed area
be very small and practically sterile.
The
aim of operative procedures in this group was to remove intolerant scar
and to
replace it by freely movable healthy skin. The following methods were
used and found
successful.
In
short below-the-knee stumps the presence of the fibula is usually not
desirable;
moreover, by its removal, sufficient skin can be mobilized to cover
successfully a fair-sized scar
area. In addition, muscular tissue of the calf may be removed quite
extensively without injuring
the stump in any way. In conjunction with these measures it was usually
necessary to employ
one of the following methods of skin mobilization: (1) Single or double
pedicle swing, in which
case flaps of skin and subcutaneous tissue of various shapes were swung
from the lateral surface
to the terminal surface of the stump, closure of the donor area being
accomplished by
diminishing the circumference of the stump. (2) Double pedicle
transplant. A rectangular flap taken from the posterior was dissected
free and moved to a terminal position with double
pedicles, internal and external. This method was very successful in
short leg stumps with a
broad, smooth, bony surface. Total end bearing was usually made
possible. (3) Distal pedicle
transplant. This is a well- known method and requires no further
mention here.
In
short thigh stumps closure was usually made possible by using the
single pedicle swing
flap. Occasionally it was necessary to remove a limited amount
731
of muscles. It was found best to remove a triangular section with
the base external. Muscles on
the inner surface could be removed with the least damage.
Thiersch
and Reverdin grafts were occasionally tried. Healing was of course
hastened, but
closure was not firm enough for practical purposes.
GROUP III
Amputation
through the ankle joint may be cited as an example of this group. In
this case
the Syme amputation could not be considered, as sufficient soft parts
are not available, so that the
middle and lower third of the leg is the site to be selected. Another
example is sagittal
amputation one-half inch below the knee joint, requiring a formal
amputation. In this group it
was possible largely to disregard pathology referable to the terminal
part of the stump and to
proceed with the final amputation much earlier than in the other
groups. In all cases, however, it
was found advisable to adhere strictly to the rules regarding delay
until the general condition was
sufficiently improved to withstand a major surgical procedure, and to
those regarding edema of
the soft parts and associated lymphangitis and lymphadenitis. The
treatment in this group was
formal reamputation.
A
reamputation is equivalent practically to a primary amputation under
ideal conditions
and necessarily involves careful consideration regarding the site of
amputation and its influence
upon the ultimate functional result. The value of a stump in terms of
function can be correctly
estimated only when the stump and its prosthesis are considered as a
composite functioning unit. It
follows then that in order to choose the proper site one must consider
carefully the
comparative value of prosthetized stumps.
SITE OF AMPUTATION OR REAMPUTATION
WITH REFERENCE TO PROSTHETIC REQUIREMENTS
LOWER EXTREMITY
FOOT
Phalangeo-metatarsal
amputations and transmetatarsal amputations.- These were
infrequent, but it was noted that amputations anywhere in the
metatarsal area gave good function.
All the bone length possible should be saved. It is a mistake, however,
to attempt to preserve
bone length in the foot at the expense of perfect skin covering. A sear
on the foot healed by
granulation, directly overlying bone, inevitably will ulcerate and
cause intermittent disability
which eventually will lead to a reamputation. Every effort should be
made to obtain a dorsal
linear scar, the ends of the bones being well covered with a plantar
flap. The use of the distal
pedicle transplant will sometimes obviate the necessity for
reamputation in these stumps.
Lisfranc's
amputation.- Amputation at the transmetatarsal joint gives
reasonably good
function. Dorsal flexion of the foot is better preserved by anchoring
the dorsal flexors to the ends
of the bones. The same general surgical considerations apply here as
described for metatarsal
amputations. The
732
only appliance necessary for this, as well as the former, is a
filler for the toe of the boot and a
steel inset in the sole to prevent turning up of the toe.
Transtarsal
amputations.-Transtarsal amputations distal to Chopart's joint
seemed
preferable to Chopart's amputation, as proper balance of the dorsal and
plantar flexors of the foot
is better preserved. However, the same prosthetic objections apply to
this amputation as to the
Chopart.
Chopart's'
amputation.-Mediotarsal (Chopart's) amputation usually resulted in
bad
function for surgical as well as prosthetic reasons. The majority seen
were sagittal amputations at
this site, in no sense classical Chopart's amputations, but rather
guillotine amputations at or near
the mediotarsal joint. It was assumed that it was not the intention of
the surgeons who performed the primary amputations that these should
function as Chopart
stumps. Most of them
required reamputation. Attempts to improve them by plastic methods were
usually not
successful. The conclusion drawn from experiences in treating a limited
number of classical
Chopart stumps are as follows: (1) Surgical difficulties--(a) The type
of injury requiring a Chopart
stump seldom
FIG.
166.- A typical
sagittal Chopart
stump
leaves sufficient plantar flap to permit the scar being well placed
on the dorsal surface. (b)
Equinus deformity of the stump eventually develops in spite of efforts
to preserve foot balance by
tenoplastic procedures. As equinus develops the scar which is usually
terminal and poorly
vascularized is pressed upon, and end bearing, the greatest asset of
this stump, must be forfeited. (2) Prosthetic difficulties-The stump is
too short to properly anchor the necessary"fill" in the fore
foot, so that constant friction between the toe "fill" and the end of
the stump takes place, usually
resulting in ulceration and consequent disability. Lack of stability in
the toe part of the appliance
prevents the necessary forward thrust in walking so that slight limp is
invariably present. In many
Chopart stumps it is necessary to anchor the fore foot by extending a
steel rod to the ankle joint
and connecting this by a joint to a steel upright which is laced to the
leg. This appliance requires
a special shoe with a very unsightly ankle.
The
percentage of surgical successes in Chopart is so low and the
prosthetic difficulties
so considerable that it is not a justifiable amputation unless it is
intended that a simple elephant
boot be worn continually instead of the
733
articulated appliance. This point is mentioned because there are
undoubtedly cases in which
occupational considerations should predominate over the esthetic.
Pirogoff's
osteoplastic amputation.- Two cases are recorded which required
reamputation
on account of displacement of the remaining portion of the calcaneum.
The added risk of an
osteoplastic procedure is not compensated for in any way, as the
percentage of total end-bearing
stumps following the Syme amputation is quite as high as in the
Pirogoff. The added length in
the Pirogoff requires that the other shoe be raised at least an inch to
make up for the space
required for the ankle movement.
Syme
amputation.-The chief advantages noted in the perfect Syme
amputation were that it
is total end bearing and that the length of the limb is approximately
preserved, so that the patient
can move around in the nude without his appliance, and that either the
straight boot or the
appliance with an articulated foot can be worn with reasonably good
function.
Unfortunately,
the percentage of perfect Syme stumps was not high. Failure was usually
attributed to one or more of the following causes: Sloughing of the
planter flap due to cutting the
pedicle too narrow: lateral displacment of the flap; sawing the bones
at right angle to the terminal
axis of the tibia rather than to the long axis of the leg; making the
bone section too near the joint
to allow space for the mechanism of the artificial ankle.
Functionally,
a perfect, total end-bearing Syme stump is a satisfactory stump. The
choice
between this amputation and one at the ideal site in the leg is one
which involves an analysis of
the occupation and habits of the patient. A laborer is better satisfied
with the Syme amputation
because he can wear astraight, nonarticulated boot during the working
hours, and he is less likely
to be dissatisfied with the bulky, unsightly ankle mechanism when
"dressed up"than a
professional man, for example, would be.
THE LEG
Amputations
in the lower third.- The rare opportunity of observing a
considerable number
of amputations in the lower third of the leg was offered. All required
reamputation mainly on
account of poor vascularity and associated complications. Nothing is
gained by the additional
bone length in these stumps, as excessively long leg stumps interfere
with proper shaping of the
ankle portion of the artificial limb and may actually interfere with
the ankle mechanism.
Amputation
at the ideal site.- Amputation through the middle of the leg, or a
little below,
as recommended in an official publication,13 proved to be
the preferable site. The essential points
in the technique adopted were: (1) Long anterior and short posterior
flaps, the scar line being
posteroterminal; (2) circular division of muscles without suture or the
use of a thin flap of muscle
and facia sutured over the bone ends to prevent adherence of the skin
to bone; (3) division of the
fibula one-half inch higher than the tibia; (4) beveling of the tibial
crest; (5) drainage when
necessary through a small stab wound in the middle of the posterior
flap.
The
appliance for this amputation is simple, durable, and shapely. If the
fitting is proper,
disability is scarcely discernible. Stump tolerance to the appliance
734
is quickly acquired and the functional result is very
gratifying to all concerned.
In
amputations of the leg above this level every effort was made to
preserve all bone
length possible. When the amount of bone length that can be preserved
with good soft part
coverings is 3 inches or less, it is justifiable to sacrifice ideal
conditions as regards the soft parts,
if bone length may thereby be increased It was generally considered
early in the war that it was
not justifiable to attempt to amputate below the knee if the amount of
bone length possible to be
saved was less than 3 inches. Subsequent surgical and prosthetic
developments warrant a revision
of this opinion. In these cases the leverage may be increased. to the
point of utility by removing
the fibula, cutting away practically all of the muscular tissue on the
back of the stump and
severing the inner hamstring. Special study and experimentation in the
prosthetic treatment of
short stumps carried out at various clinics gave promise of increasing
the functional utility of
stumps not less than 2 inches in length, so that it seems best to defer
reamputation until surgical
attempts to increase bone length or to increase leverage by other
methods have failed.
FIG. 167.- Transcondylar
reamputation. Total
end bearer
THE THIGH
If
it was not possible to amputate below a point 2 inches from the
kneejoint (bone length),
the next best site proved to be the high transcondylar amputation. This
excludes knee-joint
amputations, all osteoplastic amputations at or immediately above the
knee joint, and low
transcondylar amputations. All of these are too long to allow the use
of the standard artificial
knee action and require a cumbersome and faulty mechanism outside the
clublike stump.
Osteoplastie amputation (Stokes-Gritti) offers nothing in function
above the high transcondylar
to compensate for a rather high percentage of
735
surgical failures (in three seen by the writer at Walter Reed
General Hospital all required
reailputatioii) and the prosthetic difficulties already mentioned. In
the high transcondylar
amputation the bone section is made at the point where the condyles
begin to merge with the
shaft. It is important to keep within the spongy bone just below the
beginning of the medullary
cavity proper. A long anterior flap of skin and quadriceps tendon is
used. The scar is placed well
posteriorly, away from the end-bearing surface. Surgical failures are
few. Practically all of them
ipermit total end bearing. Ample space is left to place the standard
artificial knee action in the
proper place.
Above
the site for the high transcondylar amputation every effort was made to
save all
bone length possible to a point 2 inches below the lesser trochanter.
All stumps having bone
length of from 2 to 4 inches below the lesser trochanter require a
pelvic band. This is an
objectionable feature. so that a special effort was always made to
preserve more than 4 inches, if
possible. A stump having bone length of less than 2 inches below the
lesser trochanter does not
have sufficient leverage to operate the thigh appliance. The only
choice, then, is to give a stump
suitable for the so-called hip-joint appliance.
From
a prosthetic and functional viewpoint the classical disarticulation at
the hip is not
preferable to amputation through the neck, which is much more quickly
and easily performed. In
the latter the mortality is lower, and the resulting stump is better
adapted for the fitting of and
appliance. It was not, however, considered justifiable to reamputate a
stump too short to operate
the usual thigh appliance for prosthetic reasons solely.
UPPER EXTREMITY
The
role of the appliance in the functional utility of stumps of the upper
extremity is
considerably less important than is time case in stumps of the lower
extremity. In fact, it is
debatable whether or not appliances in the case of single amputations
of the upper extremity are
of sufficient value to constitute a deciding factor in the selection of
site. The young soldier who
has lost an arm is eager for his appliance, because he is desirous of
masking his disability and
because lie hopes that it will be functionally useful. To his great
disappointment, lie soon realizes
that it is indeed a poor substitute for either purpose. It has been
found that approximately 60 percent of individuals who have suffered
the loss of a single arm do not
find existing prostheses
sufficiently useful to compensate for the inconvenience of wearing
them, except occasionally for
esthetic reasons. The following conclusions regarding sites are based
upon the use and
requirements of American prostheses existing at the time our amputation
cases were being
treated and do not involve a consideration of surgical and prosthetic
experimental work being
carried out in various foreign clinics during and after the World War,
as opportunity for
exhaustive study and practical applications of these appliances and
methods was not possible in
the short time offered.
THE HAND
In
primary surgery immediately following the trauma nothing more should be
lone than
débridement, trimming the devitalized tissues, and establishing
736
thorough drainage, the question of site being totally disregarded.
The prevention of contractures
of the fingers following infection and of the formation of scar tissue
demands special attention
from the beginning. In the secondary surgery of the hand radical
alteration in the site of
amputation is seldom advisable. The usual conditions demanding
treatment are, sluggish,
unhealed areas associated with localized osteomyelitis, or tender and
adherent scars with
deforming tendency. The latter condition usually demands special
plastic procedures, the aim of
which is to displace the scar by freely movable tolerant skin. The
distal pedicle transplant gave
the best results where it was important that no bone should be
sacrificed. Usually a portion of a
phalanx of any of the fingers except the index and thumb can be
sacrificed without serious functional damage in order to obtain good
soft part covering. The loss of the thumb or any part
of it constitutes a serious disability. A badly damaged thumb, with
loss of muscular power or
ankylosis, or both, is preferable to no thumb at all. Heroic efforts at
reconstruction of the thumb
are justifiable. One case in which a thumb stump was lengthened
one-half inch, with gratifying functional improvement, has been
reported. 17
Prostheses
for amputations of individual or multiple digits are very useful but
are usually
inferior to even a severely mutilated stump. They are most useful if
the thumb is amputated or if
all except the thumb are gone, as apposition is made possible by their
use. If sufficient of any of
the fingers remain to make active apposition possible, prostheses are
seldom worn except for
esthetic reasons.
Transcarpal
amputation is preferable to amputation at the wrist even though there
may be
an adherent terminal scar. The latter can be repaired by distal,
pedicle skin transplant.
Wrist-joint
amputation is distinctly preferable to any higher up, as pronation and
supination are better
preserved, and the fitting of an esthetic hand or a work appliance is
facilitated by the more or less
club-like end of the stump, which permits the elimination of much
attachment apparatus.
THE FOREARM
Amputation
in the forearm should be done as low down as possible. In the lower
third
circulation is often poor, but usually not troublesome enough to
warrant amputation higher up
solely on this account. Primary amputation should seldom be done higher
up for this reason, and
reamputation should not be considered unless all efforts to improve the
circulation have failed.
The importance of preserving pronation and supination warrants special
attention to surgical
details; i. e., careful treatment of the periosteum to avoid shredding
and consequent
overproduction of bone and the interposition of muscle to prevent bony
bridging.
No
matter how short a forearm stump may be, it should not be sacrificed,
as in the
majority of cases a forearm stump, no matter how short, is more useful
without prosthesis than an
upper-arm stump either with or without an appliance. They should never
be shortened to correct
inequality in the length of the bones. Tender scars or scars
objectionable for any reason should
not be corrected by the
737
sacrifice of bone, but by plastic methods involving the soft parts
only. The presence of redundant
soft parts in this region constitutes an indication for plastic methods
to increase length rather than
for their removal.
THE UPPER ARM
Transarticular
and transcondylar amputations are generally considered objectionable
from
the standpoint of existing prosthesis, because the fitting is difficult
and there is inconvenience to
the patient in applying and removing the apparatus. Moreover, the
artificial joint must be placed
lower than normal. On the other hand, experience shows that in single
amputations less than 20
percent of persons with amputation of the upper arm wear appliances.
Of these it is reasonably
safe to assume that the majority are wearing a practical (work)
appliance rather than the dress-up
type. The newer types of the former, are more securely fitted with less
"harness " if the bony
prominences of the condyles are present, so that before deciding upon
the sacrifice of the
condyles a careful analysis of the requirements in the individual case
is necessary. The transcondylar is preferable to the transarticular
amputation n any case. Above this all bone length
possible should be saved.
It
was found that short arm stumps could be improved as regards leverage
by severing or
raising the insertions of the pectoralis muscles, the latissimus dorsi
and the teres major. The
humeral head should always be saved if possible, as the shoulder
contour is preserved thereby. In double amputation of the upper
extremities the necessity for prosthesis is unquestionable, so
that the rules regarding site for amputation as influenced by
prosthesis and previously outlined
18 apply more forcibly here. The most successful cases of double
amputation seen, however,
were those using special, usually self-designed, appliances
particularly adapted to their
individual requirements. In the latter case the more conservative
surgical methods would be
most applicable.
CINEMATIZATION OF AMPUTATION STUMPS
Cinematization
of stumps is accomplished by connecting at the end of the stump the
antagonistic muscles, or by giving them artificial insertion into the
prosthetic apparatus.
In
July, 1918, the report of a special committee directed to investigate
the question of
cinematization was available for the information of those engaged in
amputation work.19 Briefly
the conclusions of this committee were that enematization was still in
the experimental stage and
that it could not be recommended except as an experimental procedure
and that it should not be
attempted unless adequate facilities were available for pursuing the
experimental prosthetic work
necessarily associated with it. No doubt the few who were interested
felt that they were not
adequately fortified with the requisite knowledge and experimental
facilities to undertake this
work on a really progressive scale. Three cases were done in the base
hospitals in the United
States and two cinematized stumps were returned from overseas.20 In
only one of these cases
was the final functional result a distinct improvement over that
obtained with the usual methods.
Two were failures and required excision of the tunnels. Lack of
738
success was due to failure of coordination in the surgical,
physiotherapeutic, and prosthetic
treatment, which resulted from the frequent transfer of patients and
perhaps in a measure to the
breaks in follow-up coincident with frequent changes in personnel after
the beginning of the
armistice.
POSTOPERATIVE TREATMENT
In
all stumps in which there was even moderate tension, traction straps
were applied in
the operating room. It was found best not to apply weights in undrained
cases until the following
day, unless tension was marked. In the average case of this type,
traction, if applied at once,
seemed to favor oozing and the accumulation of clot. In addition to the
advantages of traction
previouslv mentioned, there seems to be no doubt that it adds to the
comfort of the patient by
preventing muscular spasm and that it is instrumental in preventing
postoperative hemorrhage in
the same way.
Blood
drainage was removed in 48 hours. In case secondary hemorrhage
occurred, with
ballooning of the flaps, it was found best to remove the sutures, clean
out the clot, and reapply
traction. Secondary infection was the rule in all cases in which
special attention had not been
given to the elimination of dead spaces and in those in which secondary
hemorrhage occurred.
After
the wound was healed, massage of the muscles was begun. Adjacent joints
were
moved passively once daily through the full range of motion. After
healing was firm, if the
patient was able to be out of bed, he was sent to the shop for his
provisional fitting. Daily baking
and massage was continued after fitting, in order to remove edema and
to generally improve the
circulation. The stump was bandaged at all times when the appliance was
not being used.
USE OF PROVISIONAL APPLIANCES IN
AMPUTATIONS
LOWER EXTREMITY
In
all stumps of the lower extremity, with the exception of partial
amputation of the foot
and the Syme amputation, a portion of the stump is called upon to
function in a manner entirely
new and for which it is poorly adapted, i. e.. weight, hearing. Radical
physiological changes
necessarily take place in the weight-bearing portion of the stump,
pressure atrophy of the soft
parts; increased tolerance of the skin to lateral pressure from the
encasing socket of the
appliance; development of balance and sense of position; tolerance to
pressure on and adjacent to
bony prominences. The other important task of the stump leg is
propulsion of the limb and its
appliance. In spite of the fact that the artificial limb is not as
heavy as the amputated part, more
power is required in swinging it on account of its comparative
inertness. Increased difficulty in
balancing undoubtedly adds to the demands made upon the muscular power
of the proximal part
of the stump leg. The preservation of normal muscular power, or better
the development of
increased muscular power in the proximal part of the stump leg, is of
vital importance. Since
certain definite physiological changes must take place both in the
stump and the proximal part of
the leg before a stump can be considered functionally fit fora
permanent appliance, it is clearly
the duty of the surgeon to use all methods
739
at his disposal to hasten these changes and to obtain a good
functional as well as a good surgical
stump before a permanent appliance is used.
PRINCIPLES OF FITTING
Weight
bearing in the case of below-knee amputation is distributed as follows:
Cone
bearing (lateral surface bearing); bony prominence bearing (head of
tibia, tuberosity of tibia,
fibula below head) partial thigh-surface bearing (thigh cuff); and, in
a certain percentage of cases,
end bearing. In a finished appliance the stump is incased in a solid
shell which is molded or
carved to fit the stump in such a way that all the bearing points and
surfaces are usedto a variable
degree. The physiological changes in the stump will depend largely upon
the predominating type
or types of bearing chosen in a particular ease.
Cone
and bony prominence bearing with slight partial thigh bearing are found
to be
applicable to most leg stumps except in the Syme amputation. Pressure
atrophy is rapid and
marked, consequently repeated remolding of the socket is imperative.
End bearing diminishes
pressure atrophy of the stump. In amputation of the thigh, bony
prominence bearing (ischial
tuberosity) cone hearing, and, in certain cases, end bearing, are
utilized. Bony prominence
bearing predominates so that pressure atrophy of the stump is slower
and less marked than in leg
stumps. End bearing has the same relative advantages, but to a lesser
degree.
Undoubtedly
end bearing is possible in a high percentage of stumps; success in
obtaining
it is largely dependent upon faithfulness and persistence in carrying
out the necessary preliminary
measures to increase the tolerance of the end of the stump. Experience
has proven that a definite
distinction must be made between total and partial end bearing, and
that in certain instances end
bearing may not be desirable, i. e., in long, below-the-knee stumps.
Cone and bony prominence
bearing have given nearly perfect function. If end bearing is attempted
in these stumps it is found
that there is a certain lack of adhesion between the appliance and the
stump and that the gait is
not as good as with cone bearing. In thigh stumps of moderate length
total end bearing is not
preferable to ischial and cone bearing for the same reasons. There is
little doubt that partial end
bearing is always an advantage.
The
following stumps, in addition to partial foot amputations, were found
to be especially
well adapted for end bearing: (1) The Syme stump; (2) short below-knee
stumps, and (3) that
resulting from a transcondylar amputation. The bone section in each of
these is through spongy
bone, which seems to give a more tolerant end bearing surface. Each is
clubbed more or less on
the end, which favors proximal methods of attachment of the appliance,
thus avoiding instability
of the appliance mentioned above.
An
ideal provisional appliance should possess, in the main, similar
mechanical features to
those found in permanent appliances. The socket should be of solid
material and should be
molded or carved in the same accurate manner, as in a permanent one.
Excavations and additions
which are customarily made to influence bearing on certain definite
points, which are known to
be adapted for this function, should be carefully made. A provisional
appliance which
740
merely shrinks the soft tissues of the stump and does not develop
the tolerance of the bearing
points and surfaces, which will be called upon to function in a proper
permanent appli- ance, is not an efficient provisional appliance. The
provisional socket must be ne which can be
remolded frequently and comparatively inexpensively. In addition to
changing sha ne in a certain
percentage of cases it is not only desirable, but necessary to change
the position of the socket so
that a complete change of socket rather than a reshaping is sometimes
necessary. This feature is
important in all cases in which there is more or less malposition of
the stump, which is gradually
being improved by the use of the appliance.
Various
types of temporary appliances were used in the different centers. In
most of them
the socket was made of plaster-of Paris and the framework of wood or
metal. In one center a
papier mâché socket was used and found to be very satisfactory.
The
soldier with a recent amputation usually s most concerned in removing
his physical
deficiency as soon as possible from an esthetic rather than from a
functional standpoint. Pegs
and the cruder types of temporary appliances were strenuously objected
to by a fair number of
patients. After the provisional type of appliance was available in
quantities, very few pegs were
used. There seemed to be no advantage in delaying the fitting of the
standard provisional
appliance, inasmuch as it was even more versatile
FIG.
168.- Temporary
appliance--plaster socket stock metal bars: wooden foot. This was
the best
type of temporary applicance
as regards refitting than pegs and the cruder temporary
applicances. An attempt was made to utilize a provisional leg
which in all respects looks like a
finished leg. Of necessity it was
adjustable as regards length, foot position, and socket. The
741
FIG.
169.- This and
Figure 170 show
original models of stock provisional appliances for thigh and leg
amputation. An adjustable leather cuff was used to effect refitting
742
socket adjustment was accomplished by supplying a rather large
number of stock sizes, and by
means of a leather cuff which could be adjusted to the shrinking stump
by lacing.
FIG.
170
In
addition to meeting the esthetic requirements more satisfactorily than
the temporary
appliance, it offered the advantage of quantity production and quicker
fitting. While this type of
appliance was not applicable to as high a percentage of cases as
anticipated, it was used in all
centers except one, until supplemented by a more versatile type.
743
In
thigh amputations this type of finished provisional leg was entirely
satisfactory and in
about 85 percent of cases where there was sufficient bone length to
operate the ordinary thigh
leg. Most of the remaining lo per center into the class of excessively
long stumps. It was not
possible to fit these on account of interference of the mechanism for
the adjustment of length.
The
greater part of the weight is taken on the tuberosity of the ischium and
FIG.
171.- Provisional
appliance used
at Letterman General Hospital
accurate cone bearing is relatively unimportant, consequently the
cone fitting does not need to be
very exact. In leg amputations the task of fitting this type of leg was
much more difficult. Bony
prominences are more numerous and less tolerant to weight bearing.
Consequently, the bony
prominence fitting must be more accurate and a greater amount of weight
bearing must be
allotted to the cone fitting. For this reason the latter must be
more precise.
744
In
order to meet the requirements of the more difficult cases which it was
not possible to
fit with the original model of the stock appliance, a more versatile
type was developed and the
stock parts (framework) manufactured
FIG.
172.- Letterman
General Hospital
artificial leg, assembled and unassembled
in quantity, in a variety of sizes; the only essential difference
from the original model being that,
instead of making the necessary refitting, by means of a leather-laced
cuff, a plaster-of-Paris
refitting was substituted in leg amputations.
The
plan generally adopted in all amputation centers was to fit the stump
with a
temporary appliance as soon as healing was complete, but not to hasten
the prosthetic treatment
at the expense of a good surgical result. The appliance was worn at
first to the limit of
tolerance,
FIG.
173.- The final
model of
provisional leg with a plaster of Paris
inset
745
special care being taken not to damage the soft parts. The part of
the appliance which incases the
terminal part of the stump, commonly called the socket, was changed and
refitted as pressure
atrophy progressed. Three changes were usually required. Deformities
and surgical defects of the
stump, i. e., bony spurs, latent infection and tender nerves, will be
readily discovered and should
be treated during this preliminary prosthetic treatment. Stumps were
not fitted with a permanent
appliance until they were surgically sound, pressure atrophy of the
weight-bearing portion well
advanced and the propulsive musculature of the proximal part of the leg
well developed. The
stock provisional appliances used were found to be sufficiently durable
to last from eight months
to one year. Six months preliminary prosthetic treatment was usually
found to be sufficient to
prepare stumps for permanent appliance.
Partial
amputations of the foot, Syme stumps, end-bearing knee-joint
amputations, and
disarticulations of the hip as a rule were not fitted with provisional
appliances. During the earlier
experimental period a few were fitted in the appliance shops largely
for experimental reasons. In
these stumps the fitting is difficult and there is so little change in
the stump as compared with
those in which cone and bony prominence bearing predominates that there
seems to be no reason
to delay the permanent fitting.
UPPER EXTREMITY
The
use of provisional appliances in amputations of the upper extremity
does not seem to
be so essentially necessary from the standpoint of fitting as in those
of the lower extremity. The
physiological changes in the stump from the use of the appliance are
not marked enough to
necessitate frequent refittings and it is not necessary to have so
exact a fitting as in lower
extremity stumps. The chief advantages in provisional fitting are that
(1) immediate fittings are
possible, which would not be the case in the time of war if permanent
appliances were supplied
by the artificial limb industry; (2) an opportunity is given to
coordinate the surgical, prosthetic,
and physiotherapeutic treatment and to carry out a reeducational
program which is often more
helpful than the appliance, per se; (3) surgical defects of stumps
become apparent while the
patient is still under Army control and can be corrected at once; (4)
the patient has an opportunity
to learn something about appliances which enable him to make a more
intelligent choice of a
permanent appliance.
The
first appliances used were of simple design and rather crudely made.
The socket was
of plaster of Paris. In the end of the socket was incorporated a metal
clamp to hold various
implements. Later an inexpensive arm with a universal end attachment
plate in which a hand,
tools, or any type of hook or other useful device could be used
interchangeably was adopted. The
metal parts were manufactured in quantity and issued to amputation
centers. Sockets were made
of leather, the work of fitting being done in appliance shops. No
originality can be claimed for
this appliance, as similar types were already being used abroad.
Workmanship and exactness of
fitting was probably
746
FIG.
174.- This and
Figures 175 and
176 show the type of provisional arm used, and various attachments for
work
and play
FIG. 175
747
not equal to that obtainable in the open market, but it is believed
that it served the purpose as a
provisional appliance as well its could hove been expected from any
single type of appliance
obtainable.
FIG.
176
REFERENCES
(1) The Relation between the
Amputation and the Fitting of the Artificial Limb. Military Surgeon,
Washington, D. C., February, 1918, xlii, 154. The Temporary Artificial
Limb. Ibid., April, 1918, xlii, 490.
The Care of the Amputation Stump. Review of War Surgery and Medicine,
Washington, D. C., 1919, ii, No. 2, 22.
(2) Information on Artificial Limbs
and the Care of the Stump. In The Relation between the Amputation and
the
Fitting of the Artificial Limb. The
Military Surgeon, Washington, D.
C., February, 1918, xlii, 154.
(3) Circular No. 90, Surgeon
General's Office, February 14, 1919.
(4) Letter from the Surgeon General
to Major Edgar King, M. C., August 22, 1917. Subject: Assignment as
Chief of
Division of Special Hospitals and Physical Reconstruction. On file,
Record Room, S. G. O., 115568 (Old Files).
Memorandum from S. G. O., May 6, 1918. On file, Record Room, S. G. O.,
0.024 (Division of Special Hospitals and
Physical Reconstruction).
(5) Annual Report of the Surgeon
General, t. S. Army, 1919, ii, 1106.
(6) Ibid., 1918, 399.
(7) Report from Division of Military
Orthopedic Surgery to the Surgeon General, July 15, 1918. On file,
Record
Room, S. G. O.
(8) Correspondence. On File, Record
Room, S. G. O., 442.3 (Artificial Limbs). Weekly Reports. On file,
Record
Room, S. G. O. (Weekly Report File).
(9) Letter from the Association of
Artificial Limb Manufacturers of America, to the Surgeon General,
October 19, 1917. Subject: Meeting in Washington. On file, Record Room,
S. G. O., 442.3
(Artificial Limbs).
(10) Annual
Report of the Surgeon General, U. S. Army, 1919, ii,
1105.
(11) Amputation
Reports. On File, Record Room, S. G. O., 702.2.
(12) Based on Sick and Wounded Reports made to the Surgeon General.
(13) Relation between the Amputation and the Fitting of the Artificial Limb. The Military Surgeon,
Washington, D. C., February, 1918, xlii, 154.
(14) The Care of the Amputation
Stump. Review of War Surgery and Medicine, Washing- ton, D. C.,
1919, ii,
No. 2, 22.
(15) The Medical and Surgical
History of the War of the Rebellion. Government Printing Office,
Washington,
Surgical Volume, Part III, 357.
(16) Huggins, G. M. The Surgery
of Amputation Stumps. Lancet, London, April 28, 1917, I, 646.
(17) Lyle, H. H. M. The
Formation of a New Thumb by Klapp's Method. Annals of Surgery, 1914,
lix, No. 5, 767.
(18) "Amputations and Artificial
Limbs" from Some Essentials in Military Surgery. Printed for the
Surgeon General, United States Army. Press of the American Medical Association,
Chicago, n. d., 39.
(19) A Report to the Chief
Surgeon, A. E. F., by Major Williams S. Baer, M. R. C., and Capt.
Philip D. Wilson, M.
R. C. Subject: Cinematic Amputation in Italian Hospitals. War Medicine
(Published by the American Red Cross),
Paris, 1918-1919, ii, No. 1, 218
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