- 385 BCE - Plato's Symposium, Hippocrates' De Articularis
- 1st century CE - Use of cautery for large vessels (Celsus), first mention of ligatures, removal of gangrenous extremity through viable tissue edge with bone cut shorter than the soft tissues
- 1528 - Advent of gunpowder and increase in extremity injuries
- 1529 - Ambroise Pare, ligature introduced, also thick ligature used as a tourniquet
- 1588 - William Cloves, first successful above-knee amputation
- 1679 - Younge and Lowdham, introduction of local flaps for wound closure (animal bladders used previously)
- 1781 - John Warren, first successful shoulder amputation
- 1806 - Walter Brashear, first successful hip joint amputation
- 1837 - Liston, routine use of flap closure
- 1825 - Nathan Smith, through-knee amputation described
- 1870 - Stokes, Grittis procedure modified (ie, Gritti-Stokes amputation)
- 1873 - Eschmarch -- rubber bandage used rendering amputation bloodless, reproducible, and safer; limitation of use described per procedure, as well as avoidance of use on infected limbs
- 1943 - Major General Norman T. Kirk, indicated guillotine amputations in war setting should be completed as distal as possible and completed later under calmer conditions
- 1960-1980 - Recommendation to salvage knee in vascular amputations
During amputation surgery, several actions can be taken to maximize the function of the residual limb. These include the following:
- Shortening and beveling the bone end to allow adequate soft tissue coverage
- Sharply transecting the nerve under tension to allow retraction and to decrease the likelihood of neuroma formation
- Securing the muscles with a myodesis or myoplasty to create a structurally stable and functional limb
- Positioning the wound edges to avoid bony prominences at the far distal end of the residual limb
- Keeping the bony lever arm as long as possible but covering it with adequate muscle and soft tissue to avoid fitting problems later (sometimes length will have to be given up to obtain the coverage)
- Gentle tapping and massage (with a washcloth) on the distal portion of the residual limb
- Scar mobilization and massage to prevent excessive scar formation from causing the soft tissues and skin to adhere to underlying bone
- Edema control, initially with ace wraps and, when the drainage subsides, with a residual limb (stump) shrinker
- The application of pressure to the distal aspect of the residual limb to prepare the limb for weight acceptance
- Aids in edema control and leads to rapid residual limb shrinkage
- Promotes healing by providing protection and preventing edema
- Desensitizes the limb
- Prevents residual limb trauma
- Reduces wound pain
Between 3500 and 1800 B.C.
- the first recorded allusion to a war injury that required a prosthesis can be found in the Rig-Veda. This is a sacred poem of India, written in Sanskrit which tells the tale of the warrior queen Vishpla, who—having lost her leg in battle—was fitted with a prosthetic leg made of iron so that she could return to the battlefield.
- The oldest known prosthesis, which was discovered in a tomb in Capua, Italy, was an artificial leg made out of copper and wood dating back to 300 BC. It was destroyed by bombing during World War II.
- In the 15th and 16th centuries many prostheses were made from iron. They were created for soldiers by the same craftsmen who made their suits of armor. Ambroise Pare, a French army surgeon, contributed both to the practice of surgical amputation and to the design of limb prostheses. (see picture of an iron hand designed by Pare, 16th century)
U.S. Civil War
- Created a great need for artificial limbs. The picture below is of Corporal David Cole and his leg prostheses, ca 1865. He has an amputation at the knee joint.
- The federal government committed to providing prosthetics to injured soldiers, representing the first ever large-scale program to provide prostheses.
- The Great Civil War Benefaction provided a model for government support that aided prosthetic technology development through two world wars and continues today in the Defense Advanced Research Projects Agency (DARPA) programs and in the military’s commitment of the latest in prosthetic devices and rehabilitation services to today’s service members.
**"The period from 1945-1965 is now viewed as a time of unparalleled scientific and technical advances in O&P. Key findings from this era still provide the conceptual basis for virtually all contemporary techniques. Although many factors have contributed to the long-term successes of this era, two key aspects were the coordination of research and evaluation efforts and the long-term commitment of significant governmental funding.
Although the field is currently in a relatively high state of clinical development, most advances in recent decades have been technical. Little or no advances in fundamental principles have occurred since the termination of significant governmental funding for O&P research and development in the 1960's"--from Prosthetics/Orthotics Research for the Twenty-first Century: Summary 1992 Conference Proceedings--John W. Michael, MEd, CPO, John H Bowker, MD." (personal correspondence with Al Pike, CP)
Currently--the Iraq War
- Attitudes are changing to keep service members in the service. They get sent to Walter Reed and Brooke to completely rehab so they can stay in the service. That is the goal, and they are getting really good rehab to accomplish it. The military is giving it all the latest technology. The VA is going to have to change when they start dealing with these service members when they are vets. They will be used to having the latest, most technological advanced prosthetics.
- **The VA has established four Polytrauma Centers for OEF/OIF and works closely with the DOD to provide the same new prosthetic technology to veterans of all conflicts. Current planing is to establish Amputee Care Centers following the new CARF Amputee Care Standards. (personal correspondence with Al Pike, CP)
- DARPA’s program, Revolutionizing Prosthetics, seeks to develop a “single prosthetic arm system that is suitable for trans-humeral and shoulder disarticulation amputees". This would revolutionize the entire field of prosthetics through the use of neurally controlled devices that will “restore full motor and sensory capability to upper extremity amputee patients. This revolutionary prosthesis will be controlled, feel, look and perform like the native limb,”
- It is estimated that there are between 15,000 and 20,000 new casualties caused by landmines and unexploded ordnance each year. That means there are some 1,500 new casualties each month, more than 40 new casualties a day, at least two new casualties per hour. Most of the casualties are civilians and most live in countries that are now at peace.
- In Cambodia, for example there are over 45,000 landmine survivors recorded between 1979 and 2005. These survivors often (almost always) have limb-loss. Most of these people are civilians. (Source: Landmine Monitor Report 2005)
I am amazed by this story. It shows just how far prosthetics have come. Maybe we are getting to the "Six Million Dollar Man".
There are three main military centers in the United States that deal with amputees, prosthetics and rehabilitation. *** They are :
- Walter Reed Army Medical Center in Washington, DC which has dealt with war-related
- Brooke Army Medical Center at Fort Sam Houston, TX. Walter Reed has dealt with war-related amputations and prosthetics for decades. The Department of Rehabilitation at Brooke opened early in 2005.
- San Diego's C-5 Rehab Center*** opened September 2006
SOME PROSTETIC COMPANIES
Liberating Technologies of Holliston, MA
- The company designs and manufactures prosthetic devices such as the Boston Digital™ Arm System and the VariGrip™ prosthetic controller for below-elbow amputees. These are new state-of-the-art microprocessor-based prosthetic controllers that can be customized to accommodate the individual user's needs rather than requiring the user to adapt to the controller.
- Also distributes products for three of the leading international suppliers of powered prostheses; RSLSteeper of England, VASI of Canada and Centri of Sweden.
- The company also supplies powered prosthetic accessories such as: batteries, chargers, hands, wrists, elbows and shoulder joints, electrodes and other input devices as well as silicone and PVC cosmetic gloves and custom high-definition cosmetic covers.
- Was originally established in 1974 by a group of faculty members and researchers at the University of Utah, led by Dr. Stephen Jacobsen.
- First made available in 1981, the Utah Artificial Arm is the premier myoelectric prosthesis for elbow, hand, and wrist. It represents the advanced combination of technology, superior performance, and cosmetic appearance, for above elbow and higher level amputees.
- In 1997, the second generation Utah Arm, called the Utah Arm 2, or "U2," replaced the original version, with major improvements in the electronics, motor and transmission. The U2 brought a new level of rugged dependability and user friendliness to the Utah Arm.
- In 2004, microprocessor technology was incorporated into the Utah Arm 3. Two microcontrollers are programmed for the elbow and hand, thus allowing separate inputs and therefore simultaneous control of both. This allows the wearer to operate the elbow and hand at the same time for more natural function than was possible before. In addition, the U3 uses a computer interface which greatly simplifies fine tuning the elbow and hand controls. Many veterans of the Iraqi war have been fitted with the Utah Arm 3 at Walter Reed Army Medical Center and Brooke Army Medical Center.
- Motion Control was acquired by the Fillauer Companies in January 1997, and became part of one of the most comprehensive orthotic and prosthetic development and manufacturing companies in the world. Fillauer is headquartered in Chattanooga, Tennessee, and Motion Control continues to operate in Salt Lake City, Utah.
Otto Bock of Duderstadt, Germany**
- The company was started in the year 1919 by the prosthetist Otto Bock to supply thousands of war veterans with prostheses and orthopedic products. He found the demand could not be met with traditional artisan methods. He developed the idea of manufacturing prosthetic components in series production and to deliver these directly to the orthopedic mechanics on site. This was the cornerstone for the orthopedic industry.
- From the very beginning, he continually tested new materials for their applicability in manufacturing processes. This made him a forerunner in the use of aluminum parts, which he was applying to prosthetics as early as the 1930s. His steadily growing business would later employ a staff of 600.
- C-Leg Series is has a fully microprocessor-controlled knee joint. It allows give a natural gait pattern. It is allows safe, smooth walking at different speeds and on all surfaces.
RGP Prosthetic Research Center in San Diego
- Have been innovators since the beginning when prosthetics were still made with wood.
- They were one of the first 100 facilities in the country to receive a certificate of approval from the American Board of Certification (ABC).
- Guth co-developed the CAT-CAM Ischial Containment suction socket (John Sabolich and Kevin Carroll--patent 636421)***in 1985 which revolutionized the quality of life for above knee amputees. By containing the Ischiam bone, Guth aligned the pelvis with the femur enabling amputees to walk and run leg over leg instead of kicking and dragging the leg forward. "By containing the Ischiam and providing a lightweight suction fit, we are able to put the prosthesis in a position that is aligned with the body allowing amputees to walk with a natural gait pattern," said Guth.
- One of the first facilities in the United States to obtain the BioSculptor computer aided design system, they continue to search for the most accurate fitting techniques that ensure a total-contact suction fit. "Our goal is to design a custom prosthesis that fits the lifestyle of amputees, not one that the amputee has to adjust their life to."
- Has more than thirty years’ experience in the design and production of high-tech orthopaedic devices.
- Their newest platform is Bionic Technology - a precise fusion of artificial intelligence and human physiology that is transforming the technological landscape.
- Power Knee -- replaces the concentric muscle activity of the quadriceps and can lift the user from a seated position, support the user when ascending inclines, and power them up stairs. It has an active pendulum motion that propels the user forward and enhances the pelvic rotation for a more natural gait.
- PROPRIO FOOT -- Angling itself appropriately, it also helps amputees to sit and stand up easily and more naturally. It, also, has a calibrated alignment control feature. Overall, the effect is a feeling of improved proprioception with a more balanced, symmetric and confident gait with reduced wear and tear on the back, hips and knees.
College Park Industries, Inc.
- Incorporated in 1988 upon completion of the first TruStep Foot prototype, designed and built by David L. Robinson.
- Provides the most anatomically correct prosthetic feet available today.
- End-users of College Park products are lower limb amputees of all ages who maintain low to high activity levels.
Seattle Limb Systems
- Has a corporate history with products dating back to WWII.
- Some of Seattle Systems' products have been previously introduced under these company names: USMC, SOGI, Lenox Hill, Ralph Storrs, Inc., Pope Brace Co., M+IND, Orthomedics, Johnson's Orthopedic Designs, Zinco, Joint Solutions, Seattle Limb Systems, OrthoMold and DOBI-Symplex.
- SNK 100 Knee Series -- feature pneumatic cylinders that automatically optimize the swing back speed to ensure a smooth and natural transition during changes in walking speed. They are constructed of high strength titanium that is both light and durable. The compact design can be easily used for women and children. The load brake locks flexion during stance phase and releases during swing phase for a smooth motion and stable stance.
- leading supplier of innovative prosthetic products and services, offering lower limb component manufacture and distribution to North America.
- They are a member of the Blatchford Group of companies. They are at the forefront of developing digital, electronic, and intelligent interface systems to enhance the lives of people with limited mobility.
- Founded in 1907 by a double amputee, William E Arbogast who was injured in a railroad accident at age 21years. One leg was amputated above the knee, the other below the knee.
- The Earthwalk 2 Flexible Keel Foot and Ankle System provides freedom of mobility that is more natural. The “late stop” ankle feature allows for easy roll over so the foot can maintain foot flat longer. This action is important for less-active amputees who require more stability and less dynamic response.
- Magnum Heavy-Duty (HD) System was created to stand up to the pressure of higher weight (up to 350 lb) patients, ensuring that they can continue to lead the active, self-sufficient lives.
- The GeoFlex Knee is a friction-controlled polycentric knee, created for amputees who need stability but do not want a manual locking knee. Those who are less active, or just learning to walk (U.S. Activity Levels 1 & 2), are well suited for this knee. Amputees experience stability for up to 20 degrees of flexion under load, and feel secure and confident with each step. This unique knee accommodates a hip flexion contracture without giving up knee stability and allows for easier cosmetic finishing.
**Some corrections and additions made February 14, 2008 after corresponding with Al Pike, CP. I'd like to thank him for his contributions.
***Further corrections/additions made February 15, 2008 after further correspondence with Al Pike, CP. I want to thank him for helping me get it right.
Amputations of the Lower Extremity; Janos Ertl MD and others; eMedicine Article, May 11, 2007
Lower Limb Prosthetics; Brian Kelly DO and others; eMedicine Article, Nov 2, 2007
Upper Limb Prosthetics; Brian Kelly DO and others; eMedicine Article, Oct 10, 2007
American Academy of Orthotists and Prosthetists (AAOP)
American Orthotists and Prosthetists Association (AOPA)
Revolutionizing Prosthetics; Muphen R Whitney; Military Medical Technology Online Archives, Sep 29, 2005 in Volume: 9 Issue: 6
Faculty Pioneer Development Of Advanced Artificial Limbs --UCLA History
History of Prostheses; University of Iowa Medical Museum
International Campaign to Ban Landmines (ICBL) -- I strongly believe in this.
***Prosthetic Reconstructions: Making the Industry, Re-Making the Body, Modeling the Nation; Lisa Herschback; History Workshop Journal 44 (1997): 23-57 (shared with me via a PDF file by Al Pike, CP)
SOME BLOG POSTS ON AMPUTATION
SurgeonsBlog -- Confessional; Aug 3, 2007
GruntDoc -- I cut off a finger the other day; Nov 19, 2007
Notes of an Aneshesioboist -- Amputation; Jan 23, 2008
other things amanzi -- callous; Feb 5, 2008
War Amputees--Iraq and Afghanistan (the entire blog)